■■ "■<■*. i m, i UNITED STATES OF AMERICA * . . FOUNDED 1836 WASHINGTON, D. C. OPO 16—67244-1 Surgeon General's Office Q> " Oft.." No. <£/^<^ PRESENTED^BY OPINIONS OF THE PRESS. New York Journal of Medicine and Collateral Sciences.— " It is written in a clear, nervous style, and is calcalated, as we think, to do much good. The descriptions are accurately drawn, and the remedial measures judicious. The practitioner will find it abounding in valuable hints, and the general reader will come across many useful cautions and premonitory warn- ings." Boston .Med. and Surg. Journal.—" Dr. Dixon has written much and well on various branches of Surgery ; his book shows a u: -rough acquaintance with modern practice; Stricture, Gonorrhea, Varicocele, Hydrocele and Fistula are particularly well treated of." " There are startling things in this book which the non professional reader will regard with surprise." " We have our doubts about the propriety of presenting to all sorts of readers these expositions of the vices and frailties of those who labour under a weak moral sentiment—yet the au- thor's originality and thorough devotion to the rational princi- ples of medicine, and his ingenuity under trying surgical cir- cumstances, will cause it to be looked for with more than ordi- nary interest." Globe.—" We took up this book predisposed against it from its title—but we were much disappointed. It is written in a manner that does equal credit to the head and heart of its au- thor. The plainness of its details, and the various subjects of which it treats, are only equalled by the moral tone of the en- tire contents. Startling, indeed, are some of the disclosures made in the last two chapters ! Yet every man and every father should read the book, and they cannot fail to perceive that there is startling occasion for just such a writer as its au- thor—namely, one thoroughly imbued with science and knowl- edge of human nature, full of benevolent feeling, and utterly destitute of fear. We therefore heartily wish as extensive a circulation to the work as its great merit deserves." Evening Post.—" Dr. Dixon is a pupil of Dr. Mott; the in- ventor of a great number of valuable instruments, and a prac- titioner of fifteen years' standing; his book is written with great delicacy and care, yet in decided language ; it will doubtless do great good." Horace Greeley.—" It contains no line or word calculated to excite licentious passions, but on the contrary everywhere, and will prevent thousands from rushing into a course of dissi- pation if seasonably placed in their hands. We hope it will be so published as to give it the widest possible circulation » HhWr TvT" !hi\work is ably written, by a skilful prac- titioner. The subject is one on which, unfortunately, too many require information. That it should be found necessary to popularize such a treatise is ominous of evil: but, since the JKLdT"' ^ ^ WGl1 that the dUty Sh°uld be efficiently WOMAN AND HER DISEASES, FROM THE CRADLE TO THE GRAVE BY EDWARD H. DIXON, M.J). Price, ($1,'25, Bound aud Gilt. The character of this remarkable work is pre-eminently morail, and it should be possessed by every intelligent woman. OPINIONS OF THE PRESS. " The careful and prudent mother may consult this work with great advantage to herself and her offspring. Dr. Bartlett, Editor New York Albion. " Dr. Dixon has lent a deep interest to his work, and is doing good service by its publication. Boston Medical and Surgical Journal. " Dr. Dixon has treated his subject in a sincere, earnest, and diorough manner; we think it will have a wide circulation. Tribune. " 7hr Autllor is a practical surgeon of long standing, and a pupil of Dr. Mott; he has handled the various subjects with deli- cacy, vet with an apparent determination to communicate truth with the utmost force and earnestness. Evening Post. Neto j3ork: [•UBUSHKD FOR THE AUTHOR, AND FOR SALE BY CHARLES H. RING, LORNKR OF BROADWAY AND JOHN STBKET. 1S47. A TREATISE DISEASES OF THE SEXUAL SYSTEM; ADAPTED TO POPULAR AND PROFESSIONAL READING, THE EXPOSITION OF QUACKERY, EDWARD H. MX0?f, M. D., A«Uior of " Woman and bet Diseases," SuVSijy Surgical Essays, and Lecturer on the Operative Surgery of the Eye. SIXTH EDITION. NEW YORK: FUBLISHED FOR THE AUTHOR, AND FOR SALE BY CHARLKS 11. RING, CORKER OF BROADWAY AND JOHN STREET. WOMAN AND HEll DISEASES, FROM THE CRADLE TO THE GRAVE. BY EDWARD H. DIXON, M.D. Price, $1,2.5, Bound and Gilt. The character of this remarkable work is pre-eminently moral, and it should be possessed by every intelligent woman. OPINIONS OF THE PRESS. " The careful and prudent mother may consult thiS work with great advantage to herself and her ofl[spring. Dr. Bahtlett, Editor New York Albion. " Dr. Dixon has lent a deep interest to his work, and is doing good service by its publication. Boston Medical and Surgical Journal. " Dr. Dixon has treated his subject in a sincere, earnest, and ihorough manner; we think it will have a wide circulation. Tribune. " The Author is a practical surgeon of long standing, and a pupil of Dr. Mott; he has handled the various subjects with deli- cacy, vet with an apparent determination to communicate truth with the utmost force and earnestness. Evening Post. Nero $)ork: PUBLISHED FOR THE AUTHOR, AND FOR SALE BY CHARLES H. RING, CORNER OF BROADWAY AND JOHN STREET. 1346. TD THOSI INTELLIGENT AND CONSCIENTIOUS MEN WHO BELIEVE IN THE PROPRIETY OF A SINGLE BOARD OF STATE CENSORS, TO BE ELECTED WITHOUT NOMINATION, AND THEREFORE WITH* OUT FEAR OR FAVOUR, BY THE ATTESTED VOTE OF EVERY MEDICAL MAN IN THE STATE ; AND WHO SHALL POSSESS, FOR A SPECIFIED PERIOD, THE SOLE AUTHORITY OF CON- FERRING DIPLOMAS, AFTER A PUBLIC, EXAMINATION, AS THE ONLY TRUE METHOD OF ELEVATING THE INTELLECTUAL CHARACTER OF A NOBLE PROFESSION, THIS TREATISE IS RESPECTFULLY DEDICATED BY THE A.UTHOR. No 5. Mercer St. N. Y. CONTENTS. Dedication—Preface. $art X.—Sspfitlis, $ct. Chapter I. History of Syphilis; its modern origin disproved; alluded to in Levi- ticus, chap, xv ; and in Psalm xxxviii, Dr. Clarke's Commentary on; statutes of Jane I. Queen of the Sicilies, and of Queen Elizabeth; true method of investigation ; author's opinion of its origin. Chapter II. Chancre defined ; first symptom; does not always appear; several kinds ; instant cure without medicine. Chapter III. Bubo defined ; second symptom; not constant; not always syphi- litic ; time and place of its appearance; treatment—local and constitutional. Chapter IV. Syphilitic sore throat; often the first constitutional symptom; how distinguished from ordinary ; treatment. Chapter V. Ulcers in the nose and mouth; mercurial swelling of the cheek; treatment. Chapter VI. Eruptions of the skin and ulcers ; inutility of local without constitu- tional treatment. Chapter VII. Nodes and swellings of the tendons; are they connected with mer- cury? treatment. Chapter VIII. Excrescences near the anus, and swellings of the testicles; treatment. Chapter IX. Alopecia, or loss of hair; physiological explanation; treatment. CONTENTS. Chapter X. BHndness and deafness; treatment difficult; inflammation of lids. Chapter XI. Irregular and occasional symptoms ; rheumatism and ulcers; treat* ment. Chapter XII. Are there any proofs that the disease is eradicated from the system ? Chapter XIII. Communicable to the child before birth; often the cause of miscar- riage ; interesting case ; great care and incredulity necessary in examining patients in such cases. Chapter XIV. Treatment of syphilis; secondary and tertiary symptoms ; evils of quackery; necessity of mercury ; accursed compounds of quacks ; author's opinion of the action of mercury; fumigation ; inunction; internal use of. Chapter XV. On the duration of a mercurial course ; regimen to be enforced. $art MX.—®KmoKt$tat Chapter I. Gonorrhea defined; totally different from syphilis; period of attack; first symptom; originates feorn other causes than contact; symp. toms; instant cure without medicine; often exists with syphilis} may be contracted at the same time; cases. Chapter II. Second stage; ardor urinse; chordee; injections hurtful; treatment Chapter III. Third stage; inflammation of prostate; diognosis; treatment; sop. pression of urine; treatment; diagnosis from leucorrhea in females waits on. the glans., ~~**, CONTENTS. Chapter IV. Gleet defined ; its importance ; when does it cease to be infectious T author's opinion; local means of cure preferable; regimen. Chapter V. Second stage; its connexion with stricture ; effect on the mind; iodide of iron; introduction of bougies ; regimen; examination of pros- tate ; regimen. Chapter VI. Strictures of the urethra; sad result of quackery; correct definition , always preceded by gleet; impossibility of retaining urine; situa- tion and description of strictures ; spasmodic ; the use of injec- tions, defended by experience and analogy. Chapter VII. Cure of strictures; various kinds of bougies ; use of them; cure by caustic; its legitimate use defined ; great caution requisite ; author's invention, with plate; not to be used as a destructive agent; mon- strous nature of the proposition for forcing a stricture; incision of stricture; author's invention. Chapter VIII. Fistulse, or false passages in the urethra; operation for vaginal and rectal fistulae ; malformation of urethra, operation for ? remarkable case. Chapter IX. Phimosis, paraphimosis, and circumcision; admirable custom of the Jews; a great preventive of disease ; operation on the adult fre- quently necessary ; case of; author's mode of operating. Chapter X. Swellings and other enlargement of testicle; venereal; treatment; sarcocele ; hardening of the epydidimis ; castration; hydrocele; do. of cord; do., encysted ; do. anasarcous; hsematocele; great importance of diagnosis ; different modes of treatment. Chapter XI. Malignant, or cancerous diseases of the testicle; fungus htematodM; granular fungus ; diagnosis ; operation. CONTENTS. Chapter XTI. Varicocele, or enlargement of the veins of the cord; diagnosis; vari- ous modes of cure ; new method of the author. Chapter XIII. Cancer of the penis; do. of scrotum ; sarcomatous enlargement of do ; imperforate vagina, operation for ; cases of author; herma- phrodites explained; absurdity of such an idea; closure of the urethra, at birth ; polypus uteri; instrument invented by the au- thor, with plate; cases. Chapter XIV. Prolapsus of the vagina and womb, and leucorrhea; causes of the former; utero-abdominal supporter invented by the author; leu- corrhea always cured by caustic ; author's speculum. Chapter XV. Spermatorrhea; its causes venereal excess and onanism ; causes for these vices; they are. the origin of our physical infirmity and of con- sumption ; copulation only designed for the production of offspring; absurd desire for youthful precocity; morbid development of nervous system. Chapter XVI. Onanism ; derivation of word ; symptoms and general physiognomy; the frequent cause of phthisis; morbid development of nervous system of children ; mode of address to onanists; moral and sur- gical treatment; author's caustic catheter, with plate; author's speculum, with plate; polypus ligator, do; caustic stricture catheter, do. PREFACE, The writer of these pages is unwilling to subject himself to the aspersion which will probably follow their appearance, without an explanation of the motives that induced him to prepare them; and as those who censure often doubt the statements of such as incur their animadversion, he hopes by the nature and distinctness of an avowal rarely made by authors, as well as the internal evidence of the book itself, to obtain full credit for what he is about to say. In the first place then, the motive is self-interest. The author has long been urged by numerous professional friends as well as patients, to publish such a book. Both^ smarting under the influence of licensed and other quack- ery, have assured him that it would be approved by intelligent professional and other men. This> not only from conviction of the candour of his friends, but extensive personal observa- tion, he believes. A diversified practice of fifteen years' du- ration, with a minute and comprehensive knowledge of the medical policy of the day, has entirely convinced him that the most effective causes are operating, to break down the slender barrier hitherto existing, between the accomplished surgeon and the vilest empyric. This has long rested on a foundation as feeble as the public intelligence on medical subjects, and the only wonder is, that it has so long withstood the on- slaught : the late act of the legislature is the legitimate se- quence of its own miserable policy, in granting to colleges monopolies to teach, or rather to huckster diplomas. The profession is now open to all:—yes, so far as the fos* tering care of that great " caterer and dry nurse of the state," s PREFACE. an American legislature can extend its maternal arns, the most profound of our number may enter the lists for public favor, with his boot black. This kind protection of the pub- lic health, was absolutely a necessary appendage to their pre- vious enlightened act; for these colleges, alas for poor hu- manity, have been animated with such persevering zeal for the numerical, not the intellectual strength of their graduates, (upon the yearly number of whom the subsistence of many of their professors entirely depends,) that the country is flooded by men totally destitute either by education or habits of philo- sophic thought, for the profession to which they have so un- happily been admitted. This has gradually destroyed the only perceptible difference between the physician and the patient: for although a spe- cious and bland exterior, or as Bacon hath it, "a person ex- cellently well qualified for artifice in general," will do much to ensure respect, still the absence of a thorough education, will in a protracted and difficult case, often convince the at- tendant that it is unwise to make indefinite calculations upon the stupidity of his patient; he will eventually require an explanation of his treatment, which however incompetent to understand, he will so much the more pertinaciously demand. From a deficiency in the medical education of his attendant, this may be difficult; to a person thus situated, we say in all candour, possess yourself of this little book; 'twill give the necessary information, and make your patient tractable ; whilst you go home and consult some of those great authors you would have been obliged to study, had you been properly edu- cated ; and for fear the patient should discover your motive should you present him with the volume, tear out nicely this preface, and leave the blank leaves that intervene expressly for this purpose. So much for interest; and it will be seen we anticipate an extensive sale. In addition to a description of numerous delicate and dis- tressing affections to which we are all liable, and which require PREFACE. XI the utmost nicety of discrimination and treatment, we have attempted to show how the very sources of its earliest exist- ence in its mother's womb, are impressed by the vices of its parents ; and to trace the web of error that is wound round the nervous system of the little infant, even from the pure fountain of maternal love, till having entered the " dark la- byrinth of sin," he presents himself to the surgeon, a fellow- being of ungoverned passion, with his very life-blood sapped in the citadel; he has imbibed "The leperous distilment; whose effect Holds such an enmity with blood of man, That, swift as quicksilver, it courses through The natural gates and alleys of the body— Curdling like eager droppings into milk, The thin and wholesome blood." And it his duty to give the patient the benefit of his hearty sympathy, and all the aid that modern science can afford. The reader cannot fail to perceive that the whole object o* the book is to prevent the folly of an attempt at self-treat- ment. Surely, if we have been successful in enumerating half the legitimate consequences of the affection, none but a madman would attempt to tamper with himself. We have spoken at length on the primary symptoms, be- cause it is in that stage that he is most susceptile of scientific treatment. Alas ! how often does he present himself in the loathsome condition of secondary disease, when perhaps, the merciless ignorance of quackery has exhausted itself upon him, and he becomes conscious of his credulity. How often at a period of life when the glad heart leaps at the very con- sciousness of existence, and he beholds his companions buoy- ant with hope and the elastic energy of youth, surrounded with all the endearments of conjugal and parental love,—the sweet smile of infantile innocence lisping the name of father —mother ;—his melancholy condition of disease and decay sheds its subduing influence on the spirit, and he awakes to his true condition. Well did David exclaim, " There is no xn PREFACE. soundness in my flesh because of thine anger." " My heart panteth, my strength faileth, as for the light of mine eyes it is gone out from me." Under such emotions, it was once the sad fortune of the writer to witness the death of a noble young man by his own hand ; the symptoms, after repeated affections had become utterly unmanageable, and his physician a most amiable and skilful man, told but too plainly by his countenance his lost hope ; he seized a razor and severed both the jugulars, ere his hand could be arrested or even his purpose known, thus end- ing his sorrows in the grave, where the light of hope and life had nearly expired together. It is from despair like this that the humane surgeon is to rescue the victim of passion, and it is his duty to prevent the soul-sickening anguish of many a mother's heart, ere it be* come her sad fate to reflect, that her unborn babe is poisoned in the secret springs of its existence, and, instead of the in- vocation for its safety, her prayer shall be that its death may be granted her as the most merciful boon of Heaven. It is indeed often the case that the surgeon is called to treat disease of this very character in the bosom of domestic life, where all around gives evidence of happiness : alas, " That lust, though to a radiant angel linked, Will sate itself in a celestial bed And prey on garbage." Yet this is one of the many pages of life presented to us,. and, whilst we cannot prevent the melancholy fact, let us ap- ply our best efforts for the removal of the consequence : how far this will assist the profession is yet to be seen. The wri- ter will only add, that though their approbation will be agreeable, their censure will not distress him. CHAPTER I. HISTORY OP SYPHILIS. There are so many points of interest connected with the history of syphilis, not only to the physician and general reader, but also in a medico-legal point of view, that I shall offer no apology for the length of the first chapter, but my regrets that it has not been done in a more acceptable manner. The reasoning advanced on its origin, is in accordance with principles recognized by some of the highest names in our profession. Not only bibliography, but facts and analogy, tend to confirm it; and although the idea of there being constantly entire new points for its origination, by means of morbid secretions, would seem to favour the belief that both the varieties of venereal, syphilis and gonorrhea, might occasionally merge into each other, as was supposed by Mr. Hun- ter, and involve the treatment in obscurity, still, I apprehend no such result in the hands of judicious prac- titioners. Neither is it likely that this volume will be read by them, if perchance it should not be entirely con- demned from opposition to popular instruction. The writer well knows, and long himself held the same doc- trine, that by no possibility could the people be inform- ed on medical subjects. Increased knowledge of men and things has taught him better, and he now sincerely believes, that the blasting influence of quackery might 1 2 HISTORY OP SYPHILIS. long since have been checked, had the profession devot ed half the effort they have made, in instructing the pub- lic, rather than opposing them. The importance of the subject of the occasional re- origination of syphilis, is very great; and although I certainly have never met with a case, in which I had reason to believe this has occurred in syphilis, I can by no means say the same of gonorrhea, for I firmly be- lieve I have, and by parity of reasoning, on syphilis, a like result will follow. Although ulcers of the genital organs are mentioned in Hyppocrates and other ancient writers, the Bible fur- nishes us with the first written assurance of syphilis ; and it is very evident that Moses, that profound legisla- tor and physiologist, well knew its nature ; see Levi- ticus, chapter xv.— " 1. And the Lord spake unto Moses and to Aaron, saying, " 2. Speak unto the children of Israel, and say unto them, When any man hath a running issue out of his flesh, because of his issue; he is unclean. " 3. And this shall be his uncleanness in his issue; whether his flesh run with his issue, or his flesh be stopped from his issue, it is his uncleanness. " 4. Every bed whereon he lieth that hath the issue, is unclean; and everything whereon he sitteth, shall be unclean. " 5. And whosoever toucheth his bed, shall wash his clothes, and bathe himself in water, and be unclean un- til even. " 6. And he that sitteth on any thing whereon he sat HISTORY OP SYPHILIS. 3 that hath the issue, shall wash his clothes, and bathe himself in water, and be unclean until even." The rest of this chapter is devoted to an explana- tion of the necessary ablutions and offerings to be made by the male, and female ; for in verse xix. we have a similar injunction for her, viz. " If a woman have an issue, and her issue in her flesh be blood, she shall be put apart seven days; and whosoever toucheth her shall be unclean until the even." Then follow still more emphatic commands respecting the menstrual period, to which, there is no doubt, the preceding injunc- tion refers—verse xxiv. to which we refer the reader, pre- ferring to add, in its place, the commentary of the learn- ed Dr. Adam Clarke,—see Commentary on the 15th chapter of Leviticus. " When any man hath a running issue," &c. " The cases of natural uncleanness, both of men and women, mentioned in this chapter, taken in a theological point of view, are not of sufficient impor- tance to us to render a particular description necessary, the letter of the text being, in general, plain enough. The disease mentioned in the former part of this chap- ter, appears to some to have been either the consequence of a very bad affection, or of some criminal indulgence ; for they find that it might be communicated in a variety of ways, which they imagine are here distinctly speci- fied. On this ground, the person was declared unclean, and all commerce and communion with him strictly forbidden. The septuagint renders " ha-zab," the man with the issue, by o yovo^vtji, the man with a gonorrhea, no less than nine times in this chapter, and that it means, what, in the present day, is commonly understood by 4 HISTORY OP SYPHILIS. that disorder, taken not only in its mild, but in its worst sense, they think there is little room to doubt. Hence they infer, that a disease which is supposed to be com- paratively recent in Europe, has existed almost from time immemorial in the Asiatic countries ; and that it ever has been, in certain measures, what it is now ; and that it ever must be the effect of sensual indulgence, l and illicit and extravagant intercourse between the sexes. The disgraceful disorder referred to here, is a foul blot which the justice of God, in the course of providence, has made, in general, the inseparable consequent of these criminal indulgences, and serves, in some measure, to correct and restrain the vice itself. In countries where public prostitution was permitted, where even it was a religious ceremony among those who were idolaters, this disease must have been frequent and prevalent. When the pollutions and libertinism of former times are i considered, it seems rather strange that medical men should have adopted the opinion, and consumed so much time in endeavouring to prove it, viz. that the disease id modem. It must have existed, in a certain measure, ever since prostitution prevailed in the world ; and this ) has been in every nation of the earth, from the earliest | era. That the Israelites might have received it from the Egyptians, and that it must, through the Baal-peor and *• Ashteroth abominations, which they learned and prac- tised, have prevailed among the Moabites, &c, there can be little reason to doubt. Supposing this disease to be at all hinted at here, the laws and ordinances enjoin- ( ed were at once wisely and graciously calculated to re- [ move and prevent it. By contact, contagion of every ' HISTORY OP SYPHILIS. 5 kind is readily communicated ; and to keep the whole from the diseased, must be essential to the check and eradication of a contagious disorder. This was the wise and grand object of this most enlightened legisla- tor, in the ordinances which he lays down in this chapi- ter. I grant, however, that it was probably of a milder kind in ancient times; that it has gained strength and virulence by continuance; and that, associated with some foreign causes, it became greatly exacerbated in Europe about 1493, the time in which some have sup- posed it first began, though there are strong evidences of its existence in this country ever since the eleventh century." So far Dr. Clarke's learned commentary on this interesting matter, we have no doubt, will very sa- tisfactorily precede any ideas of our own ; and as it is more than probable our use of his commentary, as well as his own explanation, will be condemned by well- meaning, though prejudiced readers, we think it right to give the full benefit of all existing light on our sub- ject to be derived from the Bible; we shall therefore continue our reference to that work. The ordinance so wisely promulgated by Moses, dates as early as 1400 B. C. More than five hundred years later, the xxxviii. Psalm was written, on which we find the following expressive announcement by Dr. Clarke, vide his Commentary:—" Several conjectures have been made relative to the occasion on which this Psalm was composed; but it does not appear that, out of all the titles given it, we can gather the true intent of the Psalm : the most likely is, that it was in reference to some severe affliction which David had, after his illicit 1* 6 HISTORY OP SYPHILIS. commerce with Bathsheba; but of what nature we are left to conjecture from the third, fifth, and seventh verses." There can be little doubt that Bathsheba, from her willingness to assent to David's propositions, was a per- son who valued her virtue very lightly, notwithstanding the possession of a husband, of so many graces, and such distinguished valor. The exposure of her person, whilst bathing, to the public gaze, (to what extent we are not informed, though it seems it attracted the notice of David from the roof of his house,) was sufficient evidence of her lightness of character, and the proba- bility of her being affected with venereal. The Psalm is dated, B. C. 1034, not quite one year after the dis- graceful act, or enough for the developement of syphilis in its worst form. " 3. There is no soundness in my flesh because of thine anger; neither is there any rest in my bones be- cause of my sin." Pain in the bones, or rather, as the reader will see in the symptoms of secondary syphilis, in their invest- ing membranes, and the deeper ligamentous structures of the body generally, is common in syphilis. Dr. Clarke remarks, " This seems to refer to some disorder which so affected his muscles as to produce sores and ulcers." " 5. My wounds stink and are corrupt, because of my foolishness." " Taking this in connexion with the rest of this Psalm, I do not see that we can understand the word in any figurative or metaphorical way. I believe they HISTORY OP SYPHILIS. 7 refer to some disease with which he was at this time afflicted: but whether the leprosy, the smaW-pox, or some other disorder that had attacked the whole sys- tem, and showed its virulence on the different parts of the surface, cannot be absolutely determined. " 7. For my loins are filled with a loathsome disease: and there is no soundness in my flesh." Dr. Clarke—" Or, rather, a burning; nikelah, from kalah, to fry, scorch, &c.; hence nikelah, a burning or strongly feverish disease." " 10. My heart panteth, my strength faileth me: as for the light of mine eyes, it is also gone from me." " There is no soundness in my flesh."—"All without and all within bears evidence that the whole of my sol- ids and fluids are corrupt." " 11. My lovers and my friends stand aloof from my sore ; and my kinsmen stand afar off." " For fear of being infected by my disease." It would certainly be difficult for the most eloquent and observing physician, to describe the secondary symp- toms of an aggravated case of syphilis, with more graphic earnestness, than is here set forth. It had not only affected the entire circulating system, but even the eyes, with some one of the three principal varieties of inflammation of that organ. See chapter x. To the unbiased mind, there can be no reasonable doubt that the above quotations allude to syphilis; and we think Dr. Clarke's Commentary conclusive. More- over, when we come to treat of some other diseases of the penis, we shall show conclusively, that the enlightened and humane right of circumcision, in connection with 8 HISTORY OP SYPHILIS. proper ablution, so often and forcibly enjoined by Scrip- ture, is the most efficient way to prevent the occurrence of the disease. Hyppocrates, who lived 460 B. C, describes ulcers of the genital organs of both sexes, as of frequent oc- currence. Now, though these were not called syphilitic, their frequent occurrence in so suspicious a locality, is evidence enough of their contagious character. A host of writers follow, who describe so many ulcers affecting these parts, that it is really difficult to conceive what use writers could assign these organs, that rendered them so pecuharly unfortunate, who try to support the idea of its modern origin. A very curious document is preserved, from the stat- utes of Jane I., Queen of both the Sicilies, respecting the regulation of the public stews of Avignon, in 1347. We cannot withhold our approbation from the truly kind and philosophic attention of her majesty to the welfare of her subjects, however her delicacy may be questioned. The document is as follows:—"The Queen commands, that on every Saturday the women of the house be singly examined by the abbess, and a surgeon, appointed for that purpose by the directors, and if any of them have contracted any illness by their whoring, that they should be separated from the rest, and not suffered to prostitute themselves, for fear the youth who have to do with them catch their distem- pers." Queen Elizabeth, who found, if report say true, a peculiar use for the finest of her male subjects, despite a proper attention to maidenly decorum, made the HISTORY OF SYPHILIS. 9 enactment, " that every male in her train of attendants, who had a running from the pentle, should pay into the public treasury forty shillings." About the year 1500, a writer, Benedict Victorius, advan'ced some curious views, to the correctness of which the more astute philosophy of the present day would find it rather difficult to assent, viz. that the vene- real disease was epidemic, and originated, in his own words, " from an unwholesome disposition in the air," and " a spontaneous corruption of the humors, contract- ed by an error in diet, or the abuse of the non-naturals." This writer seems, moreover, to have found it necessa- ry to defend la belle France, from a mischievous impu- tation, by the English, of having originated it, by their wickedly calling it Morbus Gallicus. He produced an elaborate essay, going to prove that the state of the air, together with that of the putrid humors, is sufficient to produce it; and to put the matter beyond all doubt, he testifies that he happened to know " some very worthy and religious nuns, who were confined in the strictest manner, unfortunately contract the disease, from the pe- culiar state of the air, together with that of the putrid humors, and the iveakness of their habit of body." This doctrine, though at the present day we smile at its ab- surdity, was really not only believed, but stoutly defend- ed by physicians, many of whom being monks, and of course immaculate, and having access to nunneries, may have had some private reasons for their pertinacious adherence to their own tenets. In 1496, the French, who had no such reasons, so far believed this absurdity, as to pass an edict, that all 10 HISTORY OP SYPHILIS. who had venereal, on pain of death, should be pro- hibited from conversing with the rest of the world, and retire to St. Germains, to places set apart for that pur- pose.