AN ESSAY ON ^ AND THE Umu anir ^mutu of Mtvtnvs IN THEIR TREATMENT. 'illustrated by drawings OF THE DIFFERENT FORMS OF VENEREAL ERUPTIONS. BIT RICHARD C ABMICHAZIZ., M.a.IJ9L. nCE-PRESIDEKT OF THE HOTAL COLLEGE OF SURGEONS Ilf inELAND, AKD OJfE or THE SUKGEOXS OF THE RICHMOND SURGICAL HOSPITAL, DUBLIN, Sec. &C. &C. WITH PRACTICAL NQiTES, &c. BY G. EMERSON, M. D. > PHILADELPHIA :tj PUBLISHED BY JUDAH DOBSON, (AGENT,) AND A. SHERMAN. J. HARDING, PRINTER. 1825 TO SIR JAMES M^GRIGOR, M.D. F.R.S. PHYSICIAN EXTRAORDINARY TO THE KING, AND DIRECTOR GENERAL OF THE ARMY MEDICAL DEPARTMENT, Whose elevated office is a source of pride or gratifica- tion to him, only because of the ample opportunities which it affords him of advancing the cause of medical science — whose right to this appropriate tribute of respect is indisputable and exclusive ; as^ without his powerful influence in promoting this most important investigation in every corner of the globe occupied by Bintish soldiery, no efforts of mine, in this disregarded province of the empire, even though assisted by the warmest adherents of my vieivs in the ordinary walks of the profession^ could have established, at so early a period after their first promulgation, those truths, IV hie h have created so remarkable a revolution in the treatment of a class of diseases, the most perplexing, difficult, and unmanageable in the catalogue of human afflictions. The value of those truths he 7'ecognised as soon as they came within his knowledge ; and he encouraged^ their dissemination with, perhaps, still greater zeal, than if the author had been personally known to him, or had obtruded those opinions on his notice, which he has spontaneously honoured with so extensive and efficient a share of his attention. To him, therefore, to whose sagacity, intelligence, and candour, I owe so much ; and to whose liberality, vigilance, and indefatigable energy society is, in such a variety of ways, so deeply indebted, this treatise is gratefully and affectionctiely inscribed by His faithful and devoted fine nd, RICHARD CARMICHAEL, ADVERTISEiMENT. It is now ten years since the first edition of this work was submitted to the public. The novelty of the views, as well as the numerous host of facts adduced, perplexed the profes- sion at that time not a little ; and were it not for the authen- ticity of the latter, the former, by their boldness and opposi- tion to long established opinions, would hav^e been totally disregarded. The opinion of the profession, and of the pub- lic, has been since that period materially altered, and in place of the belief that no venereal complaint can be cured with- out mercury, it is now very generally acknowledged that every form of venereal disease may be successfully treated without that remedy. This fact, which no individual^ however extensive his practice, could satisfactorily establish, has been domonstrat- ed chiefly by the testimony of those enlightened surgeons of the army who, adopting my practice, prosecuted with great effect an enquiry for which their situation peculiarly adapted them. And it is now so firmly established, that I no longer think it necessary to burthen my work with an accumulation of cases, with a view of proving that mercury is not necessary for the cure of the greater proportion of venereal complaints. The reader, therefore, will find, that in this edition no new cases are adduced, except for the purpose of illustrating the treatment of some particular symptoms, chiefly those apper- taining to that congeries of symptoms which I have named the Phagedenic Disease. A vast deal of new matter, of the importance of which I leave others to judge, has been added, and the general arrange- ment of the work has been so materially altered, that were it not that I made use of some of the old materials of the first edition, and of those of my " Observations on the Uses and Abuses of Mercury," the present edition might be esteemed altogether a new work. It must be acknowledged that the profession are at present quite unsettled with respect to the treatment of venereal com- plaints ; so much so, that probably no two practitioners think alike on the subject, or pursue precisely the same mode of VI ADVERTISEMENT. treatment for their cure: This is exactly what might have been expected. The public mind, when thrown into doubt with respect to any long established usage, must take time to reflect and examine facts before it can settle upon the pro- priety of any new system. He must be Quixotic, indeed, in his expectations, who at so early a period, could look for more than this. But even in the present state of uncertainty, much good has arisen; for we seldom now witness a constitution run down by the excessive use of mercury ; or find that that medicine is now ever exhibited, when it is obvious that a con- sumptive tendency, or other causes, might render it hazar- dous to the patient's constitution : and I assert, that even if nothing more than this advantage were achieved by the in- vestigation, it has already conferred important benefits upon society. It is a fact, that the consumption