* Nevertheless we find certain sagacious old doctors, in England, as late as 1380, who give reason to suppose, by their treatment, that they had no views grounded on the innocence of the nuns. They went at it in a workmanlike way, and cured up their patients, secundem artem, paying very little attention to the agency of the ah", or the non-naturals. About the same period, a very learned Latin author, John Gadisses, gives ample proof that he knew of its contagious na- ture, and was very successful in its treatment. Without dwelling longer on the history of the dis- ease, I will merely remark, that after long disputes about its identity with leprosy, its originating in Amer- ica, and being brought to England by Columbus's sai- lors, the peculiar kind of venereal found, on the discov- ery of this country, in Canada, the Sivvens of Scot- land, the Yaws of Africa, the Judham of the Jews, and the Venereal of Norway,—it was reserved for the genius of the English, to investigate this subject philos- ophically, by directing their attention to the general laws of the diseases of that peculiar membrane, called mucous, that lines the genital organs of both sexes. That this is the only philosophic plan of investigating the nature of the disease, is evident, not only from the absurdity of supposing a single point of the whole * This edict related to the disease that broke out during the siege of Naples. Now there is great doubt if this was actually syphilis, ai the reader will see directly that it was communicated without contact. HISTORY OP SYPHILIS. II earth's surface for its origin, when the genital organs, being of similar structure and functions, must inevita- bly have been affected with similar general diseases, throughout the world ; and if the general results of in- flammation, for example, were the same, why not the individual one in question, or the secretion of a spe- cific poison, from similar, though inappreciable causes. See, for one moment, what forcible analogies may be found;—the specific virus of a mad dog's saliva, inva- riably produces similar results all over the world; and yet it is constantly originating, de novo. Why ! those who would have a single point of origin—as from America—might as well assert that all rabid dogs were in turn bitten by each other, and that the necessary an- tecedent to hydrophobia, was to be from some one indi- "idual of the species. Yet this would be deemed an absurdity. Moreover, the reader will see the various effects produced upon different constitutions by the same virus; and, as it has always been known that the secretions even of healthy individuals, have their essen- tial differences, (the dog even distinguishing the smell of his own master,) is it not a fair inference, that dis- ease would produce equal changes in the secretions of the private parts, and that these secretions might, when united with others, become specific. Again, it is well known, in the various modifications of Leucorrhea—a disease to which the most virtuous females are subject—under this same law, from the most simple state, this very disease will pass into the nost virulent and distressing one, producing great irri- tation and offensive discharge, and often affecting theii 12 HISTORY OP SYPHILIS. legal partners with every symptom of gonorhrea. It has always been known that anatomists, cooks, and butchers, have been subject to severe and often fatal af- fections from vitiated animal decomposition ; and this again is another forcible analogy, affording the strong- est reasons for our conclusion, taken in conjunction with the disgusting want of cleanliness about the geni- tal organs, so universal amongst a very large portion of the human race. The writer would not be misunderstood on this im- portant point. The object is to convince the reader, that there must have been, and by the same mode of reasoning still are, and will continue to be, (however rarely,) entire new points of origin, somewhere upon the extensive sur- face of this earth. He is perfectly aware of, and will soon show from the investigations of Hunter and Ricord es- pecially, (for to them, almost exclusively, belongs the credit of rigid experiment and induction,) that the form of venereal productive of the most serious constitution- al mischief, is the result of a primary sore, to which has been applied, from its first observer, the term Hunteri- an Chancre; and that this is almost universally suc- ceeded by a characteristic eruption over the body. Mr. Carmichael, a very distinguished and philosophical sur- geon, pnblished a work in London, in 1825, on the plu- rality of venereal poisons. Although he believes the disease now recognized as syphilis, to have been first brought to England by Columbus's sailors, still he as- serts, as we also have endeavoured to show, that vene- real diseases, " strongly resembling the imported one," have existed for three centuries, and been, from their HISTORY OF SYPHILIS. 13 marked resemblance, confounded with it. Mr. Samuel Cooper, in his surgical dictionary, (a work of the high- est authority,) remarks, that the army of Charles VIII. at the conquest of Naples, in 1494-5, were afflicted with a supposed venereal disease, " that spread with un- exampled rapidity and virulence." There is a decree of the parliament of Paris, dated 1496, in which this disease is mentioned as having ex- isted two years ; and as it is said to have spread " with such unexampled rapidity," in that period, and more- over to have been communicated merely " by the touch, residence in the same chamber," &c, it could never have been ordinary venereal. Indeed, Mr. Cooper also remarks, " unless some other mode besides coition be supposed, its extension throughout Europe in two years, would imply a depravity of manners quite unexampled, and beyond all credibility." As we find about this period, however, the attention of writers strongly directed to its investigation, it seems fair to infer that it had undergone some important change—perhaps in virulence. Above all other data, however, must be placed the introduction of mercury in its cure. This took place in 1516. See Cooper. As this is the nearest approach to a specific, it must, in the absence of a better mode, which certainly did not then exist, have been the surest way to determine what was, and what was not, specifically syphilitic. 2 CHAPTER II. CHANCRE. The term venereal disease, we shall not employ, as that would imply any disease following coition ; nor shall we, in this chapter, say a word of gonorrhea or clap, as that is, beyond all doubt, a local disease, that cannot permanently affect the constitution ; although its distressing, and often permanent effects, when neg- lected, will be sufficiently apparent when we treat on that subject. The term syphilis, is derived from the Greek n the order of occurrence, is Bubo, from the Greek HovSuv, the groin—because they usually exist in that part. A bubo is defined, " a painful swelling of a lymphatic gland, produced by absorption of the venereal virus;" although, as will soon be seen, they originate from other causes. Now the intelligent reader will at once ask, what is a lymphatic gland 1 Throughout every part of the human body, as well as arteries, nerves, and veins, there is another set of vessels equally numer- ous, called lymphatics. Their specific object, being to convey the superfluous secretions made by the blood vessels, all over the body, back into a large internal and deep-seated vessel, that takes up the prepared food called chyle, and throws it, together with the lymph, into the veins ; thus again submitting the whole to the action of the arteries, and converting it to the general uses of the economy. The lymphatics, so called from their con- veying lymph, or a colourless fluid, in various parts of the body, as in the groin, arm-pits, &c,—are convoluted into small knots, called glands. They are also called, from their office, absorbents ; those that originate from the private parts, as well in the male as in the female, 3 26 BUBO. go into the upper tier of glands in the groin, or just above the thigh ; they are from five to eight in number, and might constitute as many bubos, if the chancres were sufficiently numerous to poison all the lymphatics whence they derive their origin; this is not, however, the case; there are rarely more than two, oftener one. Now as each groin has its own glands, and each side of the penis its own lymphatics, the bubo will originate on the corresponding side with the chancre or chancres. If there were but one chancre, and especially if that should be situated on the lower part, and on the dividing line of the penis, it might produce it on either or both sides. If by chance a chancre should exist on the upper and inner part of the thigh, it would produce a bubo in the lower tier of glands, on the upper part of the thigh: and if on the finger, the bubo would be in the arm or the arm-pit: about the lips or mouth, at the angle of the jaw, or under the tongue. Thus, it is seen, the superficial lymphatics will absorb poisons, as well as fulfil their proper purposes, and thus by external appli- cation to them, mercury is often made to reach the gland, and annihilate the poison on its way to the sys- tem, for it does not remain in the glans, but if the bubo be not cured, is reabsorbed into the system and enters the blood, producing all the symptoms subsequently to be explained : these are entitled constitutional symptoms. The first important point to be noticed, in treating of bubo, is, that according to the observation of some very distinguished surgeons, they may originate, (and, as subsequent constitutional eruptions prove) be distinctly BUBO. 27 syphilitic, without any chancre or even the slightest visi- ble abrasion. Mr. Hunter has seen instances, and John Bell of London, observes, that he " has recorded up- wards of twenty cases." The writer of this work has submitted to the notice of a distinguished surgeon ot this city, a case in which constitutional eruption follow ed a bubo, without a chancre. The patient declined a mercurial course, which was urged upon him from the knowledge of Mr. Bell's observation, and the persistence and suppuration of the bubo. In such cases, (fortunate- ly very rare) we have nothing to help our opinion of the propriety of mercury but the latter points, and I do not hesitate to advise mercury in all such cases, if there be no other sufficient cause for a sympathetic bubo, such as its occurrence after great fatigue, violent jumping or wrestling, mechanical injury of the generative organs, or the foot or thigh, all of which might do so, and if the patient were scrofulous, the bubo would prove very dif- ficult to remove by local means. The poison from the chancre may also cause ulcera- tion in the small track of lymphatics along the penis, before they become convoluted to form the gland, or bubo. I have known the virus stop and spend all its force in the formation of extensive ulceration at the root of the penis, and form no bubo at all. A syphilitic bubo, when open and discharging mat- ter, is in all respects similar to a chancre. It is a chancre upon a large scale, and the matter will produce other chancres, if care is not used ; hence the neces- sity of great cleanliness and circumspection. But here 28 BUBO. the specific effects end. The constitutional symptoms will not produce their like, even if the matter be applied to the abraded skin.* And now the reader understands the meaning of primary and secondary symptoms. All after the bubo are secondary; the chancre bubo and lymphatic enlargements, if any, are primary. Bubos usually form within a fortnight or less—the general period not exceeding a week from the appear- ance of a chancre, although they may be met with at any period of its existence. A chancre may remain quiet for some considerable time, then suddenly become irritated and painful, when the bubo will follow quite unexpectedly. The application of caustic to a chancre, or the rubbing of mercurial ointment on the thigh, may produce a bubo, and one that is not syphilitic, being produced solely by the irritation of the lymphatics. And yet this bubo, of course the reader will see, has a right to become syphilitic, so long as the chancre be not de- stroyed or healed. In a vigorous constitution, a bubo proceeds much more rapidly to a termination by suppuration, than in a delicate one, generally ending in that disagreeable re- sult by a fortnight. In scrofulous persons they may last for months, to the great annoyance of the patient and surgeon. And patients should always remember that their cases are peculiarly stubborn, even in the most skilful hands. And here let me remark, that the fretful and querulous stand greatly in their own light: * The ulceration of the nipples, caused by the suckling a syphilitic child, seems to be an exception to this rule. BUBO. 29 in all diseases the recuperative powers of the system are best exercised under an equable state of mind, but peculiarly so in this disease, for reasons known to every man who reflects upon the depressing influence of dis- ease in the generative organs. The patient, then, should cultivate equanimity of temper. It is the special object of the writer to show the difficulties and doubts that environ this disease, even in the most skilful hands, and to enable the unfortunate to shun the heartless igno- rance of empyricism. There are, in several authors of the most distinguish- ed character, opinions advanced that constitutional symptoms will not occur, where the syphilitic bubo dis- appears without suppurating, to which the most success- ful practitioners of our country entirely dissent. For myself I am happy in coinciding with them to say, that I do not know a single medical man who has the least doubt upon the propriety of a moderate use of mercu- rials, in all cases where it is not perfectly clear that the bubo is not syphilitic. And here it must be remem- bered that the chancre may occur entirely within the urethra, and so closely simulate gonorrhea, with which indeed it may be combined, as to deceive both the pa- tient and physician. Nay, sympathetic bubo will ap- pear in clap itself. I can only say that the patient should rely exclusively, in such cases, upon the astute- ness of his surgeon, and I need not urge the latter to give him, as they say in the law, the benefit of a doubt, and incline to prudence. I have nothing to say with re- gard to the choice of treatment. Rest, leeches, mercu- rial frictions on the thigh, blisters over the bubo, nitrate 3* 30 BUBO. of silver freely applied, moderate pressure, makeup the sum of efficient means. And I confess myself an ad- vocate for an early opening, as soon as matter has formed, believing, from my own observation and that of numerous friends, that its absorption is very rare, and that its presence can only produce injury and annoy- ance to the patient. Poultices are often applied in the early stage of bu- bos. This is wrong. We should endeavour by all possible means to prevent their opening; but if it is ev- ident they will advance to suppuration, the practitioner who is not confident of his ability to detect matter in its early stage of formation (and that is sometimes diffi- cult, as there is a dense fascia or sheath of membranous structure over these glans,) should apply a poultice till the matter is sufficiently distinct. Warm water, ap- plied by a sponge, is the preferable and more cleanly method ; but this is often impossible, as the patient re- fuses confinement to the house. The practice of open- ing bubos with caustic is very painful, and I believe now nearly obsolete. The lancet is the method most in use. As soon as the bubo ceases discharging, a so- lution of nitrate of silver, five grains to the ounce, will be of service in promoting healthful granulations. It may be increased to ten, and even twenty, and if the edges of the sore are hard and indolent, the pure stick may be applied. Yet all this rests with the judgment of the practitioner. CHAPTER IV. SYPHILITIC SORE THROAT. This is very apt to be the first constitutiona symptom, though eruptions on the skin may precede it. There is no specific period for its occurrence, and its appoach is so like that of a cold, that it is often so called by the patient. It is said, and I think justly, by many authors, that this is more likely to occur when the poison has entered the system directly by the absorbents, without the formation of a bubo. They suppose it spends its force there and we know that the bubo delays its en- trance into the constitution, for a time at least. A bubo may often be checked in its forming stage by mercury ; and then the poison, having also entered the system, either from the same chancre that formed the bubo or another, that shall form none, and an insuf- ficient quantity of mercury having been given to neu- tralize the constitutional affection, sore throat and other affections may occur. It is in such cases that the pro- fession gains discredit, and it is well to err on the side of prudence, and not to assume a chancre or a bubo to be non-syphilitic, because it soon yields to mercury: very often, if an accurate examination is made, hard- ness will be perceived, either in the chancre or jjubo, and this is an evidence of the propriety of continuing the mercurial treatment. 32 SYPHILITIC SORE THROAT. Sore throat may happen as early as ten days after infection, and it may be months after all the primary symptoms have disappeared. It often ap- pears in the form of an ulcer, copper coloured, and very small, on one side of the throat very far back : it will occasionally remain a long while stationary, and then advance with unexampled rapidity over the arch or curtain of the palate, to reach the opposite side, and on its way destroy the uvula, or hanging palate, as it is often called,—all these parts may be destroyed in a few days. This ulcer is often accompanied with general inflammation and distressing burning sensa- tions, and sometimes distinct erysipelas, if it be not con- trolled by mercury; it will attack the bony part of the roof of the mouth and ulcerate it through, thus destroy- ing the voice by opening the mouth into the nostrils. It is here also that the hearing becomes impaired, by inflammation attacking an important tube, conveying air from the mouth to the ear; this becomes closed, and thus produces deafness, air on either side of the tym- panum being essential to perfect hearing. A very an- noying secretion of mucous is often produced during this affection, causing a constant effort to clear the throat. The affection with which syphilitic sore throat may be confounded, and thus cause needless alarm, is the ordinary and violent sore throat. To this the patient is quite liable under the use of mercury; and indeed, in our climate at all times: syphilitic sore throat is attend- ed with ulcers of a copper colour, and forming on the surface,—ordinary sore throat, either with general red- ness of a much lighter hue, or abscesses having matter SYPHILITIC SORE THROAT. 33 within them; the ulcers, moreover, have smaller and buff-coloured crusts or sloughs on their surfaces; and the parts in ordinary sore throat, without being even visibly ulcerated, are often covered with an extensive milky exudation. There are on the tonsils, or as they are often call- ed, the almonds of the throat, as far back as one can see, many natural irregularities—these must not be mis- taken for ulcers. Should the patient have been for some time under the use of mercury, and either have taken it in excessive quantity, or, as is also often the case, been predisposed to scrofulous affections of the throat, other difficulties will arise, which are to be left, of course, entirely to the skill of the practitioner. In such cases, besides the ordinary rule of the preceding his- tory of the case, whether mercury has been taken, &c, as well as the general appearance of the patient, the physician, by a careful attention to regimen, and hav- ing the entire control of every circumstance likely to injure hiin, will run no risk, even if ulceration of a doubtful character should exist, by waiting a short time, and observing the progress of the disease. During this interval, he will probably test the action of caustic, a remedy of the utmost value, and one which will control more unmanageable ulcerations, under even the most opposite condition of circumstances than any other, nay, we believe, than all others put together. It is here that the most entire trust in the surgeon is necessary, and unhappy indeed is both patient and surgeon if this be not reciprocal. The surgeon, if bis heart is right, will not fail, should he deem it necessary, to suggest the 34 SYPHILITIC SORE THROAT. aid of friendly counsel; and when this is done to their mutual satisfaction, he should proceed confidently in the treatment agreed upon, and carry it out to the ut- most of his abilities. Then, even if the result be unhappy, that man is recreant to every principle of honour and manly fortitude, who visits his misfortunes (originating in the gratification of his own appetite) upon the reputation of his faithful surgeon. CHAPTER V. ULCERS IN THE NOSE AND MOUTH. Although ulcers of the throat, mouth, and nose, do not invariably attack in the order of their enumeration, still the throat may generally be called the place chosen for the first appearance of constitutional symptoms. Should the disease have been suffered to progress with- out mercurial treatment, or an insufficient quantity been given to check it when in the throat, and it appear again, it will proceed generally to the mouth and nose, as though no mercury had been given. The remarks made when speaking of the throat, apply equally to the mouth, with this exception; that when it attacks the roof of the mouth, it will often pro- ceed to the destruction of the bone with great rapidity, a few days after the copper coloured spot first appears, generally in the middle of the roof, the bone may be- come ulcerated, and a permament opening made into the nostrils, thus impairing the voice, and causing nasal utterance. This fortunately admits of the adaptation of a gold palate; several cases have been thus treated in masterly manner in this city. The first appearance of ulceration in the nostrils, is apparent by a stoppage accompanied with pain at a particular part. With the aid of a speculum, (an instrument for dilating the nos 36 ULCERS in the nose and throat. tril) it may be seen high up on what is called the spongy bone on one side. A very foetid and almost insup- portable discharge precedes the coming away of the bone itself, and a constantly weeping eye is caused by the stoppage of the tear duct, that conveys the tears down the side of the nose to the nostril. Should the great septum or dividing bone of the two nostrils be attacked, the nose falls and becomes flat with the face. The wing or cartilage of the nose may be attacked, and has been occasionally presented to the surgeon as a cancer, and in one instance had actually been removed by a quack, by means of what is called a cancer plaster,—a most cruel and accursed experiment of those wretches in human shape called cancer doctors; a class of humanity, who seem to have been formed after sympa- thy was exhausted. And here I would remark, let eveiy afflicted person beware of these and other pre- tenders :—even after long, long years, he thinks his se- cret safe, and that the virus is exhausted, these local af- fections may arise : in the chapter on anomalous symp- toms, he will find an account of these reliquiae, which occasionally pass for cancers, tumours, &c. There is an occasional result of mercury, viz.: a temporary swelling of the cheek, that may produce alarm in the patient, by pressing upon a broken tooth, and causing the semblance of an ulcer: this is readily understood by the physician. The tongue is liable to thickening and ulceration, that produces a very alarm- ing appearance, and often simulates cancer: it is too rapid in its progress, however, and the history of the case will also be sufficient to determine its nature. ULCERS IN THE NOSE AND THROAT. 3? There is one caution to be most carefully remembered by the patient: after mercury has been given, and it has, as it occasionally will, though this is always deprecated by the surgeon, produced soreness or ulceration of the mouth, and it should be discontinued for a time, and perhaps for good, the patient must not, as I have often known them do, continue taking it by stealth, for he may actually produce sloughing or mortification of the cheek, and even death itself; in fine, he should either trust his surgeon entirely, or discharge him. CHAPTER VI. ERUPTIONS OF THE SKIN, AND ULCEk^. With the exception of what remains to be said on some of the more serious affections of the bones, we have now reviewed those symptoms that excite the most alarm in the patient, and respecting which the instruc- tion we have endeavoured to give is of the most import- ance. We take it for granted that having read thus far, he either is or has resolved immediately to place himself under proper care. There is indeed so great a variety of constitutional eruptions, that it would not comport with our purpose to give their individual appearance as this would also require the aid of the colourist. The skin, as we have said, is occasionally affected before the throat or mouth ; but this is not common. The breast and arms are most frequently the first in order of attack. There is very little uneasiness and no pain attending these eruptions: a very slight itching occasionally is felt. Those most frequent are at first of a copper colour, yet of a mnch paler tint than they subsequently assume; they look often like blotches, and project very little from the skin; on minute examination, they may be found composed of pustules so slightly charged with fluid, that it dries away, and the whole surface may be rubbed off ERUPTIONS AND ULCERS. 39 like bran. They often disappear, and the skin is left sound beneath them, yet, as the reader has already ob- served, there is no tendency in parts afflicted with syph- ilis to heal; tenderness or irritability is left, and either immediately or soon after the first blotch has disap- peared, another takes its place, a thicker crust, pro- duced by the little pustules forms, and on this being rubbed off, a small ulcer appears. They have been confounded in their incipient state with tetter or ring worm, and have, indeed, somewhat the ap- Dearance in colour and shape, and the fact that they both persist, unless remedies are used. There is, however, no doubt of their nature when ulceration occurs, as the matter of syphilitic ulcers differs very much from tetter, few of the latter yielding discharge. The matter of a venereal ulcer, as we have seen, in the mouth, is viscid and flaky, and appears like melted lard ; that of tetter, with one exception, (otherwise sufficiently character- ized,) is thin. The history of the case, moreover, will give every reason to suppose what is the nature of the eruption. There is a pustular affection of the skin, that appears in distinct vesicles, like small-pox. These soon dry and leave a scab. And again, a scaly eruption, particularly about the face, in which one scale will be piled upon another, even an inch in height. This is a very stub- born and unmanageable form. Of course all these erup- tions require constitutional remedies, and frequently baths, with a very strict attention to-regknen. The pa- tient, if at all intelligent, will rely exclusively upon his attendant. The thighs and lower parts of the body^e 40 ERUPTIONS AND ULCERS. last affected,—the hands and face being commonly at- tacked after the arms and shoulders. Ulcers.—Besides the ulcers that form in the throat, mouth, and nose, and those that succeed bubos, ulcera- tion may exist in any other part of the body. Yet it is re- markable that secondary ulcers are the last to attack the genital organs, though the primary, viz. the chancre, commonly begins there. Ulcers about the body usually begin, as we have said in the last chapter, in the form of blotches or pustules. There is a remarkable difference between them and or- dinary ulcers that succeed to abscesses, such as boils, &c. Theyrarely continue on the surface, not onlybur- rowing, but from the very beginning, having a tender cy to destroy the parts beneath, as well as the skin it- self. As soon as the skin is destroyed, all the parts be- tween it and the bone are often in the same condition. Indeed, this rapid destruction of parts, is only common to this disease and mortification: in no others does it hap- pen. It has already been repeatedly noticed, that syphilitic sores, unlike others, produce no pure matter, nor gran- ulations, at least till they begin to heal. They secrete an ill-looking, thin, and bloody, and occasionally a tough and greenish discharge. The skin surrounding them has a diffused red colour, and they are almost al- ways without pain. At a later period, even in healthy persons, they seek the deeper seated parts, and always much sooner in those who are naturally feeble. They are always influenced much by the constitution, and de- mand varied treatment;—mercurial often, nay always, ERUPTIONS AND ULCERS. 4' at some period of their continuance, and frequently to- nic treatment combined. Erysipelas often attacks the skin around the ulcers, and demands its appropriate treatment, whilst the ulcer assumes such a variety of aspects, that it requires all the tact of a sound and judicious practitioner, to dis- criminate the varied phases of constitutional affection, indicated by this ever-changing affection. When they attack the bones, I am satisfied that the system best re- sists their inroads upon the performance of its functions, by a judicious combination of mercurials and tonics ;— amongst the latter that invaluable gift of chemistry, the hydriodate of potass, which is always used by the mod- ern practitioner. There is no tonic like it, and it is no doubt true, that one half the cases that formerly died under protracted syphilitic affections, and the abuse of mercury, are cured by it alone. It is an anchor of hope to the surgeon and patient; and this is the testimony of almost every practical surgeon. Nutritious diet, and even porter and wine, is here re- sorted to, but all must rest with the medical atttendant. The patient must not expect much benefit from any lo- cal applications in any form, for he will be disappoint- ed utterly in any amendment, till the poison is checked in the constitution. King David well exclaimed, " There is no soundness in my bones because of my sin." Nothing can be more annoying to a surgeon than the continued desire of the patient for some new applica- tion. I have often been wearied by these requests, and oftener felt that an apparent compliance with the pa- 4* 42 ERUPTIONS AND ULCERS. tient's wishes, as to their renewal or continuance, low ered me in my own and his estimation. Indeed, it is far best to assure the patient in the beginning, that you mean to assent to every proposition, however ridiculous, that will not injure him. Let him prescribe for the sore, and the surgeon for the disease. A very humorous and scientific friend is wont to tell his patient that he may put every thing on the sore, from " pigeon's milk upward." He may " grease it with every thing but aqua-fortis and lightning "—so long as he obeys the medical prescription. CHAPTER VII. NODES AND SWELLINGS OF THE TENDONS. Wherever the bones are thinly covered with flesh, as in the shin, or outside of the arm, the forehead, or the shoulder-bone, as it is improperly and often called, swellings, rarely larger than half a walnut, either soft or very hard, will often appear towards the latter part of the disease. These are most likely to occur either in bad constitutions, that have often been affected, or in those where the disease has been suffered to progress without treatment, but more especially in those who have been much exposed to dampness. They either exist in the substance or body of the bone, or directly beneath the delicate membrane that covers it. When the tumor attains the size of a cranberry, the skin be- comes red and tender ; gradually it ulcerates in those that do not remain stationary, and upon discharging its contents, the bone itself is found carious: in the state of progression it is exquisitely painful,—this ceases as soon as it is opened. The administration of mer- cury usually stops the progress of these tumors, and causes them partially to recede. Should the constitu- tion regain its full powers, frictions with appropriate ointments will cause a very slight diminution, but they generally remain enlarged for life. 44 NODES AND SWELLINGS. It is not to be denied that these thickenings of the bone, as they are familiarly called, or nodes, are most fre- quent in those who have undergone repeated and injudi- cious courses of mercury ; and it has even been said that they never exist in those who have not taken it. And what of this ? Does it follow that the patient should not take it ? If he prefers the constitutional eruptions and sore throat, with the destruction of his palate, he can be accommodated. In a late very distressing case that came under the notice of the author, it was urged, amongst other reasons, by a quack of the homoeopathic order, that " mercury rotted the bones, and produced tumors upon them," (these sentiments being shown in Cooper's Surgical Dictionary, a truly distinguished authority,) to the patient. Homoeopathy was his only salvation, and he had it, at the expense of a constitu- tional eruption, and the entire loss of his palate, both processes going on at my first visit. It is a principal object of this volume to assist the patient in forming a correct conclusion, and to put him so far right in his train of thought, that he may not be victimised by quackery. I shall not attempt to conceal, when speaking of mercury, its actual dangers. One half the trouble from the use of this utterly indispensa- ble medicine, originates in the injudicious concealment of its administration, or an inadequate representation of the necessary cautions to be used whilst taking it. Rheumatism often attacks many of those under a mer- curial course, and it is a most unmanageable and dis- tressing affection. Besides permanent or hard nodes, there are soft ones, NODES AND SWELLINGS. 45 These may strictly be called, separated from unneces- sary complexity of definition, collections of matter un- der the investing membrane of the bones. The same observation respecting their permanency, does not ap- ply to them. If they do contain matter, as soon as it can be distinctly felt, which, by the way, is difficult, it should be released by a puncture with the lancet. Besides these two varieties of nodes, there will occa- sionally originate more extensive swellings, sometimes called rheumatic by the patient, in various places over the bones. They are, however, of a much harder na- ture than swelling consequent to, or accompanying rheumatism ; the latter being erratic in its location, and therefore disconnected with the bone; the former are not so. These latter, however, unlike bony nodes, admit of complete dispersion in time. The sheaths through which the sinews or tendons play, occasionally enlarge, and thickenings of the ten- dons themselves, with consequent impediment in their functions, occur. Mercury, either by the mouth or fric- tion to the limb, is the remedy for these symptoms- nothing else has the least effect upon them. They are by far the most likely to exist with debilitated or scrof- ulous persons ; and a correct estimate of the actual ex- isting powers of the system, and its capacity to tolerate this medicine, with a judicious combination of tonics, can only be made by the careful and observant sur <*eon. CHAPTER VIII. EXCRESCENCES NEAR THE ANUS, AND SWELLINGS OP THE TESTICLES. Around the verge of the anus, there will at times occur, particularly in such as have often had syphilis, enlarge- ments of the skin in isolated portions : sometimes they project half an inch from the surface ; they are round or irregular in form, observing no rule either in the time of their appearance, or shape. The most rapid and least painful method of removing them, is to clip them off with scissors. Although swelling of the testicle is almost peculiar to gonorrhea, as will be seen when treating on that com- plaint, still it occasionally occurs in syphilis, where there are no existing symptoms of gonorrhea; for, the reader will observe, the diseases may occur together. Swell- ing of the testes, in syphilis, is not common, however, and it is only noticed because it does, though rarely, occur, and is from its unexpectedness peculiarly alarm- ing to the patient. The enlargement, as it is appropri- ately called, to distinguish it from permanent hardening or cancer of this organ, a disease to which it is also sub- ject, appears without pain of an acute kind, and only excites the attention of the patient from its increase of bulk and weight. In the swelling of this gland, that SWELLED TESTICLE. 47 originates in gonorrhea, the pain is considerable from its commencement, and it extends to the back and loins ; it is also much aggravated on assuming the vertical pos- Lure, and the patient is glad to seek relief by lying down. The former progresses very gradually, often requiring weeks to attain the size that the latter acquires in two days: this is often, in both, the size of a hen's egg. To distinguish it from the cancerous affection above mentioned, it may be remembered that the latter is still more slow in its accession, is accompanied with much sharp stinging pain, becomes very knotty and irregular over its entire surface, and soon extends up the cord to the groin. The syphilitic testicle may also be accom- panied with effusion of water, constituting dropsy of this part; this is described in another chapter. (See Hydro- cele.) As mercury is the only means of cure for this affection, and it removes it with certainty and rapidity, it will soon relieve the anxiety of patients. The only additional remark I feel it necessary to make, is to urge the patient to submit to the recumbent posture entirely. Nothing is more absurd than to ex- pect the benefit of a surgeon's efforts in alleviating this complaint, than by continuing on the legs, even if con- fined to the chamber, or sitting, it is all wrong alike. No benefit can follow, so long as the blood is prevented from returning to the great vessels of the body, by com- pelling it to ascend through a long and tortuous system of vessels, before any of it can be driven from the dis- eased organ. This is, without any exception, the most necessary observance in treating any diseases of the genital organs. The whole of this matter is fully ex- 43 SWELLED TESTICLE. plained in the chapter on gonorrheal swelled testicle, and it will then be seen, that amendment whilst stand- ing or walking about, is considerably more absurd than expecting water to run up-hill. CHAPTER IX. ALOPECIA J OR, LOSS OP HAIR. From what I have heard in conversing on this sub- ject, I believe it to be productive of greater anxiety, I had almost said, than the actual loss of virility itself There are so many causes of a general or constitution- al nature for this symptom, and that too in such as have never known any form of syphilis, or ever taken a grain of mercury, that I intend to set forth its nature in the most frequent cases, with sufficient minuteness to pre- serve, if possible, the illusion of its reproduction by the thousand and one nostrums of the day. Any person of common powers of observation and reflection, cannot fail to have observed, that the hair is the first point on which the hand of time makes its im- press, even in those, who long after the appearance of actual baldness, give the greatest proof of physical power, and plainly show, that they are in the very me- ridian of strength. Nay, if the proof that is supposed to be beyond all other assurance be wanting, nothing is more common than the birth of numerous children to those who have doffed their raven locks, and whose gray hair and bald crowns, with an erect and youthful bear- ing, bring to mind an inauspicious spring in our ever- varying climate. 5 50 ALOPECIA ; The remarkable difference in the growth of hair after cutting, and its reproduction after ordinary sickness in extreme youth, shows conclusively great difference in the constitutional power of the circulation. Look, for instance, at the brown hue and firm muscle of an ur- chin we now and then pass, and the doughy appear- ance of his companion. The one with drooping, red- skirted and lack-lustre orbs,—the other sparkling with health, and reflecting the brilliancy of his eyes upon his wan companion. Shut your own eyes, and pass your hand over the faces of these children. Is it fancy, or is there a great difference in their warmth, and if I may so say, pungency in their skin ? The eye-lids and the skin of the head, are both in the same condition. The contractibility of the individual blood-vessels, in the one, is impaired, and they cannot force along the blood, or yield to the action of the heart, so as to feed the glands which produce the hair. The blood is not renewed oft- en enough, and diseases of the skin show themselves in consequence- These are called congestive in char- acter. Each individual hair is supplied with its separate gland, which elaborates it, and continues its growth from the blood. It is in all respects similar to any other gland, so far as its powers of production are concerned. Now the testicle is a gland, and if we have been at all successful, when speaking of the swelled testicle, the reader will understand that the gland is affected with want of action, or congestion. All this as we see ap- plies, so far, to a state in which there is no syphilitic poison. OR, LOSS OF HAIR. 51 If the falling of the hair then, be one of the first symptoms of bodily failure, though, as I have said, so insidious as to be inappreciably connected therewith in its commencement, how much plainer to the understand- ing does it become, that the depressing influence of se- vere constitutional disease, nay, the actual existence of a specific poison, in the very glands that produce it, shall effect this result. And if a gland, as large as the testicle, sometimes, and not unfrequently either, should wither, and even disappear entirely, as is well known to surgeons, how far more likely is one much less than the size of a mustard seed, to be obliterated from the same causes 1 Explain this to your own understanding, and then pes- ter yourself with nostrums if you like. The first symptom of the loss of hair, is of course its coming out in combing. And if the patient exam- ine the comb, he will find a number of branny scales. This is the scarf skin, thrown off in consequence of the feverish, congested state of the true skin below, in which the bulbs of the hair originate. This state of things will go on till the person becomes bald, and some- times in severe cases the eye-brows will come out. The beard and whiskers are the last to suffer, and generally resist the disease entirely, or become prematurely grey. There is but one remedy I have ever known to pro- duce any effect, and this is mercurial in character, and thus its action is explained upon the presumption of its direct anti-syphilitic action. It is the yellow wash, often used by surgeons as an application to sypliilitic and other ulcers. Should this fail, I would urge the patient 52 ALOPECIA. to make one or more sea voyages, as there is nothing that will elevate the constitutional powers so rapidly, as this measure. Venery should be entirely avoided, and every other excess shunned. All applications, except shaving and friction, with the yellow wash, are prejudicial. They load the skin, and prevent the performance of its functions. The benefit that sometimes follows their use is due exclusively to the friction. CHAPTER X. BLINDNESS AND DEAFNESS PROM SYPHILIS. When blindness originates from any alteration of the surface of the eye-ball, and comes on gradually, it is sufficient for all purposes to say to the general reader, that it occurs from causes precisely similar to those just explained, in treating of the loss of the hair, congestion of the blood-vessels in the internal tissues of the eye. The reader will remember the caution given him when treating of chancre, and observe that in case of the direct application of the matter of a primary sore, specific effects, and a rapid obstruction of the eye would follow. The blindness now under consideration is a constitutional symptom. Should there be no visible alteration of the tissues or contents of the eye-ball, and sight should fail, then the affection is the result of dis- ease of the optic nerve, and is for the most part quite incurable, as it never happens till the system is so com- pletely broken down by disease, that permanent disor- ganization of the retina has occurred. So far as my experience goes, no treatment will effect any benefit. The same remarks apply to diseases of the ear. If there should be discovered any alteration, either in the mouth, affecting the tube spoken of when treating of ulceration there, or should polypi, or other tumors or 5* 54 BLINDNESS AND DEAFNESS. swellings have formed in the external ear, then the loss of hearing may be imputed to such alteration or tumor. If, on the contrary, no structural derangement exist, the symptom is owing to paralysis of the nerve of hear- ing, an affection analogous to that of the eye, and as far as my experience goes, equally incurable. There is, however, occasionally occurring during the progress of constitutional syphilis, a very sudden affec- tion of both the eye and ear, quite transient in char- acter. It often disappears spontaneously, and is great- ly benefited by blisters. It is those affections only that are insidious in their approach that produce the most lasting derangement of these organs. The eye-lids also are affected with a very tedious in- flammation of a similar nature with that of the skin, having this difference peculiar to their structure, which around their edges are glandular. The reader will re- member, that it is the office of a gland to secrete or pro- duce from the blood something of a different nature from it. Now the lids secrete a mucus, of a bland and un- irritating character, to defend them from the acrimony of the tears, as they form a gutter, to convey the latter to the nostrils, through the minute holes at their junc- tion near the nose. This mucus becomes thick and gummy in its nature, and the eye-lids, unless anointed with some soothing unguent, are constantly sticking to- gether, to the great annoyance of the patient. The af- fection, however, in common with all others resulting from constitutional syphilis, can only be removed by sci- entific effort. " All within and without is corrupt." tAAPTER XI. V**EGULAR AITtl OCCASIONAL SYMPTOMS. There are a variety '. f annoyances still to be enu- merated, occasionally c %*' sequent on syphilis, amongst which the most frequent i« rheumatism. This is often most aggravating at night, and wreaks its peculiar ven- geance upon the shins and head, though other parts of the body are occasionally affected. It has been a ques- tion with the medical profession, how far this was due to the administration of meii eury, and how far to the disease. If the observations made by so many of our army and navy surgeons be t» le, that nodes and affec- tions of the investing membras./es of the bones, are most frequently to be found in those who have taken mercury, and not in others, it would setm to be due to the mer- cury ; for syphilitic rheumatism is undoubtedly often seated in these membranes : 3 et, as we said before, what then? will the patient run the risk of constitutional af- fections and destruction of his palate? for this is the only alternative:—fortunately, we are able to effect the greatest benefit, and often cure syphilitic rheumatism, with that invaluable medicine, the hydriodate of potass. How far the reasoning is correct of those who impute to mercury what may be due to the feeble powers of the system, remains to be proved. I have often seen 56 IRREGULAR SYMPTOMS. rheumatism in every respect similar to syphilis, where no mercury had been taken. A variety of local enlarge- ments occur in syphilis:—the scrotum is sometimes thus affected, and may be confounded with disease of the testicle: the opinion of an intelligent surgeon will best relieve the anxiety of the patient. No directions would avail him to form a correct one of his own. An affection may be engrafted upon this thickening of the skin, that will test the patience of both the at- tendant and patient: I allude to an ulcer attacking this part. Now it is generally known, that even if the spe- cific poison should be utterly removed from the system, still these local enlargements are so weakly organized, that if any sore attack them there is little tendency to heal; they resist treatment, and persist for so long a time, that the patient is seriously annoyed with ideas of cancer, and other grievous affections. After a trial of the most approved modern prescriptions, such as nitrate of silver, and rest; iodine ; Dupuytren's powder, &c, the writer does not hesitate to recommend excision of the skin, as the best means of simplifying the case ; but it must not be forgotten to communicate candidly to the patient that there may be difficulty in healing the wound itself, owing to the same cause that maintained the ulcer, viz: the weakness of the part; still I have sever- al times done it with success. Sleeplessness, and wast- ing of the body, with night sweats, are also occasional consequences of syphilis, and this will often induce the patient to enquire why he does not recover, " now he is cured of the specific disease." Alas, even in the height of vigour, the sun cannot set, but we are one day IRREGULAR SYMPTOMS. 57 nearer the grave ; what shall we then say of him, who has imbibed throughout his whole system a poison the most virulent 1 And will nature then resume her control, without her offended majesty complaining of the insult she has re- ceived, in her sanctuary 1 No; " the trail of the ser- pent is left over all," and the offender can only expiate his sin by doing penance, in all sincerity, at her sacred shrine. A long and tedious probation is before him, and the best advice we can offer, is, to select for his adviser a humane and conscientious surgeon, and follow his advice to the letter. CHAPTER XII. ARE THERE ANY PROOFS THAT THE DISEASE IS ERAD- ICATED FROM THE SYSTEM. And now, having enumerated the consequences of contracting the poison of syphilis, we will conclude the symptoms by a reference to a question always put to the surgeon in protracted and obstinate cases. And it must be confessed that it would be very gratifying to our feel- ings, if we could answer with more certainty, as we could then guard against occasional results, most dis- tressing to the patient, and mortifying to the surgeon. We allude to its occasional re-appearance even years after a cure was supposed to have been effected, and when the patient either has or is about to contract mar- riage. How long then may the poison remain latent in the system, and what are the best presumptive signs of its presence ? The answer to this question may be dis- tinctly given. Syphilitic disease may and often does appear years after it was supposed to be eradicated, yet we are quite certain that the acute observer will frequently find marked symptoms of its existence in the system. To make this intelligible, we must recur to the manner in which we believe the poison to have first originated, for by it we think we can perfectly explain its appearance • PROOFS OF IMMUNITY. 59 it the most remote periods of its existence in the sys- tem. We believe it to be produced by a poisonous change of some matter secreted by the genital organs of either nex, produced by chemical (atmospheric) or constitution- al causes, aided by uniting with secretions from the gen- ital organs of the other, whether male or female, of a nature suitable for that purpose, though unknown to us. There is nothing whatever absurd or unreasonable in this. On the contrary, it is analogous to an immense number of chemical phenomena. Separate substances, whose elementary nature differs only in the proportions of their constituents, not only neutralize each other completely, the compound being totally inert when the separate articles would powerfully affect the economy of the system ; and, on the contrary, the union of other substances produce the most poisonous and deadly compounds, when they were separately known to be in- nocent. And now let us see the bearing of this analo- gy on the developement of syphilis. Firstly, there is, as we have seen, no positively certain time for the appearance of the chancre itself. Even six weeks will elapse before it appears. What is the reason for this ? It is unquestionably one of two things; either the poison was not sufficiently virulent or concen- trated, or the action or living force of resistance of the part to which it was applied, was sufficient to repel it, the poison merely waiting beneath the cuticle, till the system was in a proper state to absorb it, or to present to it some changed condition of the blood, calculated, by union with it, to develope the chancre. If this is fair reasoning, with regard to a primary 60 PROOFS OF IMMUNITY. symptom, why not to a secondary? And how much more forcible does even this appear, when we reflect upon those cases (rare, though certain) in which no chancre exists, the first evidence of infection appearing —without even a bubo—by an eruption over the body, or a sore throat. And again, add to this those cases in which bad chancres have disappeared at a very late pe- riod of their existence, either without any treatment at all, or at best very little, and mild in character, and not being followed by an eruption. The first evidently finds the circumstances congenial to its developement in the blood, though it had not suf- ficient power of itself to produce a primary sore. The second, with power enough to produce a chancre, and even a bubo, is not followed by a constitutional eruption,—proving satisfactorily that it was repelled by constitutional causes. Does not all this look as though the system would tolerate a certain amount of the syphilitic leaven, till constitutional changes favoured the production of some chemical principle, essential to its developement ? We think so. And here is the reason why we cannot give the patient positive assurance of immunity from subse- quent attack. We know not this principle, nor the causes of its production ; neither can we detect its pres- ence. Fortunately however, the acute observer can dis- cover its product, viz. certain symptoms, presently to be detailed, indicating its presence. And all our experi- ence goes to prove, that when the patient is subjected to a sufficient mercurial course, under appropriate regi men, he enjoys an almost certain immunity. PROOFS OF IMMUNITY. 61 It is, however, because of the immense prevalence of quackery, and the irregular use of remedies even in skilful hands, owing to the obstinacy and ignorance of patients, as well as medical incompetence, that we are often in doubt of immunity from re-attack: and we shall feel as though essential service had been rendered the profession, if this candid enumeration of the symp- toms and doubts attending syphilis, should arouse the attention of a tythe of the afflicted, to the insanity of tampering with these hydra headed monsters; we mean either the disease of syphilis, or quackery. When a surgeon is so unfortunate, as to receive a patient who has run the gauntlet of quackery, he is by no means likely to find him willing to submit to rational treatment: medicine, and probably mercury, is de- manded with importunity : this the surgeon cannot al- ways immediately grant, for he is not only entirely ignorant of the quantity and effect of what was previ- ously given, but he cannot possibly separate the mental annoyance, which is astonishingly great in these cases, from the effects of the medicine given by the quack. Should the patient be determined on immediate med- ication, we know of no method to control him but by placebos the most important, and we speak it with all possible sincerity, should be given by the patient to the surgeon, its operation being not immediately medicinal, but moral and reflex in character; it operates mentally upon both patient and surgeon, teaching the former to value and obey, and the latter that his prescriptions and advice are desirable, because they are payed for. After this preliminary, with a proper amount of 6 62 PROOFS OF IMMUNITY. knowledge and self-confidence, the surgeon may receive enough respect, to observe carefully, without medication for a week or so, his patient's case, and then he will be able to detect, should latent disease exist, some symp- toms of its presence ; either an acceleration of pulse, sleeplessness, flying and rheumatic pains, and swellings, or some other symptom upon which he can found a ra- tional prescription. In short, if the patient applies to a regular surgeon, after beginning to entertain doubts of quackery, it is generally the surgeon's own want of knowledge either of his profession or of human nature, if he does not obtain a chance to benefit him: we would merely suggest, that to a patient thus situated, the sur- geon will probably administer in some form, that inval- uable medicine the hydriodate of potass, the chances of benefit being almost certain, even should more mercury subsequently be necessary. Those formidable and awful affections, wherein the bones, especially those of the skull are attacked by the disease, and exfoliate, laying bare the brain itself, are now almost exclusively managed by this admirable medicine, and cases now recover under its influence, that were but a few years since inevitably fatal. One other question is often asked of the surgeon, of great in- terest to the patient, and although we are in the habit of answering it emphatically in the negative, other points of great interest, completely contradicting the supposed notion that secondary symptoms are incommunicable, are connected with it. CHAPTER XIII. COMMUNICABLE TO THE CHILD BEFORE BIRTH. Can syphilis be communicated to a female, when there is no sore on the genital organs, or hidden within the urethra ? we say it cannot. Yet it can, and often is, communicated by means of the semen, to the child begotten by a syphilitic person, without affecting the mother in the slightest degree ; does not this, again, prove that the poison can only be developed when it finds a congenial and co-operative agent, and that, too, of a fluid character, to assist its progress. The reader will observe, it is only known to exist in the father by his past history ; for he has no eruption, or perhaps no other appreciable symptoms, existing at the time the child is begotten ; he does not communicate it to the mother, and the child itself is born with a constitutional eruption, and unless mercury is given, will die of syph- ilis. Why do not these symptoms exist in the father in all cases ? because the co-operating agent is not there, in a degree sufficient to cause its developement: the same agent that may subsequently exist, and cover the father with a constitutional eruption. How do these ulcers in the child's mouth communi- cate the disease to the mother's nipple, themselves being 64 COMMUNICABLE TO THE CHILD secondary or constitutional symptoms, nay, deriving their existence from the comparatively remote source of the semen of the father ? The reader will remem- ber, that in the first chapter we promulgated the idea so reconcileable to prima-facie evidence, that the mucous membranes were the natural locahty for the original production of the syphilitic poison, and we now throw out another, viz., although the discharges from constitu- tional eruptions of the skin, and syphilitic ulcers, will not produce a chancre or other syphilitic affection, if inoc- ulated, that they would do so in the mouth, (though it is said, and we do not believe, though we cannot contra- dict it,) that they will not inoculate the mucous mem- brane of the genital organs. Certain it is, that the poison flowing through the blood of the child, however attenuated and removed from its original source, the father, must find something very congenial and co-operative in the mucous mem- brane of the child's mouth, before it could so far add to its own virulence as to communicate the disease by sucking to its mother's nipple ; thus proving it to be equal in power, so far as its powers of propagation ex- tend, to the original poison of a chancre. Does not this fact, also, strongly corroborate our theory of the original production of the syphilitic poison. We advanced the idea that it was the union of some other irritating discharge, that might not by itself alone produce syphilis, yet when joined with the altered secre- tions of the female, be adequate to that end. Now the other constitutional symptoms of the infant or adult, it would seem, from the united testimony of all authors, BEFORE RIRTII. 65 will not inoculate an uninfected person. Yet the ulcer- ation of the child's mouth not only produces ulceration of the nipples, but the whole train of symptoms belong- ing to the disease? The mouth then of the infant (a mucous membrane) must furnish the necessary adjunct to produce the infecting poison. And the nipple being also covered with a mucous membrane and erectile tissue very similar in structure with the glans or end of the penis, as well as certain parts of the female or- gans, again furnishes the necessary conjunction of parts suitable by their structure for its propagation. That the child may be infected in the womb, is now universally admitted. We have several times examined the bodies of children born prematurely, and covered with the eruption ; indeed it is usually the cause of mis- carriage with prostitutes, when it comes on without arti- ficial aid. There is no doubt, and again the author's own experience is corroborated by the learned medical testimony of the profession, that very many instances of repeated miscarriage are consequent upon irregulari- ties of life in the husband. Several times we have been called upon to investigate these cases, and have found sufficient reason, upon a severe cross-questioning of the patient, to suspect a syphilitic taint. The careful administration of mercurial remedies has proved, by the subsequent birth of healthy offspring, that our suspicions were well founded. The reader will observe that in these cases, it is not necessary that the mother should be affected in the slightest degree. The poison is undoubtedly transmitted by the semen ; yet when there is reason to believe the child of which the 6* 66 COMMUNICABLE TO THE cniLD mother is pregnant is infected, and of this we are to judge by the history of the father's symptoms, and by previous miscarriages, if any have occurred, a cure of the child in utero may be effected by administering mercury to the mother. Among the variety of interesting cases of this kind, for which we have been called upon to pre scribe, one was peculiarly gratifying, and caused us to regret most keenly the errors of more youthful practice. A gentleman, a school-mate of our own, professedly, and we believe sincerely pious, married in his fortieth year a lady of great wealth and intelligence, nearly his own age. No less than seven miscarriages occurred in rapid succession between the third and fourth month, though the lady, from moral and physical training, was the last person in whom such misfortunes would be looked for. She belonged to one of our Knickerbocker families, and was perfectly healthy in mind and body, and sincerely desirous to have children. Our friend, who had always employed an estimable member of his own church, had sufficient intelligence and candour to say, upon a professional visit, that, suspecting the cause of his misfortunes, he had called upon us, because he fear- ed to confess his youthful errors to a brother-christian, and knowing we made no professions, and our long friendship, had concluded to make a clean breast of it. He had twice been affected in his early youth, and al- though he believed himself thoroughly cured, had im- bibed some doubt from a medical book accidentally falling into his hands. On questioning him, I found him the subject of frequent slight febrile attacks, and sleepless nights, together with occasional efflorescence BEFORE BIRTH. 