of mercury has been ma- terially lessened within the last ten years. Many eminent apothecaries in this city have informed me, that there is not a sixth of the quantity consumed which was formerly used in the metropolis ; and 1 have not a doubt that even this pro- portion will continue to meet with a still farther reduction. Mankind are, however, at all times too apt to run into ex- tremes. Many think that because the use of this medicine has been carried to a needless and pernicious excess, that we can dispense with it altogether. From this opinion I most decidedly dissent. Mercury, I believe, when duly, considerate- ly, and appropriately applied, will be found a most useful aux- iliary ; but it is merely as an auxiliary, and not as an indis- pensable specific that I would wish to have it considered ; and it is one of the chief objects of this work to point out where it may be advantageously employed ; and where it ought to be avoided, as a far greater evil, than the poison against which it was intended to act as an antidote. ADVERTISEMENT TO THE FIRST EDITION, PUBLISHED IN 1814. The object of the following treatise is chiefly to elucidate an important class of diseases hitherto confounded with syphi- lis, but to which the attention of the profession has of late been attracted by Mr. Abernethy; and it will be satisfactory to state, in the first instance, the opportunities w^hich conduced to enable the author to investigate a subject requiring a very ample field of observation ; and, in the second place, to make the reader acquainted with the manner in which that investi- gation was prosecuted. The Lock Hospital of Dublin is probably the most exten- sive institution in Europe, for the exclusive reception of pa- tients affected with venereal diseases. It is supported by government, and, in general, contains from two hundred and eighty to three hundred patients. The hospital is visited daily by five surgeons,* each of whom attends his allotted wards; but the entire institution is, of course, open to the ob- servation of all ; so that each has the advantage of witnessing any peculiar or interesting case which may occur in this ex- tensive institution. The manner in which the investigation was prosecuted was on the most simple plan. Whenever a primary ulcer on the genitals occurred, which was destitute of the cha- racteristics of chancre, the hardened edge and base, it was treat- ed without the exhibition of mercury ; and the same system was pursued in those cases of constitutional symptoms which had a doubtful appearance. The scaly syphilitic blotch, as de- scribed in page 129 of Willan on Cutaneous Diseases, and the excavated ulcer of the tonsil, as described in page 482 of Hunter, t were alone esteemed to be syphilitic, and treated with mercury. * The constitution of the Lock Hospital of Dublin has since been ma- terially changed ; it now only contains beds for the admission of females ; and there are but two surgeons, one an attendant, the other a resident sur- geon. f The edition edited by Dr. Adams is referred to in this Work. Vill ADVERTISEMENT TO THE FIRST EDITION. As to the aflcction of the bones: "Whenever a patient com- plained of nocturnal pa'ms in the shafts of the long boneSyOrhad a decided node or enlargement of the bone, his disease was es- teemed syphilitic and the use of mercury adopted ;* but if the patient merely complained of pains in his joints, or if there was an indication, that the coverings of the bone only were affected by an inflammatory swelling, of a doubtful charac- ter, an occurrence which was not unfrequent, the employment of mercury was postponed, until the nature of the disease ma- nifested itself by indubitable syphilitic appearances. All the cases which did not coincide with these appear- ances, were carefully noted in the following manner: — 1st. — The appearances of the patient at his admission were marked down ; his statement of his complaints, as far as could be collected from him, previous to his admission, was added ; and, lastly, the progress and treatment of his disease were noted, in general, but once in a week, but oftener, if the symptoms required any change of treatment. The cases were noted before an intelligent class of pupils; and the information contained in the following work, was de- tailed in general and clinical lectures during the two last win- ters, in which the nature of the diseases that have been con- founded with syphilis, were elucidated by a frequent refer- ence to the noted cases, and the pupils had opportunities of observing every variety of the symptoms of these diseases on the patients themselves in the hospital, and of contrasting them with those of true syphilis. Asa number of isolated facts can only acquire importance by leading to general conclusions, so it will be necessary in this work, in order to render it useful, to take a short view of circumstances already known. In the first instance, there- . fore, a brief view is taken of some morbid poisons, which stand in nearest relation to venereal diseases; under which denomination are included all complaints propagated by