67 or redness of the throat, with much difficulty of breath- ing, and rheumatic affection. In short, I found suffi- cient reason to treat him for latent syphilis, and had the gratification to see him the father of two healthy children.* These cases are very frequent, and it becomes the surgeon to use the sagacity of an Indian, to elicit the truth in some of them, particularly where there is not much intelligence. It is quite surprising to know how extensively falsehood is used, when communicating with the family attendant, of whom there is always more or less fear in these cases, especially if he has been intro- duced by the wife's relatives. Upon more than one oc- casion I have had this admitted to me by patients, with- out the slightest idea of its folly or impropriety. But are we to suspect the husband only ? I fear not. Concealment, either from ignorance or design, is often found in the other sex. Not long since a friend related to me the following case :—A lady, in most respectable life, asked his advice respecting a rheumatic affection, accompanied with swelling just below the right knee. My friend knowing a separation had occurred between the patient and her husband, suspected its possible na- ture, and on inquiry, found that syphilitic disease had been communicated years before. The lady not dream- ing of any connection between the existing symptom and previous disease, was inexpressibly shocked, but * The children in these cases have an appearance of premature old age, with wrinkled skin, and copper coloured spots about the anus and other contiguous parts : sometimes the eruption is general. 68 COMMUNICABLE TO THE CHILD wisely submitted to appropriate remedies, and was cured. This, of course, was ignorance on the part of the patient. A far more delicate state of things exists, when the wife conceals from her husband and physician, the pos- sibility of an affection before marriage. Even this, and that too in apparently respectable life, is occasionally brought under the notice of the surgeon ; and although we ought at all times to let the deportment and connex- ions of a patient have their due weight, we should not recognize the impossibility of syphilitic taint, from any such circumstances. The surgeon is to remember that the strongest possible motives are here existing for his patient to deceive him. In two instances I have suffer- ed my patients distinctly to understand, that I should use treatment predicated upon the supposition of sy- philis existing, and although they had just before made the strongest asseveration of its utter impossibility, no objection was made to the medicine. I required no stronger assurance that they knew my impression to be well founded. The idea has been thrown out, of the possibility of infection from sources such as the ordinary and natural mucous secretions of a syphilitic person who had no ul- ceration whatever ; I now mean years after the prima- ry disease, the patient having only the latent taint in the blood. This, it will suffice to say, we do not believe; and indeed the idea is not now entertained by practical men. Though it is communicated to the infant by the father, and may, as we have seen, reach the innocent BEFORE BIRTH. 69 mother, by the nipples, it cannot be communicated to the mother without ulceration of the genital organ of the father, or direct application of the matter of a chancre or bubo, by some less probable method. CHAPTER XIV. TREATMENT OF SYPHILIS. After the explicit announcement in the preface on the absurdity of self-treatment, it will hardly be sup- posed that we intend to give any directions for that pur- pose. Our object, the discrimination and avoidance of quackery, would not be attained without giving the non-professional reader a general idea of the treatment in use by professional men. Mercury, in some of its forms, is the only medicine on which reliance may be placed, and the averment of all who promise to cure by any other means, may, in the present state of practice, be taken as evidence of quackery. We now allude to all cases in which it has not previously been given, either by the quack or reg- ular surgeon ; for we are Avell aware of the existence of disease, itself caused by the injudicious use of mercury, and that too in syphilis. In these cases, tonic medi- cines, of which the hydriodate of potass and the iodide of iron, may be said to rank highest, are indispensable; and whether mercury be resumed at a more auspicious period, when the tonics have rendered the system able to bear it, must depend entirely upon the good sense of the practitioner. In a word, we fully coincide with the sentiments of TREATMENT OF SYPHILIS. 71 a large portion of the most intelligent surgeons, that mercury, in uncomplicated cases of syphilis, is a spe- cific ;—nay more, that it operates by actually neutraliz- ing the poison, directly upon coming in contact there- with. Here we have the high authority of Mr. Bell, who entertains this view. And we really think the evi- dence would long since have been deemed conclusive, could the learned cobwebs, by any possibility, have been swept away from the brains of some of our most wordy authors. The ideas entertained of its curative action, such as its operation as a counter irritant, and an evacuant, may soon be disposed of. The former supposed it to ob- literate the disease, by establishing another irritation or disease, peculiar to itself. There was an idea formerly almost universally prevalent—that two diseases could not exist, at the same time, in the human system. This is now not only known to be incorrect, but, the reader will perceive, it leaves the poison to be got rid of, entire- ly by the effort of nature: and this, although it cer- tainly has occurred where no treatment was used, would in an infinite majority of cases, as all experience proves, subject the patient to a sore throat, and constitutional eruption; symptoms that often occur, even when mer- cury has been given, but either insufficient in quantity, or too rapidly. The idea that mercury operates by its powers as an evacuant, in the natural excretory organs, as the bow- els, bladder, skin, and salivary glands, was natural enough when physicians talked about the necessity of salivation in all cases, and that it was necessary that the 72 TREATMENT OF SYPHILIS. mouth, as well as all the other passages of the body, " should run like a river." This is now reprobated by all intelUgent men. Salivation is never necessary, and when it does accidentally occur, owing to the impru- dence of either surgeon or patient, 'tis a great misfor- tune, and always does mischief. How odd it is, that those who held to the doctrine that the poison must "be run out of the body," did not reflect, that as it plainly showed its wonderful power of infecting, by poisoning the whole mass of the blood, although it was a mere atom when first applied to the genital organs, it would be necessary for all the blood to be removed from the in- dividual affected, and an entire new stock supplied- And again, every one knows that mercury operates most effectually when it produces the least disturbance of any kind in the constitution. An expression often used by practical surgeons is, " he tolerates mercury well, and will do well enough," shows the sentiment now universally held by them. The inability to distinguish scurvy and the mercurial erythema, would undoubtedly be a great misfortune for the patient, should he be so unfortunate as to fall into the hands of an inexperienced surgeon. As it is not our purpose to extend this volume beyond the import of its title, we must refer the medical reader to the works of Messrs. Abernethy, Alley, and Mathias, as they con- tain all that is worth reading on the subject. It is scarcely necessary to reason on the manner in which mercury cures syphilis ; yet we cannot forbear noticing two points, that seem to us rather unanswera- ble, as to its specific and neutralizing power. The TREATMENT OF SYPHILIS. 73 first is this—that according to the old method of curing bubos, or in other words syphilis, for the reader knows that the bubo, when it exists, is the store house whence the poison is to go into the blood, mercury was rubbed into the absorbents on the front of the thigh, and these very vessels form the bubo. Now this often melted away the enlarged gland, and they heard no more of the poison,—no, not even when they gave no mercury by the mouth. No evacuations of any kind were pro- duced, and no effect, save the disappearance of the bubo, which we know often produces the whole train of symptoms, and, in our experience, without mercury is given, always ends by the formation of matter. By what agency then, did the mercury resolve these bubos? No visible effect—no matter—and yet a complete sub- sidence of the bubo. We leave others to theorize ; we are content to view it as a neutralizing agent. The next point is, that its most beneficial effect is produced when it produces no visible disturbance; in- deed, we need not always expect to see the slightest redness of the gums, and yet the severest constitutional affections disappear ; its action here is equally conclu- sive as in bubo; according to our limited capacity, it must be specific or neutralizing. The non-mercurial treatment of syphilis, is adorned with names so distinguished in the annals of hospital surgery, both here and in Europe, that it would ill be- come us to pass it without notice; and yet it is only our purpose to remark, that although there is undoubted evidence, to show that syphilis has disappeared without the administration of mercury, when the patient has 7 74 TREATMENT OF SYPHILIS. submitted from the beginning to rigid control in his gen eral regimen, still a very large proportion of these pa- tients had secondary symptoms ; and that is what pa- tients, such as present themselves to us in the latitude of New-York, are very unwilling to endure. Moreover, from the discursive and migratory habits of hospital patients generally, the gentlemen who made those experiments, could not have had the opportunity of knowing in how many the disease returned, after the cure was supposed to have been effected. There can be no doubt of the expediency of administering mercury in some form, as the best and only certain means of cure. There are a variety of wonderful decoctions, in old authors, and some of them have found their way into the hands of quacks, and are heralded as " certain cures without mercury:" these originated at a time, when the process of cure was entirely conducted without mercury. This remedy was introduced in 1516. I believe that I utter the sentiment of the entire profession in this city, in saying that all who recovered, escaped the disease by the powers of nature alone; nothing then used, could have effected anything in curing the disease: very possibly some of them had a partial effect in sup- porting the system, but as to curative power they were utterly inert. Some of these compounds could almost shame the witches in Macbeth for the meagerness of their inven- tion : true, we do not read of " eye of newt, or toe of frog," nor " liver of blaspheming jew," but the whole vegetable kingdom was ransacked, to " make the hell- TREATMENT OF SYPHILIS. 75 broth thick and slab," and heaven help the poor wretch- es, who even now are doomed by quacks to swallow such messes. As for ointments, the " unguentum apostolorum," so called because it contained twelve in- gredients, was quite a small affair to some that are gravely set forth as working wonders: indeed, it would be time lost to attempt an enumeration of these worth- less compounds : air, earth, and ocean, were ransacked to find them, and there can be no doubt that nature was greatly impeded in her effort to cure, and thousands were sacrificed at the shrine of quackery. Would to God it had ceased with those times. There are some hundreds of mercurial preparations, yet it is now well known, that but two or three merit the attention of the practitioner, either for uniformity of action or efficiency in small quantity ; a most import- ant quality, as some stomachs are so intolerant of mercury, as to be unable to bear it at all, compelling us to introduce it by the absorbents, or rubbing it through the skin. There is also a method of introducing it through the skin in the form of vapour, by enclosing the body of the patient either in a box or tent, and suffering the head to project; then burning a preparation of mercury with- in it, on live coals: this method is now seldom used, as few patients will submit to the necessary trouble of ar- ranging the apparatus, yet it has the advantage of act- ing with great rapidity, and is useful when imminent danger threatens the palate with ulceration ; it some- times checks this symptom very rapidly. This method was proposed in 1776, by the Chevalier Lalouette of 76 TREATMENT OF SYPHILIS. Paris, and was strongly supported by Mr. Abernethy of London. The writer has found it of great use in stubborn local ulcers, that evince a very slow disposition to heal, even when the constitution is under the action of mercury ; in these cases it is an admirable adjunct, but is now seldom used in this city as a means of mer- curializing the system. The means used by the author of thus applying it, consists of a small tight tin closet about a foot square, containing room for a chafing dish of coals, on which a few grains of the red sulphuret of quicksilver is sprin- kled ; the fumes are directed to the sore by means of a flexible tube, its sides being held apart by a spiral wire; the mouth of this encircles the sore, resting upon the surrounding skin. We never apply this method to the body generally, unless the eruption is uncommonly ob stinate and extensive ; it should be used sparingly al ways, as it is impossible to estimate its effect, when used in conjunction with the internal administration of mercury. We have mentioned this method first, not because it is the most, but the least important. The two meth- ods most in use, are inunction, or rubbing mercurial ointment through the skin, and the administration by the .nouth. Inunction has the great advantage of producing the least disturbance. As it does not go into the stomach and bowels, it can produce no disturbance of them, un- less very long continued, or used in too great, quantity, when it may affect them secondarily. This is the old- est method of cure. TREATMENT OF SYPHILIS. 77 The objection to it is, that it is more troublesome, and as very few will submit to confinement: in the great majority of cases, having no eruption, they insist upon going about, and taking medicine by the mouth. When the method is adopted, a scruple of the mild mercurial ointment is to be rubbed into the front of the thigh, twice or thrice a day. It should always be done by the patient himself, as any other person would render him- self liable to salivation, by absorbing the ointment through the skin of the hands. It acts with more cer- tainty, if during the process the patient be kept in a per- fectly equal and mild temperature. The front of the thigh is chosen, not only from its facility of access, but from the fact of the absorbents passing directly into the bubo, should there happen to be one, thus curing it at once. It occasionally happens, that the friction itself pro- duces a bubo, should there be no chancre, that having been previously cured, and the ointment being used for constitutional symptoms. The patient will remember, that this bubo cannot be syphilitic. It is only sympa- thetic, as surgeons say, or in other words, produced by irritation, as when it occurs from a wound of the toe or foot, and also, as the reader will see, in gonorr- hea. They rarely suppurate, and will subside on leav- ing off the frictions, using the other thigh, or the arms for that purpose. From three to five weeks may be re- quired in this process of cure, the surgeon not deem- ing it expedient to risk the re-appearance of the dis- ease, with less application of the means. During the use of inunction, no other means should 7* 78 TREATMENT OF SYPHILIS. be used, as it would otherwise be impossible to estimate the amount of mercuiy introduced, and a distressing salivation might be the consequence. The surgeon will be governed in the length of time for using it, entirely by the appearance of the constitutional eruption, or bubo, for which it is used. It shows its action by ten- derness of the gums, and metallic taste in the mouth, and should then be discontinued for a while at least, to be resumed should the symptoms warrant it. When the method of medication, by inward use is adopted, the preparations most in use are the Pill. Mass. Hydrarg., Hydrarg. Chlorid. Mite., or the Hydrarg. Chlorid. Corrosiv. of the United States Pharmacopeia. The intelligent reader will at once see the impropriety of being more explicit, in a work designed for popular instruction. Though he would make no improper use of a more distinct announcement, there are many who would, and thus great mischief would ensue. So far as the opinion of the author goes, he is at a loss to give one the preference over the other. If there be any dif- ference, the first is the mildest, the second less mild, and the third the most active. They all require to be combined with a small quantity of opium, when used in the customary doses, always chosen when constitu- tional effects are designed. The pills of the last are much the smallest; probably for that reason it is most used in this city. The follow- ing formula is added for the professional reader : R. Hydrararg. Chlor. Corrosiv. Muriatis Ammon—aa—gr. xv. Aq. Distillat vel. font—3iss—solut. addo. TREATMENT OP SYPHILIS. 79 Panis Medul. sic.—q. s. Ut. fiat—Mass. in pill cxx. dividenda. These may be given according to the intensity of the constitutional affection twice or thrice a day. Should they evince a tendency to irritate the bowels, a pill of one-fourth of a grain of opium may occasionally be given. The other two preparations may be used in the ordinary doses, with which every practitioner is familiar. I shall say very little of local applications, because I have very little confidence in any great variety. Greasy dressings are for the most part injurious. The ni- trate of silver, sulphate of copper, and dry cantharides, with the black, and yellow wash, or dry calomel, will effect all the practitioner can desire,—the former either as a corrosive or stimulating agent, and the others either as stimulants or alteratives. The writer uses the nitrate almost exclusively for all these purposes, governing the strength of the application by the effect intended, whe- ther on chancre, ulcer, or bubo. I have said nothing as yet on the treatment of what are called tertiary symptoms. These consist of all those enumerated after the affections of the skin and throat. Although this is strictly the professional meaning, the popular one may be said to be, the persisting symp- toms—I mean all those occurring after treatment, regu- lar or empyrical, has either ceased, or ought to have ceased. If I were to state the sentiments of the most thought- ful and observant of the profession, I should say that it is impossible to separate the symptoms of this stage from 80 TREATMENT OP SYPHILIS. the specific effects of the disease and the mercury; and I most candidly add, that these are my own views, not- withstanding the freedom with which I have asserted that mercury is a necessary, nay, an utterly indispensa- ble medicine in its treatment. A man can only be answerable for his own errors; and I look back with regret upon many that 1 have com- mitted, in prescribing for syphilitic patients by rule, as promulgated in our colleges. There is no rule by which every man is to be treated. Like the varied powers of resistance in the substances surrounding us, every man has his capacity to resist disease for a certain time. Would to God he had equal capacity to resist bad treat- ment. Yet nature, more merciful than the quack, even in the infliction of evils, does it after a plan,—some warning is given by which to avoid them, if a proper use of the senses are made. Not so with the medicine giver. He has but one rule, which may thus be rendered: " If a little is serviceable, a great deal is more so." All temperaments are alike to him. The great mass of animal life, that lives but to eat and sleep, who has no thought for the morrow, and the poor attenuated bundle of nerves, whose every day brings its burden of care and sorrow,—the broken down libertine, the delicate and scrofulous youth,—all are subjected to the same indiscriminate and powerful me- dication, and for an equal length of time. Mercury is it- self a most potent irritant, as is evinced by the nervous agitation, the sleeplessness, the thready pulse, that fol- lows its continued use. Yet this is no caution to the quack,—he goes on until the energies of the system are TREATMENT OP SYPHILIS. 61 completely prostrated, and either actual mercurial dis- ease shall supervene, or in the end, the whole train of calamities, succeeded by exfoliation of the bones, takes place. It is under these circumstances that the great gift of chemistry to medicine, the hydriodate of potass, will effect the most extraordinary benefit. And the practi- tioner who becomes early convinced of this will be most likely to save his patient from a loathsome and linger- ing death. Whilst treating this subject, it will be observed we have made no especial reference to the female. There is no necessity for any difference in treatment, with the exception of the mode of examination and the applica- tion of remedies. This must be done entirely through the medium of the speculum, to all chancres within the vagina. The most difficult cases, and it is very com- mon to find them, are met with where chancres exist on the neck of the womb. And as practitioners generally will not take the trouble, and many are without the neces- sary instruments for examination, these prove exceed- ingly obstinate, and long resist constitutional treatment. The warmth and moisture of the part is the great cause of this. They require additional stimulus to overcome the relaxing effects of their position. The nitrate of silver will effect the most rapid and favourable change. The writer hopes he will be excused for his attach- ment to a bantling of his own. He cannot here avoid saying what has been said in a manner far more grati- fying to his feelings by others: that the speculum invented and described by him in Vol. xxx. No. 1, of 82 TREATMENT OP SYPHILIS. the Boston Medical and Surgical Journal, is the most efficient instrument, and can be applied without the slightest pain to the most delicate female. CHAPTER XV. ON THE DURATION OF A MERCURIAL COURSE. It will doubtless be expected that something should be said upon the amount of mercury to be given: noth- ing could be more gratifying to the feelings of every man who has a proper estimate of professional truth, than to be able to say in the infinite variety of condi- tions, in which he is compelled to use this powerful article, when it has effected its entire object; when the last particle of the poison was thoroughly extinguished, and a certain immunity produced. His professional experience is constanly teaching him, that errors are committed by his patient in his general regimen; no matter how strictly he may lay his injunctions, his best efforts are constantly thwarted by his patient's folly, and his skill and anxiety set at naught. Whatever the method by which mercury actually cures syphilis, all agree that it produces its happiest effect, under the most quiet and equable regimen; whether the delicacy of our patient demand the simulta- neous use of tonics and nourishing food, or his vigour and plethora compel us to adopt the severer rules of diatetics ; hence it is that even in the latter case, we are to effect by the strictest injunction of the simplest diet, that reduction of the inflammatory state of the system, 84 ON THE DURATION OP we could not venture to produce by the more violent means of the lancet or purgatives : for the moment we use either of these, during the mercurial course, we ren- der him liable, by disturbing the mucous membrane of the stomach and bowels, to the rapid absorption of the med- icine, and immediate salivation: this it is by no means desirable to do : nay, as we have said before, it is a great misfortune. We seek to introduce the medicine with the least pos- sible disturbance, and to make our patient " tolerate it" till the subsidence of the constitutional symptom for which it is given, shall show that it has quietly effected its end; when this has occurred, whether for a bubo, a general eruption, or sore throat, the prudent surgeon will not immediately discontinue entirely its use, but watching most carefully the gums, and being emphatic with his patient on the subject of dress, reduce the quantity one- half, and if he bears it well, continue for a fortnight longer. This is the way to avoid the re-appearance of consti- tutional symptoms, notwithstanding the occasional re- marks of the designing and ignorant, either in or out of the profession. I am perfectly willing to say, that in earlier professional life I often erred from my apprehen- sions of mercury; that apprehension still continues : for I well know its danger, from the excessive irregularity of young men in everything that relates to a rational and philosophical mode of life: and I also know the fre- quency with which they visit the consequences of their errors upon their surgeon : all this produces no effect upon the man who means to exercise his best efforts for A MERCURIAL COURSE. 85 his own reputation, and his patient's benefit. The sur- geon should tell his patient honestly the effect of mid- night debauchery and absurd dress, and then constantly remind him of it roundly, regardless of his feelings: there is no room for feeling in the matter; it is the ex- ercise of judgment and common sense that is wanting, and no man should permit his patient to trifle with his reputation, whatever he may do with his own health. A patient who is taking mercury and pursuing his ordinary avocations, should exercise such precautions in dress, as to ensure a perfectly comfortable state of the skin at all times ; with the exception of the months from the conclusion of May till the first of October, this can- not be done in our climate, without flannel worn either next the skin, or thin muslin (never linen) intervening. The feet must be protected entirely from dampness, and all drafts of air must be avoided. The diet must be perfectly regular: every young man of common sense knows what will derange his own pe- culiar system ; this he must avoid, whatever the induce- ment to indulge, for if it derange the stomach and bow- els, there must be derangement in the action of the medicine. From four to six weeks will usually effect the disappearance of most constitutional symptoms in first cases ; but where a patient has been often affected, and more especially if he should have disease of the bones, there can be no rule whatever, as to the time it will take to remove the symptoms : he should present himself occasionally during some weeks after his treat- ment is discontinued, and his physician will then be able to anticipate evil, if any should threaten. This is all 8 86 ON THE DURATION OF that can with any propriety be said on the subject of treatment, in a volume like this ; more, the true physi- cian does not need : he has his authorities, to whom he can refer with confidence, whilst his own practical ex- perience is sufficient to guide him to avoid error. We trust enough has been said to enable the patient to avoid the quack as he would a pestilence. In reviewing the horrors of this dreadful disease, it would seem as though the author of existence had inter- posed it between the passions of man, and the certainty of her end being foiled by promiscuous intercourse of the sexes; what would be the result were it not so 1 How many of the human family, with the fiercest of all passions raging in their breasts, and their impulses un- restrained by religion or philosophy, would be desolating the happiness of millions of delicate beings, whose phys- ical structure demands the aid of manhood to sustain her, and enable her to endure the ills attendant upon her peculiar position in life, without the necessity of la- bouring for bread to feed the unconscious child, that would add so largely to her misery. What a fearful in- centive to crime ! Can it be supposed that the guilty beings, who would thus bring children into the world, would desire the continued existence of the little gentle things, who can only repay a mother's love by the sweet smile of infantile innocence ? No! they would curse the innocent creatures who stood in the way of their vo- cation, and ere long, if not by neglect, would effect their death by more horrid means. Wisely indeed have the medico-legal jurists of Ger- many, when called on to investigate a case of infanti- A MERCURIAL COURSE. 87 cide, agreed to receive the proof of a mother's not hav- ing provided clothes for her expected offspring, as strong evidence of her participation in its death. The birds of the air, the beasts of the field, all show this predomi- nant law of nature, by providing shelter for their young, and the inference is wisely drawn by medico-legal wri- ters, that inattention to so universal an instinct, is prima facie evidence of guilt. A minor degree of this passion, according to the con- stitution of nature, must ever exist with those whose physical strength is brought into requisition for the pro- tection of their offspring; and I cannot withhold my opinion, that the man who voluntarily withdraws him- self from the society of the sex who still retain the dig- nity and sanctity of virtue, and prostitutes the gentler affections of his nature at the shrine of the harlot, gives to the world the most palpable evidence of a total absence of virtue, and all the graces and poetry of manhood. ON GO NORRHE A. CHAPTER I. GONORRHEA. The mucous membrance that lines the cavity of the nose, mouth, and lungs, is liable, as the reader well knows, to a species of disease derived from changes in the atmosphere, called catarrh, or a cold : it is charac- terized by a discharge of mucus and matter, of various degrees of consistence, and after continuing an indefi- nite time disappears by the powers of nature alone. In like manner the mucous membrane of the bladder and private parts of both sexes, which is precisely simi- lar in structure to that of the mouth and lungs, is sub- ject to inflammation from various causes, folkrwed by effects precisely similar, although from the stimulating and acrid nature of the urine, and the different functions of the parts, the disease rarely terminates favourably without active medical aid. This is often called catarrh of the bladder. By far the most frequent cause, however, of inflam-1" mation of the mucous membrane of the genital organs, is, the application of the specific matter of gonorrhea, occurring in coition ; we have made the comparison to the lungs, because it will give the reader a very accu- rate and familiar illustration of its general nature, and ^reatly aid us in our explanation of the principal symp- 92 GONORRHEA. torn, viz : the discharge of quantities of matter without ulceration. We know no more of the origin of gonor- rhea, than of syphilis: it has attracted less investigation, because it does not affect the system so seriously as syphilis ; nor do those loathsome affections of the bones, nor ulcerations and eruptions, follow it; neither can it be transmitted to posterity, even if existing at the time of their pro-creation ; in short, it is confined entirely to the genital organs, and does not affect the blood, though it is highly contagious. As to the period of its origin, we have nothing definite in the books, beyond the time of Moses: see Leviticus, chap. xv.: the same reasoningwith regard to the manner, will doubtless apply to both dis- eases : that it should differ entirely in its nature, is just as natural as that the same earth should produce different products. It is, when we consider the wide difference in the symptoms and effects of the two diseases, it is almost in- explicable that they should ever have been supposed iden- tical ; and it is still more astonishing that so great a man as John Hunter, should have held this doctrine. The one almost invariably proceeding to the affection of the constitution, unless checked by the use of mercury, the other never requiring it, and never producing constitu- tional affections that would not disappear without any treatment whatever. The chancre almost invariably producing its like, and the discharge from gonorrhea never producing chancre, but a similar affection to it- self. The occasional appearance of chancre in those who have gonorrhea is now completely accounted for by the frequent existence of both diseases at once; and GONORRHEA. 