sex- ual intercourse: and the term syphilis is restricted to that dis- ease supposed to be brought to Europe by the followers of Columbus, about the conclusion of the fifteenth century. The symptoms of syphilis are next adverted to;t and afterwards, ♦ It will be found in the sequel, that nodes occurred in other forms of venereal disease, besides that esteemed truly syphilitic, and were treated successfully without mercury. -j- In the present edition this order has been reversed ; syphilis, under the term of scaly venereal disease, from the character of its eruption, is the last considered. AI>VERTISEMENT TO THE FIRST EDITION. IS. the more immediate object of the work is entered on at large. By which prehminary matter, the nature of the pseudo-sy- philitic diseases, as they are termed by Mr. Abernethy, and the relation in which they stand to syphilis, and other conta- gious disorders, will be more clearly understood. Some novel, and probably important matter, will be found in the chapter which treats of syphilis; and those chapters that relate to the diseases which have hitherto been confound- ed with syphilis, are altogether the fruits of the author's ob- servation under the plan already explained. PREFACE TO THE SECOND AMERICAN EDITION. Investigations relative to the nature and treatment of vene- real diseases, commencing with the present century and carried on by some of the most able men of the age, have led to results subversive of the doctrines and practice hitherto inculcated by all the standard authors who have treated of this impor- tant subject. But it so often happens that innovations in medi- cine, though announced and received with all the eagerness and confidence of enthusiasm, are observed to sink when stripped of their novelty and specious gloss, that we are called upon to cherish suspicion as a professional virtue. It is only when this distrust becomes so great as to obscure reason and hinder inquiry, that it is to be considered as reprehensible ; for it certainly behooves us, in the present imperfect state of our science, to embrace with pleasure all such desirable im- provements as have withstood the test of time, and been con- firmed by the experience of the intelligent and dispassionate. Such, we think, should be the reception of the jiew principles and practice presented in this work by Mr. Carmichael, who has not only shown himself entitled to the credit due to Mr. Abernethy and other skilful pioneers, but to the still higher merit of having reduced his acquirements to systema- tic order. Perhaps there may be some who will think that the editor of the present American Edition has undertaken a useless task in superadding any thing to the work of the author. Al- though he could, if necessary, adduce many good arguments in favour of his undertaking, he will trust his justification to a very few. Plants of one soil usually undergo some variation when removed to another. This order of nature applies with great force to diseases, so that modes of treatment however well adapted to the climate and other circumstances of one country are not often perfectly applicable to those of another.* Some * Differre quoque pro natura locorum, genera medicinx; et aliud opus esse Romse, aliud ip ^g^^pto, aliud in Gallia.— Ce/s. Lib. 1. X 1 1 PREFACE. inoJifications will, therefore, oficn be found ^equi^ite to accom- mocJate the details of foreign works to new localities. For want of such adaptation, principles and discoveries have been often abandoned which otherwise might have augmented our stock of useful resources. Hence the utility of such comments as serve to point out variations, and to correct or confirm opinions and practice of foreign origin. To this task the editor felt himself strongly inclined, from having for many years followed in the same track with the author. Such in fact has been the success of his practice founded upon similar principles, that, independently of the testimony of other phy- sicians of this country, whose more ample opportunities have added the strongest confirmation, he ventures to recommend their general adoption v»-ith unhesitating confidence. Early led to commiserate the sufferings of those unfortunate fellow beings whom he beheld in hospitals and private practice a prey to inveterate disease, and almost sinking under the remedy, plans for amelioration were naturally suggested to his mind. He had been taught to believe that the slightest ulceration or abrasion upon the genitals called for the routine of salivation, which was seldom less than two or three months, and so violent as rarely to admit of recovery without some serious local or constitutional injury, and therefore felt no reluctance in aban- doning a miserable alternative when he discovered a course far more humane and efficacious. The established practice seems indeed to have fully verified the old opinion that the cure of the venereal disease, often entrusted to empirics and unskilful persons, is attended with the greater difficulty, that the repentance may be proportioned to the crime of unbridled lust and lasciviousness. That such ideas were