93 the chancre concealed within the urethra or vagina, ac- counts for constitutional symptoms in those supposed to have only gonorrhea. The appearance of bubos, as well as slight constitutional eruptions, may easily be known not to be syphilitic by their sudden disap- pearance without treatment, an event rarely occurring in syphilis. Finally, should not the two diseases, if identical, have been constantly merging into one an- other, so that it would have been impossible to form any judgment respecting their treatment or progress? Yet even this was supposed to occur, for it was a common impression that gonorrhea suddenly checked would produce syphilis, and mercury was given for both. The reader must likewise remember,that as there is no definite period after coition for the occurrence of chancre or gonorrhea, the one may supervene unexpectedly up- on the other, the contagious matter existing, but from some unknown cause not being lighted into action, both the poisons being received at the same time : and again, the one poison may be received by a subsequent coition during the existence of the other. There is, as was re- marked when treating of chancre, a general excoriation of the glands occurring in gonorrhea, that to the inex- perienced looks like an extensive chancre ; it is the re- sult of great tenderness of the cuticle, causing the dis- charge of gonorrhea to prove more irritating than usual: this often causes unnecessary anxiety. The existence of gonorrhea and chancre simultaneous- ly, I have several times noticed, and known them, in one instance at least, to have been contracted from the same woman by two persons; and in another instance, one in- 94 GONORRHEA. dividual had gonorrhea, and the other chancre, though neither had connexion with any other woman for a long time previous ; both of these persons had been my pa- tients for a long time, and I had their entire confidence. Through the kindness of her attending surgeon, the writer satisfied himself of the existence of both diseases in this woman : a violent gonorrhea existed, and by the speculum we ascertained the presence of chancres on the neck of the womb. The remedies used in gonorrhea with success, have no effect whatever upon syphilis; and,mercurials, as they are used in the latter, do not benefit the former in the slightest degree. This, it seems to us, should be conclusive. The term gonorrhea, is derived from two Greek words, you^, the semen, and pe«, to flow; by which it appears to be decidedly incorrect, as there is no semen, but mucus and matter flovvingfrom the penis. Nevertheless, we shall retain that term as usage has sanctioned it. The disease is vulgarly called clap, from the old French word clapises, or houses of prostitution, occu- pied by single prostitutes. In French, it is also called chandpisse, from the scalding in passing water. In German, a tripper, from the dripping. Although the discharge called gonorrhea, does al- most invariably originate from direct contact with an in- fected person, still it may be produced by an altered se- cretion of the mucus membrane of the vagina, in per- sons who are perfectly virtuous. I have known several instances in which, from the character of the parties, there was no reason to suspect that the husband had re- GONORRHEA. 95 ceived the infection from any other source than a very bad leucorrheal discharge, existing in the wife. I am well aware of the necessary incredulity to be used in these matters, yet where I have had the entire confi- dence of both patients, I am quite satisfied of such a result being possible. Moreover, the idea is entertained by many experienced practitioners in this city, and is reconcilable to all analogy. Atmospheric causes will, I am also satisfied, produce a violent discharge from the urethra, accompanied with great scalding in passing water and chordee. Whether this will inoculate a healthy person with the same dis- ease, I am unable to say, as I have always urged cau- tion in those who were thus affected. 1 have several times been consulted by boatmen and raftmen, whose occupations exposed them to the weath- er, and who had certainly no moral reasons for con- cealment. They have had all the symptoms of clap, after long exposure to wet feet and cold weather. I know a gentleman in this city, who never gets wet feet without this result, and I have a most incredulous med- ical friend, who has another patient subject to the like annoyance. I would not be misunderstood. I believe that ninety nine out of a hundred claps originate in the legitimate way, and the more anxious my patient is to "convince me, as they often do attempt, that he got his disease in a privy, or in some other than the natural way, the more I am satisfied he endeavours to deceive me. Yet every man of experience can discriminate between these persons. I know cases in which I shotdd be sorry to 96 GONORRHEA. believe the most solemn asseveration of persons, whose word in trifling matters might be depended on. Yet where character is concerned they are not to be believ- ed, if interested in deceiving. Patients often take an unnecessary amount of trouble in these cases, for surgeons are the receivers of many secrets, and they generally keep them so long, that they forget where they are. There is no definite period after an impure connex- ion, for the discharge to show itself. A few hours, or six weeks may elapse, before the discharge appears. From the third to the eighth day is the most common period. Much depends upon the susceptibility of the patient's temperament, and his manner of living at the time. The first symptom that appears is uneasiness in the end of the penis, accompanied with perhaps the light- est redness, and difficulty in passing water, the stream being slightly contracted. There is no invariable col- our to the first discharge. It is often white, straw col- our, turbid, and rarely bloody. This is accompanied with tenderness upon touching the part immediately by the redness. These symptoms may be accompanied with scalding in urinating, or that symptom may be de- layed a day or two. The discharge comes not over an inch from the end of the penis. The writer cannot forbear expressing his surprise, that there should be any practitioners willing to pass by this stage with the trifling treatment often adopted. If there be any truth in practical experience, in nine cases out of ten, should the patient apply on the first or sec- GONORRHEA. 97 ond day, the disease may be at once arrested, and weeks of annoyance saved. An injection of from five to twenty grains of the nitrate, according to the physi- que of the'patient, and retained from one to five min- utes, will generally effect the cure. It should be in- troduced with the glass syringe, the fingers being pressed upon the urethra, two inches from the end of the penis. There is no doubt that the timidity of the practitioner often prevents the use of this remedy. I am happy to see, however, a greater distrust in medicine, and a growing reliance on local medication. In these cases we are not to ask the patient's advice) or to consult his wishes. We are to act for him. He knows nothing about the annoyance of a six weeks or three months' siege, and then a stricture to boot. The popu- lar notion that injections cause strictures, is well known by every practical man to be false. They prevent them, by rapidly curing the disease, and thus stopping the ef- fusion of lymph. I would not have it supposed that this powerful treat- ment is to be adopted without due attention to regimen. On the contrary, the physician must have entire control of the patient, if the radical cure is to be adopted. He must be directed to keep his chamber, and consent to live, for a few days, on six crackers and a glass of water per day. The circulation must be kept down, com- pletely, and in cold weather this is peculiarly necessary. Should the first injection prevent the passage of water for a few hours, it is of no consequence ; it will gradu- ally pass off. If on the second day after the use of the remedy, the discharge should be almost suppressed, it 9 98 GONORRHEA. may be again used, of half the strength first applied, and its further continuance will rarely be necessary. I have left it to the discretion of the practitioner, whether to use this injection of five or twenty grains. The effect, the reader may be assured, will prove most emphatically different, if used the full strength, and I do most cordially advise him not to meddle with it himself, as he might be grievously disappointed in the result. Temperament, and the period of the disease, is to gov- ern us entirely in its use. When we have the advan- tage of a patient who has had much experience in the use of remedies, we can profitably avail ourselves of it in conducting the treatment. A nervous temperament will be most sensibly impressed by the remedy, if used half the strength of a scruple, whilst a lymphatic one will easily bear that quantity. It is impossible to define the stages of gonorrhea by number of days. Should our attempt at a cure fail, or should the patient be submitted to no treatment, the second stage may appear after a week—rarely sooner. If the patient be fortunate enough to have the dis- charge checked, he is most distinctly to remember, that all kinds of liquor, hearty food, spices, chills, coition, and wet feet will, nine times out of ten, bring it on again, when the second stage will appear; but as that requires totally different treatment, we refer him to the next chapter. CHAPTER II. SECOND STAGE. We have proceeded so far upon the principle of en- tire control of our patient; nevertheless, we are well aware that this is rarely possible, the patient either be- ing compelled, or supposing himself to be obliged to attend his ordinary business. Still we should attempt the radical cure, as well as circumstances admit, and we shall often be successful. The second stage may be known by violent scalding in urinating, chordee, or a constant persistence in the penis to become erected, with partial inability, from the inflammation and construction of its lower part, and an increased and often profuse discharge of greenish mat- ter, often tinged with blood, coming from a much greater distance down the urethra. When this stage is fairly established, the matter comes from as far down as the scrotum, where there are some small glands that have ducts leading into the urethra. These often become en- larged, and may be felt outside the skin. There is more or less pain in the back and loins. It is the nat- ural tendency of this poison to extend along the lining and mucous membrane of the urethra, if no treatment is used. Those who are not familiar with practice of this 100 GONORRHEA. kind, occasionally find it convenient, for various rea- sons, ignorance perhaps, to say that injections aggra- vate these symptoms. So they undoubtedly would, if continued in this stage, but if applied for a radical cure, they never can, when used before there is much scald- ing. The analogy between the mucous membrane of the throat and penis, is perfect, and we all know that the pure nitrate is often applied, when local inflamma- tions are forming there, with the effect of stopping them immediately. The same practice applies to the eye, where the most violent inflammation—nay, that actually produced by the application of gonorrheal matter itself —is often at once obliterated by the same agent. In this stage injections of no kind are to be thought of. Stimulating ones would greatly aggravate the in- flammation, and increase all the bad symptoms ; and soothing ones, as they are called, are child's play,—they can do no possible good, and the irritation of the syringe will do harm. The whole body of the penis may be affected in this stage, and abscesses may even form. These should be opened, as soon as matter is detected, before they break into the urethra, as in that event, the urine would find its way into the substance of the penis, and produce dis- tressing results. Should the patient object to this, or the surgeon delay the puncture, the abscess may break both externally and internally, producing a disease we shall have occasion to speak of hereafter. Suffice it to say here, should this occur, it will so far emasculate the patient, as in all likelihood to hinder him from pro- creating. SECOND STAGE. 101 The first step to be taken in this stage, is to direct profound rest of body. The patient, if at all inclined to fulness, should be bled, decisively, and leeches ap- plied along the penis. The diet should be low. For the ardor urinae, or scalding, there is no remedy like the Liquor Potassav30 drops in half a tumbler of water twice or thrice a day, according to the urgency of the symptoms. In those whose habit of body, or constitutional affections, as of the lungs, &c, may ren- der bleeding improper, nauseating doses of antimony are useful. The antimony may be combined with salts, as an emetico cathartic, should purging be desirable. Some authors recommend blisters over the perinaeum. I have never tried them from a conviction that they must irritate excessively, and do harm; leeches are always preferable. Holding the penis in warm water is sometimes resorted to with partial relief of pain, which is the precursor of chordee. This symptom is often ex- cessively painful, and is the greatest evil the patient has to endure in gonorrhea. There is no remedy like laud- anum, fifty drops of which may be given by the mouth, and a pill of belladonna, hyosciamus, or camphor, de- posited in the rectum. The hyosciamus is often given by the mouth, but it requires caution, as it is poisonous. It should only be given by the physician. A laxative of oil will often benefit chordee. A symptom that astonishes and alarms the patient in this stage is, the abundant secretion of matter; he concludes that this implies disorganization or ulceration of the parts whence it comes ; but he has only to remember what profuse discharges of matter occur in ordinary catarrh, when 9* 102 GONORRHEA. extensively affecting the mucous membrane of the lungs; and where there is no disorganization, or death would often ensue, as in consumption, where there is destruc- tion of parts ; this matter is secreted or produced, by the mucous membrane of the lungs and penis, from the blood : there is no ulceration whatever, but simply in- flammation. After all the inflammatory symptoms are subdued, the remedies now most in use are the balsam co- paiba and cubebs. I shall say no more of their appli- cation here, as I shall have occasion to speak of them again ; whenever they are proper, they are always to be used in a similar manner. The patient will already ob- serve that although the blood is not poisoned in gonor- rhea, it is attended with far more distressing results, to his comfort at least, than most cases of syphilis: as a general rule, a practitioner would rather treat ten cases of syphilis, than one second, or subsequent stage of gonorrhea. CHAPTER III. THIRD STAGE. Authors frequently divide the remaining symptoms of the disease into two stages; but as they comprise af- fections of the bladder, and its appendages, exclusively, I shall include them in one. This stage commences when the inflammation has reached the lowest part of the urethra, just as it enters the bladder. Surrounding this part of that passage, and lying upon the bladder, in front of the anus, there is a gland of the size and shape of the largest chestnut, which has ten or twelve ducts opening into the urethra. On either side of it, lie the receptacles for the semen, each of which sends its own duct into the urethra, immediately in front of the prostate gland. It is the inflammation, extending through this gland, and thus irritating the neck of the bladder, that causes the distressing desire to pass water ; and because of its contiguity to the rectum, the irritation is extended to that, and the patient is constantly trying to pass the contents of the bowels, but is unable to effect it. This is called tenesmus. Nothing can be more distressing than the condition of one thus situated. From the bed to the stool, and back again, continually, often with constant pains and chordee. Ah me ! says he, if I ever 104 GONORRHEA. get in this way again ! He sends for his surgeon, and on his entrance of course complains bitterly. The sur- geon, having possibly left him comfortable, inquires what he has been eating. The reply is, "nothing," of course. Upon inquiry, systematically however, he had ventured to take a'glass of wine, or a little ale ! This is a common affair to the practical surgeon, and well does he know the trouble of disobedient patients. Those who are not familiar with these cases, proceed to make examinations, thrusting their finger into the rectum, to feel the prostate gland, and perhaps a catheter into the urethra, to draw off the water. God help the patient; 'tis all unnecessary. The practical man does no such thing, but bleeds his patient, unless there are good reasons to the contrary. If so, he ap- plies leeches plentifully, twenty or thirty at least, and half that number, if he does bleed, is good practice. Fifty drops of laudanum, in a wine glass full of warm water, may be thrown up the rectum, and if that will not stay, a pill of opium may be deposited there. This will control the tenesmus and chordee. I have often known this state of things brought on by pottering with injections. They are all wrong, whether astringent, emollient, or sedative. All the good that can possibly be done by injections, even theoretically, (we denounce the practice utterly in this stage) is much better effected by depositing them into the rectum. The mechanical irritation of the syringe is highly injurious, and the presence of the mildest injection likewise, and long before its sedative action commences it is expelled, from the annoyance of its distension. Those who wish THIRD STAGE. 105 to be doing something extra, and we know there are too many such, had much better envelope the penis in cloths wet with laudanum, or solution of belladonna. Injections in the urethra, in short, we deem utterly in- applicable to this stage, or any other, where the symp- toms of prostatic irritation, much scalding, or pain in the testicles prevail. The diet, in this condition of things, must be very light. Toast and tea, or rice, and a soft egg, and an oyster, without any butter or spice, is the highest nour- ishment admissable, until the urgent symptoms subside. I have no confidence whatever in what are called de- mulcent drinks, such as gum water, flax seed tea, de- coction of mallows, althea, Sec. It happens unfortunately in some scrofulous cases, that swelling of the prostate gland is very slow to sub- side, and it may remain permanently enlarged. The treatment adapted to these cases is very various, and cannot properly find a place here. It is observed that matter rarely forms in this part. Upon one occasion the writer was requested, by Dr. Bancker, of this city, to operate upon a patient, who had the most extensive disease, all centering here, he ever witnessed. No less than seven distinct sinuses, or false passages for urine, had been produced from the neck of the bladder, in consequence of obstruction in the gland. They were all laid open, and a cure was fortunately the result. We say fortunately, for in such an extensive affection, it was not reasonably to be expected. This case is re- ported at length in the Boston Medical and Surgical Journal. 106 GONORRHEA. There are several smaller glands lying near the urethra, in front of the prostate, called Cowper's glands, from the name of their discoverer. These are quite lia- ble to suppurate, and I have seen several instances where they made their way into the urethra, and also through the skin, thus forming that distressing state of things termed perineal fistula, or a false passage into the urethra, through which the urine passes, involunta- rily, whenever a call is made to expel the contents of the bladder. These may often be detected, by great care, before they burst into the urethra. By an external open- ing, the surgeon may save his patient great distress, and himself much mortification and blame. Although the subject of perineal fistula, and what is called infiltration of urine—that is, when there is an opening only into the urethra, letting the urine escape into the surrounding tissues, under the skin—is too ex- tensive to be minutely noticed here, our object would not be attained, without warning the patient of his dan- ger, should he be so unfortunate .as to fall into incom- petent hands. Firstly, then, to explain the cause concisely, there can be no such thing as an obstruction in the urethra, sufficient to stop the passage of urine, for more than a couple of days at furthest, without rendering the blad- der liable to give way, by inflammation causing its ulcer- ation. This may occur in any part of it. If the ob- struction exists in the course of the urethra, however near, as in Cowper's glands, for instance, scarce an inch from the cavity of the bladder, the urine, if it cannot pass, even drop by drop, and a catheter cannot be in- THIRD STAGE. 107 troduced, to draw it off by, will force its way through the urethra; or perhaps the little gland itself, as we have said, will suppurate and break, thus letting urine out of the urethra, into the loose connecting tissues under the external skin. If left here, it would cause extensive mortification, by its acrid nature. I have seen it left, and continue to accumulate, the obstruction remaining, from permanent stricture of the urethra, (see that chap- ter,) until it caused mortification of the skin all round the private parts, completely denuding the testicles. It should be freely opened, and as soon as possible a catheter, or flexible India-rubber tube, introduced into the urethra, through which the urine must pass whilst the fistula heals up. Yet this is a tedious affair, and it is often a long while before any kind of catheter will be borne, the urethra being so irritable and inflamed. It is the duty of the surgeon, if he cannot, by judi- cious treatment, or an operation upon the stricture, ob- tain a passage for the urine, and cannot pass the small- est gum elastic catheter, not to let his patient run the imminent danger to life incurred, by a rupture of the bladder, but rather to puncture this viscus through the rectum. This is not to be done until bleeding by the arm, leeches, the warm bath, copious doses of lauda- num, the muriated tincture of iron, and clysters of lau- danum have been tried, the choice of the remedies de- pending upon the nature of the obstruction. The professional reader will see, that these remedies are directed as much against spasmodic as inflamma- tory obstruction. Indeed, they always go together, and it is on this account that the tobacco enema has been 108 GONORRHEA. recommended by great surgeons. I have a horror of this, from having twice witnessed the near approach of death from its use, and cannot urge it, if the potent remedies, above enumerated, have been faithfully tried. I would not use it myself, nor permit it to be used in my own case. This is a view of the third stage of authors. The fourth is naturally connected with it. It may be known by the pain extending over the whole lower part of the abdomen, and constant and increased desire to pass water andfseces, with great quantities of slimy discharge from the bladder. This separates in time from the urine, and subsides to the bottom of the vessel. There is often intense pain in the end of the penis, and occa- sionally in the anus. Most of the treatment applicable to the last stage, is equally so to this. Opiate fomenta- tions, over the lower part of the abdomen, may be ad- ded, and gentle laxatives of castor oil. We have how- ever two admirable remedies, from the vegetable world, Uva Ursi, and Diosma Crenata. Equal parts of each may be infused in hot water, and when cold drunk occa- sionally, by the patient, a wine glass full of a strong de- coction every hour. This, with laudanum injections by the rectum, and profound rest, will soon relieve from the more urgent symptoms. After a few days' interval, the use of Balsam Copaiba may be tried. Yet I need not say so active a remedy, under such circumstances, should only be entrusted to professional hands. This medicine acts very favourable in producing tolerance of its contents by the bladder, yet I have observed that wheie the mucous membrane THIRD STAGE. 109 of this organ has been much affected in gonorrhea, a long time elapses before the patient feels as he did before his attack. He is unable to bear the least excess ;— wine, late hours, damp feet, women—all have a very bad effect. He must be content to vegetate for a long time, if his attack has been serious, and his habits ir- regular. I have reserved all mention of the Balsam Copaiba, and Cubebs, Cantharidcs, &c, as they are so various- ly applied by physicians, and that too of equal preten- tions to practical skill, that it might seem invidious to speak with great decision on any one method of using them. As a means of controlling the discharge in a chronic stage, they are quite indispensable, yet, for my- self, I never use them without other local means. It is to be regretted that the uncontrollable nature of our patients, in this stirring city, is the cause of our hav- ing so many cases requiring these remedies. Were it possible to subject them to early discipline, very few, I am convinced, would require them. It sometimes though rarely happens, that an ex- cessive flow of blood occurs from the penis, and it has heen known to continue with such uncontrollable vio- lence as to destroy life. An instance lately happened to a very careful practitioner in this city, and occurred without any assignable cause. Nothing but the intro- duction of a catheter, and passing a tight bandage around the penis, controlled it. It was necessary to let it remain an entire week. Should such an accident occur, before resorting to this measure, I would use in- jections of alum or gum kino. 10 110 GONORRHEA. There is some difficulty in detecting the presence of gonorrhea in women, especially if they should be in- clined to conceal their symptoms, in consequence of the frequent existence of leucorrhea, or the whites, to which they arc so subject. If, as in the male, there was but one passage, there would be no difficulty, as the ardor urina, or scalding, would make it certain. Yet gon- orrhea may exist in the vagina alone, where this symp- tom cannot occur, and leucorrhea often produces every individual symptom of gonorrhea in this passage. Should it attack the urethra, which is veiy short, it soon reaches the bladder, and produces all the usual symptoms, as above enumerated, except the urinary fis- tula. These do not happen, as there are no obstructions from the enlargement of glands, or strictures. There are none of them near the bladder, as in men. There are, how- ever, small mucous glands around the vagina, and near the larger labia?, which close the passage. These may suppurate, and they should be early opened, to prevent their burrowing extensively, which they are very apt to do. As all the other treatment applies to females, as well as males, it is useless to repeat it. The use of in- jections, however, requires distinct notice. It is quite useless, nay very wrong, to attempt to instruct a female patient in the use of a syringe, for the urethra. The passage is so short, that if the radical cure should be at- tempted, the injection is dangerous, in careless hands, for it may pass into the bladder, and produce excessive irritation, causing perhaps actual inflammation. Al- though disagreeable, I fear the practical surgeon must THIRD STAGE. Ill submit to the duty himself. This is excessively trouble- some, yet it is quite unavoidable. A female will use the ordinary syringe, adapted to the vagina, very well. They should always be made of glass, as many of the substances used as injections, act chemically upon me- tallic ones. There is one symptom that is laid down in medico- legal authors, by which we may distinguish gonorrhea from leucorrhea. The discharge from the former stains the linen of a greenish hue,—that from the latter is merely albuminous. There is also much more heat about the parts in the former, than in the latter. I take occasion here to remark, that in consequence of my attachment to the radical cure, I have not no- ticed until now, the method recommended by some em- inent surgeons, of using injections much milder in char- acter, than those I have recommended. There is no doubt whatever, that their known inefficacy depends principally upon the infrequency of their use, and their weakness, and that they should be much oftener used, if designed to have any other effect than irritating the parts, and injuring the patient's prospects of cure. These sentiments are now held by many judicious prac- titioners. Balsam Copaiba, notwithstanding the elegant form in which it is got up, in capsules, &c, is a remedy very apt to disagree with the stomach, and so long as there is a choice, I prefer relying upon decisive injections. The popular idea that they produce strictures, origina- ted in medical ignorance and indolence. It is, as all pathologists well know, the long continuance of inflam- 112 WARTS ON THE GLANS. mation that produces them. In the article on stricture, I shall fully explain the theory of their formation. Warts on the glans.—One of the frequent and troublesome consequences of gonorrhea, is the forma- tion of groups of warts over the glans, or end of the penis. They are often very extensive, completely cov- ering the whole glans. They should be snipped off with scissors, and their roots touched with caustic. This is by far the best way to treat them. Sometimes their renewed growth is prevented by touching them with strong acetic acid. CHAPTER IV. GLEET. In the preceding article, we have treated of the im- mediate consequences of an application of the specific poison of gonorrhea. There is a long train of results often dependant on this, that involves the happiness of the patient to an extent almost as great as in syphilis. Indeed, when we take into consideration the importance of an assurance of their perfect virility to most men, with the greater frequency of these affections, and their more direct influence upon the functions of the genital organs, there is no doubt that they affect their future happiness, if we leave posterity out of the question, to a much greater extent than syphilis. The jealous care which nature has implanted in the breast of every man, for the preservation of his virility, does not however originate in that instinctive passion, that he shares in common with the lowest grade of ani- mals, but in that more exalted part of his moral nature, the desire to love and to protect some object, physically his inferior;—hence the connexion of sensual passion and the sentiment of love. The intimate union of the two emotions, with their mutual dependence upon the physical integrity of the genital organs, invests this sub- 114 GLEET. ject with a degree of interest that can scarcely be sur- passed by any department of medical science. If the practical surgeon, whose abilities exist in a re- gion more exalted than his fingers' ends, were asked to define the cause of the physical and mental inferiority of the young men that meet our gaze at every corner of the street, he would be obliged to say, if he spoke a truth corroborated by his daily experience, that their in- tegrity is impaired either by actual disease of structure, or unmerciful exactions upon their nervous systems. See chapter on spermatorrhea. A correct definition of gleet, involves a matter of great importance, upon which the surgeon is constantly importuned for information, and which unfortunately he may give incorrectly, producing most disastrous results to the happiness of the patient. We will explain. There are many surgeons who define gleet to be, "the discharge that is left after the specific inflammation has entirely ceased in gonorrhea." The patient (perhaps a married man) is desirous of knowing when his dis- ease ceases to be infectious ; and here lies his danger. Some surgeons observe, that the discharge must be colourless, and then it will not infect. Granting this were true, and we are by no means convinced of it, we know it may be colourless for weeks, and then assume a perfectly purulent character, precisely as in the sec- ond stage of gonorrhea; and then it may again be, and as every surgeon well knows often is, infectious. Now who can say at what period this may occur ? Gleet must exist a long while before all danger of infection is past; how long we cannot say, for we have GLEET. 