formerly held by enlightened persons, may be inferred from the language of Dr. Paman, who, in a letter upon the subject written to Syden- ham, observes that — " he seems to have been touched with a sense of humanity and sin at the same time, who openly wished that (his foul distemper might be but once cured." Although the wise and good Sydenham showed the most sincere incli- nation to alleviate with becoming humanity the condition of those whom thoughtlessness and greater faults had subjected to misfortune, it may well be doubted whether his meritorious intention was achieved by his scruple doses of calomel and moderate salivations of two quarts a day. It may not be amiss for the editor to state, that so far from being inimical to mercury, he ranks himself among the truest friends to the cause of that invaluable medicine, regarding PREFACE. Xni those as its greatest enemies by whom it is indiscriminately and injudiciously employed. Those surely have reason to estimate its value most highly who find it can be employed with little or no inconvenience or injury to the patient, and with a certainty of its performing a cure. The popular no- tion of a mercurial disease superseding the venereal, he has always considered as founded in error, the specific title being generally misapplied to an aggravated train of syphilitic symptoms occasioned by the injudicious or immoderate use of mercury. As well might we call the injurious effects ari- sing from the improper administration of Peruvian Bark, for the cure of an autumnal fever, the Bark disease. The misno- mer in the one instance would not be exceeded by the other* Among those whose authority has greatly contributed ta sanction and favour the doctrines of Mr. Carmichael on this side of the Atlantic, the name of Professor Chapman stands deservedly conspicuous. From one of those coincidences which are by no means unfrequent in the relations of this and the mother country, he was early induced by the course of his inquiries to adopt and publicly inculcate in this city, views relative to venereal diseases very similar to those sub- sequently promulgated by Mr. Carmichael. The first edition of this work was gladly received, and promptly ushered be- fore the public by him. In his preface, he expresses his gratification at the support it afforded to his sentiments, hi- therto regarded as abominable heresies, and recommends it in strong terms to the students of the University of Pennsyl- vania. The value of the present work is greatly enhanced by a very considerable accession of original matter, the new and improved arrangement of the materials, a useful synopsis, ad- ditional plates, and what is of no less consequence, the in- creased weight to which the doctrines are entitled, from the ten years experience which they have since received. The editor has endeavoured to make the American copy more convenient as a book of reference for the practitioner and student, by the addition of a copious index, and the introduc- tion of practical notes wherever the text appeared to be defi- cient in detail. G, EMERSON. Philadelphia, November, 1825. CONTENTS. CHAPTER 1. PAGE Observations on those Morbid Poisons which stand in nearest relation to the Syphilitic, and evidence of the existence of Venereal Diseases which do not arise from that poison - 1 CHAP. II. General observations on Venereal Diseases — their speci- fic distinctions, and appropriate mode of treatment - 38 CHAP. IIL Papular Vftiereal Disease 67 CHAP. IV. Pustular Venereal Disease - - - - 147 CHAP. V. Phagedenic Venereal Disease - - - 162 CHAP. VI. Scaly Venereal Disease 286 CHAP. VII. Diseases most likely to be confounded whh those of Ve- nereal origin. — Synopsis of the Work * 341 AN ESSAY ON VENEREAL DISEASES, AXD THE USES AND ABUSES OF MERCURY IN THEIR TREATMENT, &c. CHAPTER I. OBSERVATIONS ON THOSE MORBID POISONS WHICH STAND IN NEAREST RELATION TO THE SYPHILITIC, AND EVI- DENCE OF THE EXISTENCE OF VENEREAL DISEASES WHICH DO NOTARISE FROM THAT POISON It is a curious fact, that morbid poisons, which excite considerable fever, such as the small pox and measles, yield to the powers of the constitution, and are capable of a spontaneous cure, while, on the contrary, the poison of syphihs, which produces scarcely any fever, or one so low as in general to escape observation, yields so slowly and imper- fectly to those powers as commonly to require, for its extinction, the intervention of art. In the former instance, the increased action of the system is suffi- MORBID POISONS. cient to overcome the poison ; but, in syphilis, it seems to be nearly, if not altogether, insufficient. Thence, it would appear, arises the necessity, in this disorder, of artificially raising an action by means of mercur}?