115 known infection communicated in the sixth month. Some very distinguished authors deny this ; but we give simply the results of our own observation, having been severely blamed for being governed by theirs. In one instance particularly, our feeble powers of eloquence were taxed to the utmost, to restore the domestic hap- piness of a very amiable, though foolish man, who ex- torted our permission to resume his marital rights, when in truth, we ought not to have given it. Suspicion was excited in the wife, in this case, by the unwonted absti- nence ;—and this will often make patients importunate, in order to avoid suspicion. That is his affair, not the surgeon's, who is bound to avoid all responsibility in these matters. Still we have not defined gleet. It is the thin and generally colourless discharge, that occurs some weeks after the subsidence of all the inflammatory symptoms of gonorrhea. I have had several cases, analogous to one mentioned by Mr. Bell, in young people, who had been affected months before marriage, having their worst fears excited, a day or two after, by the appearance of a profuse col- oured discharge. This however, in all the instances, has been unaccompanied with heat or scalding, and has subsided upon abstinence. Mr. Bell recommends a slight injection. I prefer, however, leaving it to nature, as the cause was excitement alone; it is more rational, when that is withdrawn, not to interfere. I mention the fact, in order to prevent unreasonable suspicions of the chastity of either party. It is always best to discour- no GLEET. age the green eyed monster. He is obtrusive enough, to many, without encouragement. When treating on stricture, it will be seen that the ef- fects of alteration of structure, and gleet, are mutually dependent on one another, and, therefore, that the re- moval of structural derangement, has much to do with the cure. Here it is not our purpose to go into an in- terminable discussion, on the subject of active and pas- sive discharges. We think we can do much better, than to offer any ideas of our own, on this most important point, by presenting an analogy, in the treatment of ex- ternal or conjunctival inflammation of the eye. There is a period, in the decline of inflammation of that membrane, when all practitioners ought to recog- nize the propriety of using stimulating remedies, ap- plied directly to the relaxed vessels of that surface. These have the best effect, and the only caution 1 would suggest is, that a sufficient time should be allowed to elapse between each application, to observe correctly the effect produced, whether good or bad ; for it is by no means unlikely, that the practitioner may be com- pelled to resort to internal medication. The only way is to try, and observe if local means will answer. I should always use them ; not only because more imme- diately agreeable, but from the fact, that I have seen many instances, in which months elapsed, before the distressing derangement of the stomach subsided, after the free use of copaiba and cubebs. Gleet also has its stages, that are useful for practical purposes. In the first stage, any irregularity of living, will produce aggravation of the discharge. It behoves GLEET. 117 the patient to use the greatest care, as he may rest as- sured, the longer it lasts, the more difficult it will be to cure. From the very nature of the structure, of the mucous membrane of the urethra, its extreme delicacy and vascularity, this is inevitable; and it is quite ab- surd, for patients to rail at their doctors, when their dis- ease may be said to be so unmanageable, as to be con- stantly under the influence even of their very thoughts. It is on this account, that they should abstract them- selves from all lascivious conversation, and prurient ex- citement. The pure air, and wholesome exercise of carriage riding, in the country, will prove very serviceable. The patient should never mount a horse, for obvious reasons. It is a direct irritant to the genital organs, and will al- ways aggravate the symptoms, in the commencement of the affection. Costiveness is to be most carefully avoided. Should the patient have suffered under the second or third stage of gonorrhea, the prostate gland, as well as Cowper's glands, may be involved in the dis- charge, as well as the mucous membrane of the urethra. And as these glands are immediately in the vicinity of the rectum, not only the distension of the bowels, with hardened fieces, will operate as an irritating cause, but the straining at stool, will aggravate directly the disease. Such is the anatomical conformation of parts, that two immensely powerful agents compress these glands, as well as all the urinary appendages, within the lower part of the body, whenever the patient is at stool, and the less effort he makes, the less pressure they sustain. The professional reader will see that we mean the ab: 118 GLEET. dominal and lavator ani muscles. There is no remedy equal to a little good Turkey rhubarb. Any other is worthless. The patient should keep it in his pocket, and bite off a piece, half the size of a pea, twice a day. Purgative medicines are highly injurious. The rhubarb imitates nature only. Some patients will persist in swallowing medicine, and using injections, constantly. We should never yield, in the slightest degree, to their whims. Yet I have been surprised, by the patient's curing himself with an injection, made against my express orders. It is therefore much better for the surgeon to try them oc- casionally. He will do less mischief, if any is to follow, than the patient, who always overdoes the matter. The stronger mercurial solution, is the best remedy, in these cases. Any of the usual injections may answer ; but the surgeon never can tell the actual effect of his trial, till several days have elapsed. It often does great ap- parent harm in the beginning, and at the end of the week the patient is cured. It will by no means answer, as in the radical cure of gonorrhea, to use these remedies of a powerful strength. They must be prepared with great care, and of the min- imum strength, because we do not know the actual state of susceptibility of the membrane, and if we are to do no good, we should, at least, endeavour to avoid injur- ing the patient. All the precaution of diatetics should be attended to, as in gonorrhea, only the same rigid ab- stinence is unnecessary, in food, though it is especially so in stimulating drinks. The food may consist of a moderate amount of ani- GLEET. 119 mal matter, avoiding fat, and gravies, which are power- ful stimulants. Vegetables are useful for the bowels. No spices whatever; nor would I advise salt food, as that stimulates thirst. The writer confesses complete heter- odoxy, on the subject of demulcent drinks, in all ordi- nary cases, and candidly believes, the less we drink, at all times, the better; but especially so, when the organs for the reception and voiding of urine are deranged. We seek rest for them, and I must confess, drinking always seemed an odd way to attain it. CHAPTER V. SECOND STAGE. Inasmuch as I believe the third stage of gleet to be intimately connected with permanent stricture of the urethra, I shall consider it as belonging to the chapter on that subject. The only benefit to be derived from the division of this disease into stages, is its practical application ; and this, I conceive, to be very important here. No person accustomed to treat these cases, if he enjoys any higher range of observation, than what ap- pertains to physical facts, and the mere mechanical treatment of disease, can fail to observe the effect of an obstinate gleet upon the mind of his patient, and to con- nect this with its operation upon the disease itself. If the patient be nervous and imaginative, and above all, if he cannot control the many annoying circum- stances which often influence imprudent people, the physician may congratulate him upon his speedy cure, on one day, and on the next, without any other irregu- larity, than some unpleasant intelligence, find him in a state of actual despair, and his symptoms greatly ag- gravated. This is one evil. A very delicate and san- guineous patient, is so liable to impression upon the slightest change of diet, and boarding is so common, that it is almost impossible to control that; and in our SECOND STAGE. 121 climate, during two thirds of the year, the regulation of clothing is equally impossible, at least with the amount of forethought those who get gonorrhea, usually pos- sess. Thus it is, that a variety of causes conspire to introduce the patient into a period of the disease, in which, from its long continuance, the powers of body and mind reciprocally act upon one another, and so far enervate the system, as to demand constitutional treat- ment and tonics. This is what I mean by the second stage. So far as medicine can exert an influence upon such a case, I know of nothing that equals the syrup of the Iodide of Iron. Twenty drops of this beautiful prepa- ration, thrice a day, in a wine glass of sugar and water, will produce extraordinary tonic effects; and if it is possible to add to it the restorative influence of agreea- ble society, and good air, with a well chosen diet, the patient will soon be brought up to an ordinary standard of health. Yet there still remains the discharge ; and as this is local in character, many suppose that it can only be removed by local remedies ; others, that noth- ing but natural causes can effect it. In truth, there is no doubt that nature is best competent to the removal of every abnormal state, were it possible to submit en- tirely to her laws. But as this is impossible, and art can only be resorted to with propriety, when it is known to be in direct harmony with nature, we must endeav- our to imitate her, as closely as our limited perception will admit. There is supposed to be this difference, between the condition of parts in pure gleet, and in stricture, which 11 122 GLEET. is usually accompanied with gleet. In- gleet, the part of the mucous membrane, where it exists, is supposed to be merely gorged with blood, and puffy or relaxed in its condition. In stricture, either the mucous mem- brane, or the parts directly beneath it, are permanently thickened or enlarged, by a substance actually produced by the inflammation. Therefore it will be seen, could the puffy condition of the parts resume its tone, the dis- charge would cease, for the puffiness is only a condition of the blood vessels, in which they throw out, or pro- duce, the mucus. Stimulation may compel these vessels to subside. The injections were used for that purpose, and if they have failed, we are obliged to resort to other means. The remedy to which I attach the most consequence, in this advanced stage, is the introduction of bougies. It will be understood by the reader, not because he has stricture, but for fear he may have one. The mechan- ical presence of the bougie, is sometimes very effica- cious in altering the action of the blood vessels, and thus stopping the production of the mucus. After a daily trial of this, for a few days, cubebs may be used simul- taneously, a tea-spoonful, in any convenient vehicle. If this should be efficacious, it must be continued occa- sionally, for a day or two at a time, for weeks together, as the discharge is apt to return. During this late period, the patient may use mode- rately wine, or malt liquor, if accustomed to it; and observing the effect, continue it, if not injurious. Some- times it actually benefits as much in this stage, as it in- jures him in the previous one. SECOND STAGE. 123 If, after a few more weeks, the disease still persists, a very careful examination must be made of the pros- late gland ; a bougie, of the full size, must be intro- duced into the urethra, and then the finger being passed into the rectum, the surgeon will be able to form a more correct judgment of its actual state. I make the sug- gestion of this mode of examination here, because the books give no such directions in gleet, and I know its value from experience. Whether disease be found or not, in addition to the means usually adopted in that event, I have always found the best results from direct- ing the patient to the sea-side. Mr. Hunter remarked, that more patients were cured by sea bathing, than any other means, and actually directed injections of sea water, supposing that the iodine, in solution therewith, benefited a possible scrofulous state of the gland. Although, in the treatment of gleet, cubebs has effect- ed the most benefit of any internal means, I have used copaiba, cantharides, and turpentine, with occasional relief. In this stage, an issue in the perinceum has likewise relieved, and the mechanical action of riding on horseback, which we know greatly aggravates the disease in its first stage, has cured it effectually; yet it is much to be regretted, that gleet so often passes into the third stage, or that of stricture, in spile of every remedy that is applied. When this occurs, there is but one remedy, and that is the bougie. On this there is no room for difference of opinion, although the manner of using it is not so well settled. The subject of seminal weakness and impotence, is one that may be thought naturally connected with gleet, 124 GLEET. but as I conceive that to be produced by venereal ex- cess, or masturbation, and that gleet is the immediate cause of stricture, I shall rather proceed to that subject, and leave those for future consideration. CHAPTER VI. STRICTURES OF THE URETHRA. In those who have had obstinate attacks of gon- orrhea, stricture is a very common consequence ; and inasmuch as gleet is the result of gonorrhea, and only occurs in cases that have proved unmanageable, it al- most invariably may be taken as a symptom of stricture. The importance of a correct definition of stricture, will be very apparent when we speak of the treatment; for it will then be seen, that it must vary with the na- ture of the obstruction, and can only be pursued with- out great injury to the patient, when its nature is clear- ly understood. If we have cause to lament the exis- tence of quackery, and its deplorable results, in other affections of the genital organs, our regrets are, if pos- sible more frequently elicited here, where the ill effects of rude and ignorant mechanical interference, often produces results that no skill or gentleness can over- come. A single instance will suffice, to show the danger of submitting to irregular practice in these affections; and although it was the result of inebriety in the operator, we hope it will prove a caution to some in avoiding similar practices ; for the individual who performed the 11* 126 STRICTURES OF THE URETHRA. act, is an empyric of extensive practice, particularly in strictures, in this city. A young man, who was supposed to have stricture, laboured under the natural deformity of phymosis ; a state of things, in which the foreskin is so formed by nature, that it is nearly closed, and cannot be drawn back, so as to expose the glans, or end of the penis. In such cases, this of course requires to be slit up ; see chap, on phymosis. The quack, instead of inserting the knife under the membrane, actually put it into the urethra, and opened that passage full two inches ! The writer was called in, by an eminent physician of this city, to operate for the closure of the part. It was for- tunate indeed, that he chanced to direct the incision downwards, as he might otherwise have opened the body of the penis. The size of the urethra, in the male, has of course no definite proportions, varying from eight to ten inches in length, according to its distension, and still more so in its lateral dimensions ; its sides lying in contact, when not distended with urine, or when the penis is not erect. A bougie, of a quarter of an inch in diameter, may be passed in some individuals, and others, even in a healthy state, will not admit one more than the eighth of an inch. Although there have been disputes about its muscu- larity, there can be no doubt of it, in the mind of any one who has been accustomed to pass the bougie. In- deed, an important division of stricture, is made upon the certainty of its mucularity, viz. the spasmodic. It is lined with a delicate membrane, similar to the mouth STRICTURES OF THE URETHRA. 127 and lips, and is surrounded, between this membrane and the external skin, with a highly distensible tissue, that can, like the body of the penis, be filled with blood during erection. This makes great care necessary, to avoid wounding the membrane, in passing instruments. The reader is already familiar with those causes that may produce a narrowing of the urethra, by encroaching on its calibre, and compressing its sides, viz. the en- largement of the prostate gland, Cowper's glands, &.c, occurring in gonorrhea ; and although there are other causes, such as wounds, tumors, calculous concretions, &c, that may obstruct the passage, and render surgical interference necessary, we mean to confine our attention to those which come under the following definition, and originate principally from gonorrhea. Mr. Wilson, a distinguished British author, gives the following :—" A stricture of the urethra, consists of some morbid alteration of action, or structure, by which a part of the canal is rendered narrower than the rest." This is a very complete and philosophical definition, because the expression " alteration of action," will give any in- telligent reader, in connexion with the following explana- tion of spasmodic stricture, a comprehensive idea of a surgeon's meaning, when he speaks of "a mere altera- tion of action," as contra-distinguished from "an altera- tion of structure," which is the second great division of stricture. A spasmodic stricture, is a contraction of a small por- tion of the muscular fibres, whilst the others remain re- laxed, often opposing the entrance of a bougie, for a 128 STRICTURES OF THE URETHRA. short time, and then suddenly allowing it to pass. See Cooper. A permanent stricture, is a contraction of the canal, from the effusion ofcoagulable lymph between the mus- cular fibres, outside of the mucous or lining membrane of the urethra, as well as upon and within this mem- brane, diminishing the passage for the urine, or com pletely closing it up.—Sir Everaid Home, Phil. Trans 1820. Although these may exist separately, as we shall soon see, we take occasion to remark, that there can, in our opinion, be no case of permanent stricture, without more or less combination with spasm. And this we would urge as a reason for the exercise of the greatest steadiness and gentleness, in passing the bougie. In no case, and under no circumstances, should the mere mechanical passage of a bougie, give the patient actu- al pain; and that man is doing his patient injury, in whose manipulations this occurrence is more than a very infrequent consequence. We have said that gleet is almost invariably a symp- tom of gonorrhea; and although ample experience has verified this in our own practice, we prefer quoting two of the most distinguished European authors, rather than offer our own knowledge on the subject. Our rea- sons may not be obvious. We design this book as an aid to the practitioner, as well as a warning to the pa- tient. It often happens, upon a serious announcement of the actual extent of his evils, and the necessary means for their removal, the patient, who has always a desire to STRICTURES OF THE URETHRA. 129 be cured by medical means, immediately calls to mind the assurances of quackery. He has no notion of struc- tural derangement producing gleet, and upon the bare mention of a bougie—the mildest and only means of cure—hastens at once to the quack ; and when he dis- covers his error, his difficulties have greatly increased, rendering, perhaps, measures of a more complicated na- ture absolutely unavoidable. John Hunter remarks :—" The spasmodic, and more especially the permanent stricture, arc generally attend- ed with gleet. The latter complaint is often suspected to be the only one, until all efforts to procure a cure are found to be useless." Benjamin Bell, p. 147.—" It is somewhat remarka- ble I hat the formation of strictures is often so gradual, that a patient is not sensible of their taking place, till the disease has been of long continuance. Being sel- dom attended with pain, till the flow of urine is much impeded, any partial degree of it passes without notice, by which they arc apt to be rendered much more fixed and.permanent, than they otherwise would be. The patient, indeed, has seldom any suspicions of strictures, till the surgeon, for his own satisfaction, where gleet continues for a long time, proposes to introduce a bou- gie. Gonorrhea having given rise to gleet, any diffi- culty that occurs to the passage of urine, is considered to arise from the same cause ; and thus a great length of time often elapses, before any such examination is made as can, with any certainty, lead to a discovery. This proves often, in its consequences, highly distress- in;?, and ought therefore to be as much as possible 130 STRICTURES OF THE URETHRA. guarded against; for strictures, by long continuance, become much more firm, as well as more extensive, than they were at first, by which they become much more difficult to cure. Cases, which at first would have yielded to the first attempt with bougies, are, by delay, often rendered so obstinate, that nothing will re- lieve them, but the most exact application of bougies, continued for a long time." Sir Astley Cooper remarks:—" The earliest symptom of stricture, is the retention of a few drops of urine in the urethra, after the patient has made water, which drops soon escape and wet the linen."—" The next thing noticed, is an irritable state of the bladder, evinced by the patient not being able to sleep as long as usual, without discharging the urine."—"As the disease in- creases, the stream of urine is forked, spiral, or scat- tered ; and in a more advanced stage, the water is often voided only by drops, especially when the urethra is under the irritation of cold, or intemperance." In these cases, Sir Astley advises the introduction of a bougie; and if one of a common size can be passed, the difficulty depends upon enlargement of the prostate gland, as this would, from its distensible nature, admit its passage, but, from its increased general enlargement, prevent the stream of urine, by any ordinary effort of the contraction of the bladder. In addition to these symptoms, the patient will ob- serve an immediate effect, particularly after drinking liquor, or leaving a warm room, and going into the cold air. There will be a difficulty, more than ordinary, and often for a short time, a complete inability to pass 8TRICTURES OF THE URETHRA. 131 water. On returning into a warm atmosphere, he will be able to urinate. Nocturnal emissions of semen, are a very frequent symptom of stricture. Nothing also is more common, than for a strictured patient, shortly after coition, to have a discharge of matter from the urethra. This is often supposed to be an attack of gonorrhea, and is treated accordingly, the patient congratulating himself upon a speedy cure. Upon the frequent recurrence of this, he, perhaps suspecting the cause, and receiving a more minute examination, learns the nature of his af- fliction. I have known actual suspicions of a wife's chastity, thus excited, in a newly married and rakish husband. The reason why those who have strictures, are una- ble to retain their urine as long as healthy persons do, is this:—In consequence of the stricture, and the diffi- culty of urinating, the patient defers it as long as pos- sible, and thus the bladder, being constantly kept upon the stretch, its muscular fibres lose their patience, as it were, and become irritable. This will gradually pro- duce thickening of the bladder, and if the stricture is permitted to remain, serious and fatal disease may ensue. The writer has a patient, now under care, in whose case this has occurred. The strictures are so numer- ous and complicated, that it is doubtful if they can be dilated before death occurs, from irritive fever, and gen- eral exhaustion. This person has, for so long a period, retained the contents of his bladder, until compelled to urinate, that the urine has been absorbed continually, and thrown off by the skin. It is quite unpleasant to 132, STRICTURES OF THE URETHRA. sjt in a close room with him, in consequence of the strong smell of urine, constantly escaping from his en- tire surface, whilst the disease of the bladder and pros- tate gland, causes a constant discharge of pus and mu- cus, which escapes, drop by drop, from the urethra. Should no effort be made to overcome a stricture, and it becomes quite impervious to the passage of urine, either ulceration of the bladder, or of the urethra, between the stricture and it, must occur. If the former, almost inevitable death ; and in the latter, as in the ulceration of Cowper's glands, an opening through the skin, or a permanent fistula will occur. The latter, with any one who has much pride of character, is about equal to death, and more than one case of suicide has occurred in this city, from that cause. Disease of the kidneys will often exist, in a greater or less degree, from stricture. They become oppressed with urine, which it is their office to produce, not to re- tain. Ulceration and death is not uncommon from this cause. Occasional, sudden and violent attacks of fe- ver, with an intensely cold stage, followed by one of equal heat, may occur. There is nothing to prevent the existence of many strictures, though there are rarely more than three, and these are apt to occupy definite positions, in their distri- bution in the urethra. The most frequent position, is the one nearest the bladder, averaging from six and a half to seven inches, from the end of the penis. These, and if we consider diseased prostate a stricture, which it is, so far as the effects are concerned, are the most difficult to cure. The next position is about three and STRICTURES OF THE URETHRA. 133 a half inches from the glans, or end of the penis, and the third, is often within an inch of the opening of the urethra. I doubt whether there is any definite order in the comparative frequency of these two. The first men- tioned, or deepest situated, usually exists, whether the others do or not. The two latter often exist together. Those which originate from wounds, and other causes than gonorrhea, and enlargement of the prostate, have no definite position. They are, comparatively, very rare, and the rules that concern their treatment, do not differ from others. We have left the systematic enumeration of the symp- toms of spasmodic stricture, till the last, because when not combined with permanent, it is the most infrequent. It is often called irritable urethra, because there is no definite part for its attack. It depends upon general irritation of the mucous membrane,—and as that is the condition preceding inflammation, and the most effi- cient treatment, is such as we adopt for that state, the symptoms will be found analogous to ordinary inflam- mation of that membrane,—or, that which is not spe- cific in character, viz. general uneasiness over the whole extent, with more or less pain in passing water, and sudden spasms, particularly on going into the cold, from a warm room. In this respect, it is like permanent stricture. The urine differs in its stimulating property, and often, upon any unusual change of living, it will become excessively painful, and produce violent spasm, and temporary stoppage. The passage of an instru- ment causes instant spasm, and its progress is arrested, for a greater or less length of time. 134 STRICTURES OF THE URETHRA. I conceive it to be so well settled, that gonorrhea ia the great cause of stricture, that I shall assume it to be admitted, and again quote Mr. Bell, because his author ity is sufficient to overthrow all the cavils of the inex perienced, on the absurd idea of injections causing stricture. There is one reason however, that reduces this notion absolutely to an absurdity, and that is, that the most frequent position of stricture, viz. nearest the bladder, is where the injection never reaches. More- over, would it not be infinitely more likely to produce it in that part where it most readily finds access, viz. the middle of the urethra ? In the following passage, a good idea of the manner of their formation, is given. Mr. Bell says: " Instead of injections being a frequent cause of stricture, I have much reason to think they are more effectual than any other means of preventing them. Although I have ad- mitted that strictures are sometimes produced by severe degrees of inflammation, I do not consider that as a fre- quent occurrence. Strictures, I conceive to be, most frequently, the consequence of a state directly the re- verse of inflammation. In a great porportion of cases, they will be found to take place, where, either from no injection being used, or from some other cause, the dis- charge has gone on to a very unusual extent, where all symptoms of inflammation were gone long before, and where nothing but a gleet remained. At least this has been the result of my observation, and I believe it will be admitted by all who have paid attention to the point in question. " I therefore conclude from this, as well as from ap- 12 STRICTURES OF THE URETHRA. 135 pearances which these parts exhibit on dissection, that this variety of obstruction depends upon a state of mor- bid relaxation, or debility, induced in these parts of the membrane of the urethra, upon which the inflamma- tion at first fixes with most violence, and from which the subsequent discharge is, in a great measure, pro- duced." The whole treatment of every mucous membrane in the body, whether that of nose, eye, or mouth, corrobo- rates this idea. In all these cavities, we recognize pre- cisely the state Mr. Bell describes, and in their passive stage treat them with powerful stimuli—even with pure caustic. The writer, and one, at least, of his friends, univer- sally admitted to be one of the best practitioners of this city, treat leucorrhea by the speculum, and pure nitrate of silver, with certain success. And this is a perfect analogy Leucorrhea would often assuredly be stricture of the vagina, if the passage were narrow enough to render this possible, and the principal use made of it had not a preventive effect. No doubt we could apply nitrate of silver, with benefit, in bron- chitis, as in pharyngitis, could we get at the lungs to do it. So far as the analogy of general treatment goes, stimulation, or nutrition, is the best means of cure. At any rate, the Sangrado practice of bleeding, purg- ing and starving, that has filled the grave with thousands, is now done away with, unless in the hands of a few prartitioners of the last century. CHAPTER VII. CURE OF STRICTURES.' Inasmuch as strictures present, from their different de- grees of density and extent, varied amounts of resis- tance, it follows, that agents, corresponding in power, must be used for their removal. Some strictures are so slight, that they may be represented, in extent and re- sistance, to the bougie, by a piece of thread, passed round the urethra. These are not common, as patients rarely apply, till they may be compared, in extent, to a piece of narrow tape. And again, there may be a combination of both these, or a whole inch, or more, in extent, of the urethra, may be implicated in the nar- rowing of the passage, to a greater or less degree. Rare and incurable cases exist, in which, from entire neglect and inflammation, the whole urethra is closed. Of course, in these cases, there is an opening and fistu- la, near the bladder, produced by ulceration. There are three means of cure, occupying the order in which they are enumerated, as to the propriety of their choice, though this depends, in some degree, upon the nature of the obstacles to be overcome; 1st, dilat- ing the stricture by bougies; 2d, the application of caustic ; 3rd, incising the stricture with a small lance, concealed in a catheter or tube, or cutting down from CTRE OF STRICTURES. 137 the skin upon the stricture, and then passing a catheter for the urine to run off by, and allowing the part to heal up over it. The first, is the method adopted by careful and per- severing surgeons, whenever possible. It is destitute of pain, or danger, and will overcome all but the worst cases of stricture, if faithfully and methodically applied, to a patient having sense enough to do as he is di- rected. The second, with the beautiful improvements of the instruments used in its application, is also a safe, and not a painful method, in very careful hands. It is adapt- ed to those cases which resist the former method of treatment. The caustic acting as a destructive agent to a very limited extent, if at all; the smallest piece, not larger than a pin's head in size, being used. This agent, moreover, must take the place of the third, when the first is impracticable. The third, or incisions by either process, is only to be used in desperate cases, although, in the hands of a skilful surgeon, it is not a desperate remedy, by any means. Of course every patient would choose this re- course, rather than submit to the only other alternative, ulceration of the bladder itself, or a permanent open- ing between the stricture and the bladder, or a fistula, made by the surgeon. Of the two methods last enu- merated, the incision by the concealed lancet, is by far the most desirable; yet this is only applicable to the least extensive strictures, of the worst class. The worst always demanding the incision from without, or through the skin. 12* 138 CURE OP STRICTURES. There ie no such thing as treating a querulous and discontented person for stricture, with any advantage; and the surgeon who will consent to do so, is more re gardless of his reputation than the writer. The men tal depression of the patient, in all these cases, is almost incredible ; and the humane surgeon will always give his patient every possible assurance of comfort. But it should be remembered by the patient, that it requires some slight application, and a few years of study, to un- derstand the detail of a matter, that may all seem very simple to him ; and he may think unreasonable diatetic regulations are enjoined ; but let him remember it is a mutual and honourable contract between them—the surgeon and the patient. The reputation of the former, and the happiness of the latter, is at stake. The sur- geon is to do his duty, the patient is to obey, or it is the surgeon's duty to leave him. He has no right to risk his own reputation or the patient's cure. Bougies are now made either of linen or catgut, coat- ed with India rubber, or of a very flexible metallic com- position, perfectly smooth, and the ends evenly rounded —not pointed. The linen ones are now most beauti- fully made in Paris. We prefer them much to all oth- ers. They taper so perfectly and gradually, that a point for the smallest stricture, receives adequate sup- port, whilst the necessary gentle pressure is made, to cause its entrance into the stricture. Previous to their use, the metallic bougie had to be used for all small strictures, the finest linen English ones curling up in the urethra, upon the slightest pressure. They were good for nothing. CURE OF STRICTURES. 139 The non-professional reader may imagine that the bougie acts upon mechanical principles, dilating the stricture like a wedge. This is even asserted by very high British authority ; see Cooper. But we think the idea of dilating living animal fibre, absurd. The bou- gie could effect no benefit, if it dilated only. The part would, immediately it was withdrawn, approximate as before. It operates like all other pressure, by producing absorption. If the smallest bougie can be made to enter a stric- ture, and the surgeon and patient will persevere, the cure can be effected by that method. It often happens that spasm occurs instantly upon the introduction of a bougie. Steady and gentle pressure will always over- come it. The greatest care should be used in the selection of bougies without flaw in any part, but particularly near the point, as they might otherwise break off, and thus enter the bladder. In such an event, (and it has hap- pened in this city,) the operation of opening the blad- der, or lithotomy, would have to be performed, as a stone would soon form round the piece of bougie, or its presence cause inflammation of the bladder and death. In passing the bougie, aftei the surgeon has used gen- tle and continued pressure, for a minute or two, he should withdraw his hand suddenly, suffering the bou- gie to remain, but holding the penis gently grasped in' the other hand. If the bougie recoil, it has not entered the stricture, but doubled upon its point, and on with- drawing it, he will find it bent. Should it not recoil, and resist gentle traction, it has entered. 140 CURE OF STRICTURES. The surgeon is not to expect, when he first passes a bougie, with a well tapered point, that when it passes, should it do so, (and this is by no means certain, even in small strictures,) completely through the obstruction, that he will feel it pass through. This he cannot do, for it is a wedge. But after he has used several sizes larger than the one he began with,—and this will take several sittings,—he can then try a round pointed one, of suitable size, and it will often go through with a jerk, and thus he can judge of the extent of the stricture. When the patient is used to the bougie, for it often produces faintness at first, the surgeon may introduce, as was the practice of Sir Astley Cooper, two sizes at a sitting. The time a bougie is to be permitted to re- main in the urethra, is to be judged of entirely by the feelings of the patient; much pain should never occur At first, only a minute or two each time ; gradually longer, till ten or fifteen minutes elapse. Patients differ very much in their capacity to endure them. After a few weeks, they may bear them for hours, and even all night. It is often convenient to introduce them on re- tiring, in order to save time, as well as irritation, when it is necessary they should remain a long time. The increase in size is to be governed entirely by the density of the stricture. If firm it will necessarily be slow ; if otherwise more rapid. As soon as the sur- •geon judges that the full size of the urethra is attained, and he can pass the instrument with facility, he may entrust it to the patient himself, who had better use it for a quarter of an hour at least, every night for a month, then twice weekly, and so on, for a few weeks. CURE OF STRICTURES. 141 Here the surgeon's duty ends ; for it is not to be de- nied that the stricture has a tendency to return ; and the patient can keep himself clear, by its occasional use, as well as the surgeon. After a year or two, how- ever, it often happens, if patients live regularly, it dis- appears entirely. Cure of Strictures by Caustic—When, from the extent, or density of a stricture, it becomes impossi- ble to pass a bougie, cither caustic must be applied, or it must be pierced with a stilet, or lancet, as hereafter to be noticed. Although we have advised the use of the bougie alone, when that would suffice, we have stated that strictures, thus treated, are apt to return. In 1752, the great John Hunter, of London, first ap- plied caustic to a stricture, in a very impracticable case. After three applications, he observed that the man " voided his urine much more freely," and on applying the caustic the fourth time, the canula, or silver tube, through which it was passed, on the end of a small bougie, " went through the stricture." Sir Everard Home observes,—" Having met with a number of facts, from which a general principle appears to be established, that the irritable state of a stricture is kept up, and even increased, by the use of a bougie, but lessened, and entirely destroyed, by the lunar caus- tic, I am desirous to recommend the use of the caustic, in many cases of irritable stricture, in preference to the bougie." Mr. Home goes on to detail a number of cases, in which permanent cures were effected, during 142 CURE OF STRICTURES. many years, and speaks very warmly in favour of the method. In short, he adopted it" as a general practice.' There is no doubt that in all difficult cases, and par ticularly in irritable strictures, the careful use of the caustic, is far preferable to the lancet pointed bougie. We have often had occasion to use it, and have never met with any ill effect. But we have been exceedingly careful, and never apply it oftener than once in three days. In cases where the patient has experienced pain for several days after the passage of a common bougie, and has dreaded its introduction so much, that I feared his inability to bear it, I have, unknown to him, used a very small piece of caustic, and such has been the re- lief afforded, that, after two days, I have introduced the bougie entirely without pain, and he has urged ine again to resume it, on discovering the cause of his ease. It is unquestionably an admirable assistant to the bou- gie, when not used to the extent, or with the object of destroying the stricture. I never use it for this purpose. When the smallest quantity is exceeded, in bad cases, it requires great care, though I always prefer it to in- cision. The necessity of the greatest caution will be appar- ent, when we reflect, that the effect of caustic is in a great degree indefinite. There is no telling with cer- tainty the actual effect it will produce, nor with invari- able accuracy, the direction its action will take. Yet I think both these results may be calculated, with far more certainty, than they have hitherto been supposed capable. The first, however, is always, more or less, under the control of the cautious practitioner, who is CURE OF STRICTURES. 143 never anxious to do too much at once ; and will, there- fore, use the caustic more sparingly, only applying it for a short time, and fastening it so firmly in the end of the bougie, that it will be impossible to drop out or break off. In regard to its direction, so as to be applied precise- ly to the centre of the stricture, I am satisfied, that if the mechanical means were always well chosen, and the instrument prepared with rigid and mathematical precision, so as to be adapted precisely to the structure of the part, there would be no difficulty. But surgeons are not all possessed of mechanical skill, and instru- ment makers are often both stupid and inattentive. I have always been obliged to prepare, with my own hands, the instrument I am about to mention, and as it is designed for the professional reader, I shall describe it with accuracy. He may be more fortunate than I have been, and by close personal attention, get an in- strument maker to prepare it for him, should he think proper to adopt it. There is but one way to ensure the bringing of the catheter, directly opposite the stricture, so as to have its centre, and the centre of the end of the cathe- ter, precisely opposite each other. That way, is to select as large a catheter as the urethra will admit. A small one not only never passes with more ease, but, inasmuch as it is not directed by the pressure of the urethra, which operates evenly all round, it is apt to de- viate by any unconscious movement of the hand of the operator, and have its point directed against the urethra, just on one side of the stricture, or above, or below it. 144 CURE OF STRICTURES. Not so with the larger one, which, directed gently, the patient always standing at ease, and never sitting, is almost sure to feel no undue influence of the hand. When it will pass no further, the surgeon must hold it with his thumb and two fingers only against the stric- ture, which will now be directly opposite the centre of the end of the catheter. Now, as these are commonly constructed, the object being to draw off the urine only, the bore, or cavity, is made of equal extent up to the well rounded end ; and if a small hole were made in one thus constructed, there would be great difficulty in pass- ing a gum elastic bougie, with the piece of caustic in its end, through this hole. It could not be directed to the centre, for the same reason a small cathether would not reach the centre of the stricture, viz. want of lateral support and direction. Let the catheter then be made with one inch at the end, to unscrew;—it can be done with perfect neatness;—fill this with melted lead, and then drill a hole through its centre and end; with a small penknife, make this hole a regular cone, with its apex, the opening in the end, and its base, merging into the sides of the catheter. Burnish it well inside, and then screw it on. We think, when the caustic is once passed through a catheter thus constructed, the surgeon will never use any other. He may rest assured, it can go no where but to the very centre of the stricture. I always fasten the nitrate in a hole, made with a brad awl, in the end of a gum elastic bougie, and then, with a hot wire, melt the gum immediately surrounding it, so as to make it grip the caustic, which should be an oblong piece, as CURE OF STRICTURES. 145 thick as a large pin head only. No mechanical contriv- ance will hold the caustic, or suffer it to be passed through the catheter, better than this. Its flexibility al- lows it easily to take the necessary curve of the cathe- ter, without displacing the caustic. The great advantage of having one instrument to suit every case will be apparent to the reader. Indeed we cannot see how the caustic could possibly have been ap- plied to the stricture with any certainty, when either the bougie alone, or that with the straight canula was used. In the armed bougie the least excess of pressure must have tilted up the point, and thus misdirected the caus- tic, and the straight catheter must have been very awk ward to apply to the curve of the urethra : it will be re- membered the worst strictures and those that oftenest require the caustic, are there. It is impossible to say how often the caustic should be applied, as it depends entirely on the extent of the stricture. The interval also will depend upon the sub- sequent symptoms. It has been said that it should not be again applied till the slough or part that was destroyed by the first application, separates, so that it may be again applied in a new place, thus producing another slough : indeed, this is the idea conveyed in the term, " destruction of a stricture " by caustic ; we dis- sent in toto from all such practice. Let us examine this subject: a little close thinking will do such important matters no harm. The mucous membrane of the urethra is a very delicate structure, and is its only proper sheathing: it is so constituted by nature and lubricated with its proper secretions, as to 13 146 CURE OF STRICTURES. be quite contented to convey that variable and acrid fluid, the urine. Secondly : it is a fact universally known, that all cicatrices the result of wounds, but more especially of such as are made, whether by heat or other chemical agency, have a constant tendency to con- tract. This is often observed to a great extent, in burns and scalds. Now look at the practice: the mucous membrane, if a slough is produced, must certainly be destroyed, pre- senting in that part a cicatrized surface, unsuited to the urine, and by its very nature tending to contract. Thus the veiy thing we are endeavouring to cure, is aided to return by the means used to remove it ! This is no hair splitting—the writer has been obliged to incise a stricture greatly aggravated by this treatment; frequent total suppression was often produced by slight excess in urine or wet feet. It was by no means a very bad stric- ture at the commencement, but the patient was impor- tunate, and it was the first case the gentleman had at- tempted : he applied the caustic, as he told the writer, " to destroy the stricture." The truth is this, that those cases that were cured by Mr. Hunter and Sir Everard Home by this method, were well explained by the latter. The caustic de- stroys the irritability and produces absorption of the stricture. It is an admirable remedy, but can only be used as an adjunct to the mechanical action of the bou- gie, in producing that result. The only remaining method for the cure of stricture that receives the countenance of intelligent surgeons, is that of incision ; the practice of attempting to force an CURE OF STRICTURES. 147 ordinary metallic bougie through a stricture, though I regret to say it has been done by men calling themselves surgeons, and moreover has a place in books on stric- tures, could surely never have been attempted by any one having the least fitness for that office. . Should it ever be proposed, I can only caution the patient immediately to quit such a practitioner : the least that he can expect would be a great aggravation of the stricture, and probably a permanent false passage for the urine, eittier from the giving way of the urethra before the stricture, or the point of the instrument being actually thrust through it. It has been also proposed to use force enough, and for a sufficient length of time at each sitting, to cause ulceration of the stricture; this in my opinion is nearly as objectionable; caustic, if it were desirable, and it is by no means to be thus used, would effect the same object besides preventing spasm, symptoms that the pressure would be sure to excite. For reasons nearly similar to those which prevent the use of forcible penetration of the stricture, the third method or its incision by the concealed lancet, is always to be avoided when possible, yet there are cases in which it is utterly unavoidable ; they arc however exceedingly rare, and may never happen to those who are not ex- tensively engaged in this kind of practice; it must therefore be apparent that they should never be under- taken by any, unless they are perfectly familiar with the varied amount of resistance offered by a great va- riety of strictures: in short, if there is in any department of surgery a necessity for the " tactus eruditus," or that kind of skill that can only be had by constant practice 148 CURE OF STRICTURES. in every variety of stricture, it is in these cases. The utmost gentleness and steadiness is necessary in all of them, but particularly in this, where we are about to take so important liberty with a structure of the greatest delicacy. When in a case of aggravated and long continued stricture, that has been becoming progressively worse, so that the urine has passed drop by drop for a long time, and has often been completely suppressed, a com- plete stoppage should occur, which will not yield to the best methods always adopted for these cases, (especially when combined with inflammation or spasm,)—the warm bath, bleeding, leeching, the free use of opium, and the muriated tincture of iron,—there isno choice left, either the patient or surgeon, but the puncture of the bladder, or the stricture. The first would not of course be adopted in such a case, for the measure could only be temporary, the obstruction in the urethra remaining as before ; the patient would then rationally select the only chance for a radical cure: he will remember that this is a case in which the period when dilatation by bougies or caustic could be effected at all, has gone by, and the stricture is now so firm, and the bladder so dis- tended with urine, that immediate action is necessary. There are various instruments in use for this purpose, all of them doubtless in careful hands perfectly effective of the end designed, yet the writer must again express a decided preference for one that he conceives adapted to the structure of the part; the only respect in which this instrument differs from the one already described for applying the caustic, is in the addition of a triangu- CURE OF STRICTURES. 149 lar piercer, one eighth of an inch in diameter at its base, so arranged by means of a button on the end of the wire to which it is attached, that projects from the other end of the catheter, that it never can be thrust more than one third of an inch into a stricture: there is a very important object in this, inasmuch as if it were longer, there would be more danger of piercing the urethra be- yond, after it has penetrated the stricture; one means of preventing this, and it should never be neglected, is to cause the patient to endeavour during the puncture, to pass his urine, by which effort the part of the urethra towards the bladder will be equally distended, so as to make it one third of an inch in diameter: at least, a space which with due attention in holding the penis and catheter perfectly straight, the stilet will be sure to enter, after it has pierced the stricture. As soon as this is effected, which should be done by pushing the button home to the mouth of the catheter at once, it must be returned within the catheter, and that instrument withdrawn. Then introduce a bougie not quite the diameter of the stilet and ascertain if you have penetrated through the whole of the stricture : if so, a very small catheter may be passed, and the urine drawn off; but if it is not perforated, an instrument precise- ly like the other, but small enough to enter tke perfora- tion already made with its predecessor, must be used : great care should be taken, to make the point of the catheter enter the puncture before the stilet is again pro- jected ; all this I conceive to be necessary to ensure our keeping in the centre of the stricture, and avoiding piercing the urethra, which we should certainly be far 13* 150 CURE OF STRICTURES. more likely to do, if the stilet were to be thrust forward at once, two-thirds of an inch ; we could not then cal- culate with sufficient precision the direction of the puncture : again resuming the bougie a size Jess than the last stilet, we are to explore the second puncture; and if it is perforated, draw off the water, and then dilate the stricture twice a day with bougies, and proceed ex- actly as in a common case; we have need to pass the bougie twice daily, for there is a great tendency for this recent puncture to heal up. Though-the patient may be able to pass water with- out a catheter, still it may cause him less irritation to draw it off twice daily with a small one, just before passing the bougie. If on a second attempt at puncture, it should still be found that the stricture is not entirely pierced, the surgeon should examine carefully the urethra externally, and if upon investigation it should prove likely that more than another third of an inch is involved^ I conceive it to be the best practice to incise the stricture from without, and not to proceed with any further attempts at internal puncture, because if we should succeed in puncturing the stricture through its centre, there would be a great chance if the tendency to contract in so large a space, would not overcome our efforts to dilate it. The external incision is a matter before the surgeon's eyes, and he runs no risk of error. In this event the catheter must first be passed down to the stricture, and the surgeon is there to commence the incision. It is un- necessary to give any more minute directions, as it is a perfectly plain matter; the patient is to keep his bed, CURE OF STRICTURES. 151 lie on his back, and pass his urine through a gum-elastic catheter which is to remain in the wound: every thing depends upon the perfect quiet and the nice apposition of the wound. I always use stitches with a fine cam- bric needle, and the finest dentists' silk, and then a few short strips of adhesive plaster, going half round the penis only ; for if the great dorsal vein should be col strictcd, an cedematous state would follow, and more- over there might be a tendency to erection, and then the effect of a plaster encircling the penis, would be such as to require its immediate removal. Should the irritation of its presence require the re- moval of the catheter before the fourth day, the great- est gentleness must be used, and on no account should it be done till the fifth, if it can possibly be avoided; and even then it will be necessary to draw off the water for at least ten days or a fortnight, for its pressure in passing is considerable, and its acrid nature might also seriously irritate the wound. Dilatation by the bougie is still more necessary for a length of time in these cases than in others, because of their greater extent and firmer nature: the pa- tient must be content to pass them occasionally for years, and then he has cause to be thankful that he has escaped with his life from ulceration of the bladder, or at least without a fistula and the loss of his virility. In the description I have given of the instruments used for passing the caustic and incising the stricture, I have been sufficiently minute to enable those who choose, to adopt a method not only adapted to the struc- 152 CURE OF STRICTURES. ture of the part, but constructed, as I conceive, upon principles that ensure the application of the intended effort with the most unerring accuracy in skilful hands, and without much danger in those that are not so : and I hope, inasmuch as it is evident to all, that some of the most intellectual men are sadly deficient in manual dexterity, though actuated by the sincerest desire to benefit their patients, they will adopt the mode, should they reject the reasoning for its application. The plan of incising a stricture through the skin, should never be chosen but in cases that present no other chance of relief; there is no difficulty in its per- formance, but much more doubt of its complete success than in any of the other methods. It is to be regretted, yet truth requires the observation, that bad strictures, however skillfully treated and completely relieved, are very apt to return, without the constant use of the bougie. On the subject of strictures in females, there is in reality nothing to be said, further than the fact that they are exceedingly rare, and when they do occur require no other method of treatment than the use of the bougie. The urethra is in them so short, that the force with which the urine is expelled has no inconsiderable ability in dilating the passage: whilst its entire freedom from that complicated glandular obstruction that exists in the male, and the pressure of the greater mucous surface of the vagina, on which gonorrhea usually spends its greatest force, directly beneath it, gives it an immunity from all the graver symptoms of this disease. CHAPTER VIII. FISTUL/E; or, false passages in THE urethra. The reader is already aware, that if the stricture should not be penetrated in some way, the opening must be formed for the urine, either through the walls of the bladder itself, or what is fortunately more frequent, in the urethra, near the stricture ; the urine, by its dis- tension, causing ulceration of the mucous membrane, and escaping into the cellular tissue, a loose substance connecting all the different parts of the body together. Should it escape from the base of the bladder, it will soon be completely diffused in this tissue, which extends every where under the skin, and the sooner it is let out, by incisions, the better, as there is nothing that so read- ily produces mortification, as urine; the most formida- ble abscesses occurring, in consequence of its lodgment in any part of the body, but particularly in the loose tis- sues near the genital organs. Should the ulceration occur in the mucous mem- brane of the urethra, the urine may diffuse itself be- tween it and the skin, as far as the glans or end of the penis, and produce mortification, and perhaps destruc- tion of the whole penis. When it occurs far back, near the anus, it usually finds its way into the scrotum, and in consequence of the extreme looseness of this part, 154 FISTULA OF THE URETHRA. may distend it enormously, and produce nioi\W/c*»v .1 that may completely expose the testicles. A.U this would of course be accompanied with great fover, and prostration of the vital powers. Of the treatment of this state, we are not of course to speak here. It is only mentioned, to show the necessity of compliance with the measures necessary for its prevention. When the urine finds it way through the external skin, in the course of the urethra, the stricture remain- ing, it must become a permanent fistula. Should the patient submit to an operation for the cure of this, it is, in the first place, to be preceded by the operation of opening the stricture, and passing a flexible catheter into the bladder, which is to remain there for the urine to pass off by, the patient lying on his back, until the fistulous opening is healed. This is to have its edges cleanly excised, and to be approximated in the nicest manner, with one or two stitches, going just deep enough to leave out the mucous membrane of the ure- thra, and no more. The catheter, being first intro- duced, will prove an excellent guide for this nice mani- pulation. This operation, when judiciously done upon a patient entirely tractable, will always prove successful. It some- times happens, as we have already said, that extensive and numerous openings in the skin, or sinuses, are pro- duced by ulcerations, proceeding generally from one principal one, that communicates with the urethra ;— these often occur very near the bladder. They must be all completely laid open, to their very beginning in the urethra, and filled with lint, so that they will be com- FISTUL* OF THE VAGINA. 155 pelled to heal from the bottom. A catheter must then be introduced, as before. Nothing can ever heal them but this. Injections into the sinuses, are not worth a trial, for they will surely disappoint both patient and surgeon. The operations for these sinuses, when neglected, be- come very formidable in extent. The most extensive I ever witnessed has been already alluded to, when speak- ing of affections of the prostate gland in gonorrhea. Vaginal Fistula.—There is a fistula, communicating with the vagina, in females, caused by the lodgment of the child's head in protracted parturition ; its pressure against a single point of the urethra, for several hours, causing ulceration. This subjects her to the distressing inconvenience of the involuntary passing of urine through the vagina. An operation is performed for ex- cising the edges of the fistula, and then approximating them with stitches. It is often unsuccessful, or only partially so, from the impossibility of obtaining com- plete access to the parts, when operating. In a future work, we are now preparing, on female diseases, we hope to advance some useful mechanical hints on this subject. As strictures of the urethra, in females, are very uncommon, so fistula?, from that cause, are almost unknown. We have never met with a case, in our own practice, or heard of any, in that of our friends. There is also a similar fistula, occasionally existing between the vagina and rectum, in which the faeces pass into the vagina. Its cause is often similar to the preceding, and its cure equally difficult. 156 MALFORMATION OF URETHRA. Malformation of urethra.—There is a peculiar malformation in the meatus, or opening of the urethra, from birth, and not in any way connected with stricture, yet as it sometimes occurs, and is the subject of great annoyance, we will describe it here. The opening of the urethra, is greatly contracted in size, and instead of appearing in its ordinary position, it opens near the end, yet quite under the urethra, so that the stream of urine is greatly contracted, and passes di- rectly downwards, at right angles with the penis. This must impair the virility of the person thus formed; yet not entirely. Doctor James E. Smith, of this city, recently request- ed me to operate, in a case of this kind. The patient was a married man, and the father of two children. He was unconscious of any other inconvenience than great annoyance in urinating. The operation is one of great delicacy, and some uncertainty, as the same liability of the new opening to contract exists, as in cases of stric- ture. The old opening must be healed up, by incising its edges by an elliptic incision, circumscribing it entirely, and made transversely with the penis. The skin, which is very flexible, must then be drawn forward complete- ly over this elliptic incision, as far as its anterior edge, which is to be made directly under the glans, cutting away the froenum, if necessary. It must here be at- tached with several stitches, and a new opening made through the lower part of the glans, in the natural situa- tion, with a very delicate piercer, with a lancet shaped point. MALFORMATION OF URETHRA. 157 I am in the habit of using a similar instrument for this purpose, and the operation for lachrymal fistula of the eye. It is literally a delicate spear, one inch in length, and the eighth of an inch in diameter, at its broadest part. This is to be passed through the glans, in the ordinary situation of the meatus, in a line with the urethra, until it enters its cavity. The end of a small bougie, of sufficient length, is then to be intro- duced, the rest of it having been cut off. This is to be secured by passing a piece of thread, with a needle, through its base, and tied round the end of the penis. Thus all danger of its entering the bladder is avoided. It will have to be worn a long time, and increased in size, some two or three times, before it effects its pur- pose. But the increase of satisfaction, in performing all the functions of the part, usually induces patients to submit to the annoyance. 14 CHAPTER IX. PHIMOSIS AND CIRCUMCISION. There are two conditions of the prepuce, or that moveable part that can be drawn over the glans, and re- tracted again, that occasions, during syphilis and gon- orrhea, the greatest annoyance, and demands the inter- ference of the surgeon. The enlightened nations of the earth, should surely adopt the ancient rite of circum- cision, as admirably adapted, not only to prevent these minor evils, but, in all probability, by facilitating clean- liness, the existence of the diseases themselves, as well as other serious affections of the same parts. Hey, Boyer, and Roux, all speak of the intimate connexion of phimosis and cancer of the penis. The author trusts he will be able to give a perfectly intelligible explanation of these affections, without the aid of illustrations. They have been purposely avoid- ed, throughout the volume, because they are so apt to excite prurient ideas, in the young ; and the work be- ing designed for popular instruction, it is hoped will do no harm, if it does no good. Those filthy and obscene publications, that come fairly under our sleeping act, for the suppression of licentious prints, are a sufficient dis- grace to those who write, and those who publish them. The foreskin, or prepuce, as it is termed in anatomy, PHIMOSIS. 159 is, as every male knows, a prolongation of the skin cov- ering the penis. When drawn back, it is seen to be united with a far more delicate tissue, that is continued over the glans, and actually into the opening of the pe- nis ; it there becomes still more delicate, and forms the lining of the urethra, and so on to the bladder itself, and even the kidneys. This is precisely analogous to the skin passing from the face, over the lips, into the mouth, stomach and lungs. The inner and outer skin, if we may so speak, merge imperceptibly into each other. And we here take occasion to say, that this furnishes a good reason to be very careful in avoiding chills, and all exposure to the night air, when the mucous membranes of any of these cavities are affected with disease. The reader will remember the effect of going from a warm room into the cold air, in stopping the urine in stricture, and the great aggravation of gonorrhea by wet feet; and we all know the contraction of a common cold, or ca- tarrh, by the same cause. Whatever has a tendency to inflame and thicken the prepuce, will, in proportion to its extent, cither prevent its retraction, or when retracted over the rim of the glans, suffering it, in its thickened and contracted state, to fall into ihe deep groove, which separates the glans from the body of the penis, prevent its return. The for- mer is called phimosis, from (Jh^oj, a muzzle or bridle ; the latter, paraphimosis, from wapa, about, and i^oo, to bridle. Either of these states may also be produced b; swelling of the glans itself, although, as they are con- tinuous, the prepuce is usually affected equally with it. 160 PHIMOSIS. Phimosis is also a deformity, with many, from birth Indeed, it is those who have naturally too long a fore- skin, who are most liable to these accidents. We will now describe them in order, beginning with natural phimosis, in its greatest degree. This, also, often occurs from neglecting to retract it in very old men. A young man, aged eighteen, has just been dismissed from attendance, cured by the opera- tion. It was so complete, in his case, that the opening in the prepuce was far less than in the penis, and he experienced so much difficulty in passing his water, that he supposed himself strictured. This proved to be the case also, but it could not be ascertained till the phi- mosis was removed. The Jews draw the foreskin through an oblong open- ing, in a small silver plate, and cut it off obliquely, in the direction of the glans. This is protected by the plate, which intervenes between it and the knife. This operation can only be done in infancy, when the integu- men is delicate, and can be easily elongated. In my patient, the following operation was perform- ed : A small grooved instrument, called a director, was passed between the glans and prepuce, as far as it would go, that is, with no pressure greater than would just carry it to its destination. A sharp pointed, curved knife, was passed upon the director, and piercing the prepuce, it was severed at once completely through, so as to expose the glans. The corners were then remov- ed with scissors, and six delicate stitches, made with a cambric needle, attached the mucous membrane to the outer skin of the remaining prepuce. PARAPHIMOSIS. 161 We are in the habit of using a forceps with its two chaps curved, and an inch in length, at right angles with its shafts ; these greatly facilitate the operations upon this part; they enable us to grasp the coiners, and remove them with mathematical certainty at a sin- gle clip of the scissors, instead of the repeated and ir- regular incisions with the knife; indeed we have long since ceased to use the common forceps for any opera- tion where there is much loose skin. These instru- ments are described by the writer in the Boston Medi- cal and Surgical Journal, and it gives him great plea- sure to state, that they have been much approved of by the profession. This is a fair illustration of the operation for natural phimosis; it is often performed by the practical surgeon, and is only to be done when the parts are uninflamed, and at rest, if the surgeon can have the selection of time: yet it often happens that a patient presents him- self with chancres concealed by the prepuce whilst in a state of inflammation, producing phimosis; or such ir- ritation of the glans in gonorrhea, as causes by the swelling and inflammation of that part and its continua- tion to the prepuce, the same result: now the parts being so much inflamed, it would be highly injudicious to proceed with the same operation, as they would not unite, and a very irregular and unseemly state of the prepuce would remain. The plan we adopt in such cases is, to make the first incision only, thus exposing the glans, which enables us to examine and treat the chancres, or the urethra, as the case may be. The edges of the wound should be 14* 162 PARAPHIMOSIS. protected with lint, so as to prevent irritation either if the urethral or chancrous discharges : the latter, if any, should be immediately covered with lint: in short, the surgeon and patient must use as great care and cleanli- ness as possible. When the patient has recovered from the inflammation, the rest of the operation may be com- pleted. There are a great many means used for allaying in- flammation of these parts by those who are unwilling to operate, yet I cannot but think a single and rapid in- cision not only entirely safe, but far the best and least tedious method of relieving the patient and surgeon from a very embarrassing situation. The application of leeches is more than questionable ; the irritation and pain of their bites far exoeeds the benefit; and all kinds of injections will soon convince the accurate observer of their uselessness. Not so, however, with the immersion of the penis in warm water; this is an agent, not only mild but efficient, from its relaxing effect; it is in our hands only a preparation for the incision, as this is ne- cessary to prevent a recurrence of the evil, or what is worse, the supervention of paraphimosis. This, when it unfortunately occurs, is, as we said be- fore, brought about by the complete retraction of the prepuce behind the glans, or its projecting edge, which is called from its encircling this part, the corona glan- dis. It is a disease that calls for immediate relief, be- cause it will otherwise by completely strangulating the glans, which is highly vascular, prevent the return of its blood for so long a period, as to cause mortification and its entire loss. This same difficulty occurs in CIRCUMCISIOM. 163 children from means entirely artificial; for they mis- chievously tie strings around the glans, and have been known to endure the torture of complete mortification, rather than expose their mischief. The string, of course, must be severed. The other may, if attempted early, be relieved with- out an operation, thus : the surgeon is to place his two thumbs side by side upon the glans, and his two next fingers of each hand on the sides of the penis, steady and continued pressure thus made for a sufficient period, will gradually force out from the glans enough of its blood, to permit the stricture to be brought forward ; as soon as it slips over the corona glandis, the surgeon is to desist from pressure. He will of course use his judg- ment, and divide the stricture at once as a method far less painful, should he be called so late that the conges- tion of the glans is very great, and the pain from pres- sure excessive. Should there not be a reasonable chance of success it will be right to do this at once, as the pressure will only increase the pain and swelling, and hasten mortification. Nothing is more common to the practical surgeon than these affections, and there is no doubt that the hu- mane and enlightened rite of circumcision, if practised on all male children, would render them very infrequent, as they are generally caused by a preternatural elonga- tion of the prepuce; this, though always don'e to all Jewish male children, is of course adapted in extent to the case, some requiring the removal of much more than others : the method adopted is admirably calculated to 164 CIRCUMCISION. produce uniformity in the result, and surgeons would cheerfully adopt it if suited to the adult. But we are not only to view the ceremony of the Jewish people as preventive of these two annoyances ; there is no doubt that it would prove a most effective means in preventing the spread of syphilis. If the view we have taken of that disease be correct, viz.: that it is produced by a union of foul secretions of both sexes, the reader can at once see that a shortened prepuce, by facilitating the removal of the secretion that is constantly accumulating about the glans, it must be a great pre- ventive measure: it is very evident that the actual dis- lodgement of the syphilitic poison by immediate ablu- tion, is the best means of preventing its absorption ; the frequent occurrence of chancres in the folds of the pre- puce and upon the glans, shows that its presence is cal- culated to facilitate the contraction of the poison. It may naturally occur to some that this elongation of the prepuce cannot be a natural deformity, as its fre- quency renders it utterly disproportionate to other de- partures from the natural state; nor is it so : it is doubtless often produced by the mischievous desire of the child to be constantly meddling with this part, and finding that it yields readily and without pain, it becomes quite a pleasant diversion ; every boy is familiar with the experiment of holding the prepuce together, and then distending it with urine. The absurd and culpable fingering of nurses and vul- gar mothers, is a matter that cannot have escaped the notice of the observing physician. With what object this can be done on a delicate infant heaven only knows; CIRCUMCISION. 165 whether to minister to a filthy and prurient imagination, or to effect some profound and wonderful benefit, is un- known to the writer, for he has never been able to elicit a confession of the motive ; the fact however is undoubt- ed, and it only serves to show the importance of direct- ing popular attention to the physical treatment of infants. Nothing should escape the notice of the philosophical physician, and whatever can cause the complete physi- cal development of a perfect human being, is so much added to the well-being of the general humanity. CHAPTER X. SWELLING AND OTHER ENLARGEMENTS OF THE TESTICLE. As it is our design to connect as far as possible those diseases that are consequent upon or produced by syph- ilis or gonorrhea, we pass over the other congenital mal- formations of both sexes, leaving them for future con- sideration. It was observed when speaking of the radical cure of gonorrhea, that injections were supposed, by stopping the discharge from the urethra, to produce swelling of the testicle : this does not apply to those cases in which the injection is used upon the first appearance of irrita- tion, before the discharge is established, but after it has been running for a few days. The writer is far from wishing to deny this, on the contrary he believes it occa- sionally does so ; with him, however, it becomes a mere calculation of profit and loss to the patient; shall the discharge be permitted to go on with the certain result of a great deal of distress, and the great probability of stricture, and as we shall soon see, that of swelled tes- ticle too, whether the injection is used or not, or shall we endeavour to secure him from these evils, with the remote possibility of a slight swelling of the testicle, easily reduced by appropriate remedies ? For ourselves, SWELLED TESTICLE. 167 we choose the latter, and we have no doubt the patient would also, if he knew the contingencies of suffering the discharge to continue, and the great distress often produced by giving medicines for gonorrhea by the mouth. Moreover, injections are not the only cause of this evil; if we wish to avoid all the exciting causes, we must cease the mechanical treatment of strictures entirely, for swelled testicle is excited by any thing that produces irritation in the urethra, gonorrhea itself being by far the most active cause. The first symptom the patient observes, after the disappearance of the discharge from the urethra, is a sharp pain in one of the testicles, shooting up along the cord to the groin, and then to the back. It often happens that the testicle swells very sudden- ly to the size of a hen's egg, and occasionally the cord, through which the semen passes up into the groin, be- comes swollen to the size of the little finger : this is not frequent however: the testicle is exquisitely sensitive, fever accompanies, and the patient is obliged to lie down as the weight of the gland is insupportable. There is often an annoying rolling of the testicle, caused by the action of the muscular tissue of the scrotum : the swell- ing of one testicle sometimes subsides suddenly, and it attacks the other; both are rarely affected at once. Although there are several other enlargements of the testicle, and of a very serious nature, it is unnecessary to mention them here ; the surgeon will always recog- nise this to be the swelled testicle only, from the sud- denness of its attack as well as its occurrence simulta 168 SWELLED TESTICLE. neously with, or immediately on the subsidence of gon orrhea. There is an appendage to each testicle, called by sur- geons the epydidimis, which it is unnecessary further to define, than to say, that it is a convolution of the nu- merous tubes, of which the structure of the testicle is composed, appended to its outside, and from which the cord proceeds ; all these tubes uniting in it, and ascend- ing singly the groin. In this substance there may re- main a considerable degree of hardness, after the swell- ing of the testicle subsides ; it need excite no apprehen- sion, as it neither decreases or impairs the functions of the gland. This is often a source of great annoyance to the patient; he may rest assured, that it is exceed- ingly common in many, whose numerous families often induce them to wish that it had somewhat impaired their procreative ability. The treatment of this affection consists of leeches, in sufficient number to produce a decisive effect—that is, from fifteen totwenty,—nauseating doses of antimony, and evaporating lotions. The judicious surgeon will not attempt, by inserting bougies into the urethra, to bring back the discharge, as was the custom in the olden time, because this irritation would not only fail to effect the end in view, but it might prove highly efficient in con- tinuing the disease. Purgatives are also used, when judged proper, and the pain may be relieved by injec- tions of laudanum, by the rectum, as in gonorrhea. There is a substitute for leeches, that may be adopt- ed, if they are not to be had, viz. passing a ligature round the scrotum, as we do around the arm, in bleed- SARCOCELE. 169 ing, and opening the veins in several places, with the lancet. Immersing the scrotum in warm water, will facihtate the flow of blood. This disease is quite a common attendant on mumps, particularly in children. The treatment, if any is required, is the same. Although it has nothing to do with syphilis, still there 4 a swelling peculiar to that state. The precursor of the affection, whether chancre or gonorrhea, will suffi- ciently indicate its nature to the patient. Sarcocele.—So far, we have confined our attention to those diseases of the genital organs, more immediate- ly connected with venereal complaints. We shall now speak of those they share in common with other parts of the body. Both the penis, and its appendages, are liable, from the peculiarity of their structure and func- tions, to some affections of a malignant and obstinate character. And we regret to say, that in consequence of their incurability by other means, they often come under the notice of the operating surgeon. To avoid unnecessary subdivision, we will continue our remarks on diseases of the testicles. In designating the diseases, we shall use the scientific terms, explain- ing them immediately, so as to adapt them to popular comprehension, and enable the patient to use his own knowledge, in speaking to his surgeon, or to detect quackery, should he be so unfortunate as to fall into such hands. The intelligent attendant will not fear discovery ; he has nothing but truth and science to be, discovered. The sooner the quack is detected, the bet- ter for the patient and society. 15 170 SARCOCELE. The first and most common of the permanent en- largement of the testicles, is one of a fleshy and unma- lignant character. It is called sarcocele, from two Greek words, tfap£, flesh, and xtjxij, a tumor. Authors make a distinction, in this disease, between an affection of the body of the testicle, and the appendage described when speaking of swelled testicle, called the epydidi- mis, alleging the latter to be much more easy of cure than the former. The truth is, that sarcocele of the testicle is very rarely cured, and the thickening of the epydidimis is, as we said before, not often troublesome. We believe them to be, in the great number of cases, to- tally different diseases. Sarcocele approaches very insidiously, commencing with little or very dull pain. It is a gradual enlarge- ment and hardening of the testicle. It preserves its form, and may last for years—its principal inconveni- ence being the increase of weight, which is generally alleviated by wearing a suspensary bandage. The first appearance of pain of a severe kind, passing up the cord to the groin, usually attracts the patient's renewed attention, after it has been stationary for months, and perhaps years ; and it is then found that the cord itself is enlarging. There is now no time to be lost; surgi- cal aid becomes immediately necessary. In this state of things, castration is the only remedy. On the first appearance of the disease, the applica- tion of leeches is usually presevered in for a long time; yet I have never seen the slightest benefit from them. Mercury has been applied to them, in every formula, SARCOCELE. 171 and it is said, with occasional benefit. It has also been administered with cicuta, by the mouth. But the prep- arations of iodine merit, by far, the most attention. The success of this remedy, in my mind, confirms the idea of the frequency of the scrofulous nature of sarcocele. Were I the subject of a disease of this kind, I would submit my case entirely to this remedy, until the slight- est enlargement of the cord, satisfied me there was no alternative but the knife. In all diseases of the testicle, great care must be taken to distinguish enlargement of the veins of the cord, from permanent or structural change. See hydrocele of the cord. There is no doubt a predisposition in families to these affections. I have removed no less than three testicles, affected with sarcocele, from brothers, in this city. There is nothing of the syphilitic character in this dis- ease. The swelled testicle alluded to, when treating of syphilis, is undoubtedly syphilitic, and can only be successfully treated by mercury; whilst that medicine has very little effect in this. There is nothing to pre- vent a person from having a sarcocele, who .has had syphilis ; yet a far greater number who have never had any symptom of the latter, have the former. Although, like all glandular parts, a simple sarcocele, that often remains quiet for years, may suddenly degen- erate into a malignant disease, requiring immediate ex- tirpation, to preserve life, still, in the commencement, there is no danger of mistaking these diseases. The only affection liable to be confounded with it, is one with which, in its more advanced stage, it is often united, viz. 172 HYDROCELE. Hydrocele. Each testicle is surrounded with a separate membra- nous sack, attached to its posterior part, and moistened only, on its inner surface, with a slight exudation, we may say, to prevent friction.* This is sometimes pro- duced in excessive quantity, even to a quart in amount, and constitutes the disease called Hydrocele. It is de- rived from the Greek words, uSwp, water, and x^y, a tumor. We shall give the distinguishing characters of this, and the last affection, as we proceed in its de- scription. Persons, at every period of life, from infancy to ex- treme old age, and in every state of health, are subject to this disease. It usually exists on one side, though I have several times had occasion to operate on both. Its causes are not known, though it is observed to be often the seeming result of attrition; such as ride much on horseback, being more liable to it. It is entirely of a lo- cal nature, and not connected, in any way, with gene- ral dropsy. 11 would always present a transparent ap- pearance, when held behind a candle, in a darkened room, were it not for the very variable thickness of the membrane, that contains the water ; and this latter cir- cumstance, also, renders it very liable to be mistaken for sarcocele. Both these diseases begin at the lower part of the scrotum, but as the testicle enlarges in sarcocele, it pre- * The testicle itself, is immediately covered with a duplication of the same membrane, closely attached and identified with its propel substance. They slide upon one another. HYDROCELE. 173 Berves its oval form, whilst the hydrocele assumes the pyriform shape, with its larger extremity downwards, that being the natural formation of the sack that con- tains the water. If transparency exist, it is certain evi- dence of water; but the sarcocele itself, may be com- bined with hydrocele. Sarcocele, when alone, is usually much harder than hydrocele, and when held in the hand, is heavier than it. In hydrocele, from the natural attachment of the sack, to the posterior part of the testicle, the water can- not cover it there, and when pressed upon, at the lower and back part of the scrotum, the testicle can be made to feel pain, whilst the other part of the sack, with the water intervening, renders it insensible to considerable pressure. A hydrocele, although softer than a sarcocele, and yielding to pressure, is sometimes less so, from the thickening of the sack, especially in old cases: whilst some parts of a sarcocele may be much softer than oth- ers, thus resembling water. The upper part of the cord, in many cases of sarcocele, is much thickened, and then there is every reason to suppose it a sarcocele. This is the best symptom, by which to ascertain its na- ture, in combination with hydrocele. In this complica- tion, the sarcocele is the first complaint, and can be distinguished satisfactorily, before the hydrocele ap- pears. Hydrocele will soon obliterate the folds of the scrotum, and it will extend to the ring, or opening in the abdomen, surrounding and preventing the cord from being felt. Sarcocele leaves the cord perfectly palpable to the touch. 15* 174 HYDROCELES OF THE CORD. Rupture, or hernia as it is called by surgeons, may be complicated with these complaints, more especially a species common to children, and in the event of an operation either to cure the hydrocele or discharge the water, the deplorable result of puncturing the intestine might follow and death occur, or a false passage for the fceces. Hernia always comes from the groin and pro- ceeds downwards ; it is therefore thickest above, whilst the water in this species of hydrocele always begins from below ; moreover the hernia may be reducible, or capa- ble of being put back into the abdomen. This is a suf- ficient criterion in this variety. There are others, how- ever, which exist in various parts of the cord and even penetrate the abdomen through the ring. These are termed HYDROCELES OF THE CORD. When surgeons speak of the cord, they allude to the duct that conveys the semen from the testicle, up the scrotum, into the ring or opening on the side of the penis, into the abdomen, and so downwards into its re- ceptacles on the sides of the bladder, and thence into the urethra, whence it is expelled by appropriate mus- cles during coition. There is one of these ducts, ac- companied by an artery and vein, to each testicle ; they are surrounded with what we have already described as the cellular tissue that connects every part of the body, and a continuation of the same sack that contains the water of the hydrocele last described ; this extends from the testicle to the ring; then enclosing all, a cylindrical muscle whose duty it is to suspend the testicle. Thus HYDROCELES OF THE CORD. 176 it will be seen that the cord has three coverings; they all come out of the aperture or ring by the side of the penis, enclose the cord, and go to the testicle. The cellular tissue investing immediately the cord, is in a natural state extremely delicate, consisting of cells scarcely visible to the naked eye, but when filled with the fluid of hydrocele they become much larger ; in this hydrocele the water goes from the testicle to the ring : it cannot surround the former as in hydrocele of the tes- ticle, because there is the adhesion we have spoken of, and this produces the distinctive term, hydrocele of the cord. From its going into the ring it may be confounded with a species of rupture, for as we said before they all come through the ring; from this it is distinguishable by close attention, in the following way; when the patient lies down, the hernia or rupture may be returned into the abdomen ; the hydrocele cannot, for it is sealed up within the cells of the cord. Should the rupture be ad- herent or grown fast, this mode of determining it is im- possible, and all must then depend upon the tact of the surgeon. There is a disease of the veins of the cord called varicocele, in which they enlarge like a bundle of earth-worms ; this disappears when the patient lies down, besides it rarely goes higher than the ring, unless combined with other disease of the cord. These two dis- eases may also co-exist, and then the tact only of the sur- geon can discriminate them. ENCISTED HYDROCELE OF THE CORD. It sometimes happens that a hydrocele occurs in an 176 ENCISTED HYDROCELE OF THE CORD. isolated portion of the cord: this is caused by a fortui- tous adhesion of the investing sheaths both above and below, suffering the water to accumulate in their inter- vening portion. This variety occurs oftener in children, but is not as common as the others; the estimates of European authors with regard to its frequency will by no means apply to this country. Richerand considers it to occur in the proportion of one to two hundred; now as the writer has often seen it, this cannot be cor- rect, as we do not see the other varieties by hundreds, though they are not infrequent. It undergoes no alteration from change of posture, and is, like the others, productive of no pain in hand- ling. The testicle is perfectly distinct below, and the cord above, between the swelling itself and the groin ; yet there are occasional exceptions to this: a distin- guished surgeon of this city requested me to examine an infant in whom an incisted hydrocele was so high up the cord that it went into the ring, and might upon an ordinary examination have passed for a rupture: by placing the hand on the abdomen and pressing the con- tents downwards, no additional tension or protrusion was caused, which must have been the case had it been a hernia; darkening the room and holding a lighted candle near it, whilst it was viewed through a thick roll of paper forming a tube, and placed directly upon the tumour, showed its transparency, the tumour appearing like a yellow grape : this is as we said before decisive of all hydroceles; it proves them to contain water. The prudent surgeon will always remember that other affections such as hernia, may exist in a very dan- ANASARCOUS HYDROCELE. 177 gerous contiguity : he will therefore use all his tact in the examination, and it will reflect credit on his head and heart, and add to his peace of mind if he avails himself of other eyes and fingers than his own ; in dif- ficult cases when a surgeon has been intensely occupied with " making his diagnosis," both his touch and his perception generally become confused, from too close at- tention to one object, and a fresh head and touch will often discover an error, or confirm a doubt; but let him call in a head and heart he actually knows to be under proper and manly influences, or he will only add to his own annoyance, and endanger his patient. There is one other species of hydrocele ; it is called Anasarcous Hydrocele,—from ava, through, and