^ ; which, though capable of su- perseding the influence of the poison, does not, however, extinguish, like the natural fever in small- pox, the susceptibility of receiving the disorder again. From the accounts we have had of the yaws, a disease common among the African slaves in the West Indies, it seems to arise from a poison which holds a middle station between those of small-pox and syphilis, and has many symptoms which resem- ble those of both disorders. It may be suspended, but cannot be cured by mercury, or any other re- medy as yet discovered ; and the unassisted powers of the constitution, after a struggle of many months, at length subdues the poison, and the patient loses afterwards all susceptibility of the disease. The pustules in small-pox and yaws, we are told by Doctor Adams, in his observations on a case of the latter disease, are much alike;* each begins with a pimple, the law of each is to induce a slough, and each has its period and decline ; the powers of the constitution being in both equal to the cure. The constitution is susceptible of either but once during life ; but the chief difference between them is in the slower progress of the yaws, which commonly continues for many months before it is exhausted. *See Adams on Morbid Poisons, 2d ed. p. 196. THE YAWS. The ulcers of the throat which attend this disease, resemble those of syphilis so nearly, that, according to the same practitioner, it is impossible to distin- guish the one from the other; and this circumstance and the pustular eruption of the skin, which resem- bles that of small-pox, would lead us to class it as the connecting link between syphilis and small-pox, in the chain of contagious diseases. Dr. Bateman observes, in his Synopsis of Cuta- neous Diseases, " that the practitioners in the West Indies soon learned by experience, that active pre- parations retard the natural progress of the yaws, and that mercurials, although they suspended it, and cleared the skin of the eruption, yet left the patient still susceptible of, or rather, still impreg- nated with the virus ; which speedily evinced its presence by a re-appearance of the symptoms more severe and tedious than before. In truth, the dis- ease, it would seem, like the pustular and exan- thematous fevers of our own climate, will only leave the constitution after it has completed the various stages of its course, and removed the sus- ceptibility of the individual to future infection ; and no medicine, yet discovered, has had any influ- ence in superseding this action, or in accelerating its progress. Unless, therefore, any urgent symp- toms should require alleviation, (which seldom or never happens,) it is adviseable to dispense with the administration of medicine, and to be content with restricting the patient to a moderate and tempe- rate regimen, during the first stage of the malady. When the eruptions begin to dry, or as soon as they 4 THE YAWS. cease to multiply and enlarge, the disease seems to require the same management as other slow and superficial ulcerations, accompanied with a cachectic state of the system ; viz. a light but nutritious diet, a dry and wholesome air, warm clothing, moderate exercise, and a course of tonic medicine, especially of sarsaparilla and cinchona, with the mineral acids, or with antimonials, and small doses of mercury, according to the circumstances of the individual habit. The effects of mercury, however, exhibited so as to excite salivation, as the early West India practitioners recommend, seem to be of a very questionable nature, especially when it is unaccom- panied by the vegetable decoctions ; and, it is cer- tain, that patients have, in some cases, soon recov- ered under the use of the latter, when the mercu- rials w^ere omitted. The native Africans employ decoctions of the bark of two or three trees, which are gently purgative as well as tonic; and likewise wash the sores with them, after carefully removing the crusts."^ Such are the observations on the yaws, which Doctor Bateman has collected from the writings of Doctor Winterbottom, and other medical men, w^ell acquainted with the disease in the West Indies. Upon reading them, I was forcibly struck with the strong coincidence which exists betw^een that di sease, and the constitutional form of some of those com- plaints which have been hitherto confounded with sy- philis. This coincidence is not only striking, with re- * Dr. Batemaa's Synopsis of Cutaneous Diseases, p. 313. SIVVENS. gard to their form, the eruptions being alike compos- ed of papulae and pustules, and attended with pains in the joints ; but also, in the circumstance, that, like the exanthemata, they will run their course, and not relinquish the constitution till they have completed their various stages. This is a remarkable fact, and will be elucidated in the course of this work, by the statement of a great variety of cases. We shall find that the exhibition of mercury, in those resem- bling diseases, produces the same effects as when prescribed for the yaws, viz. it may suspend the disease and clear the skin of the eruption, but will leave the patient still impregnated with, the virus, which evinces its presence as soon as the mercurial irritation has subsided, by a re-appearance of the eruption, or affections of the periosteum bones, and other deep-seated parts. It is supposed by many that sivvens, a disease endemic in Scotland, is a peculiar modification of sy- philis; but Doctor Adams who took particular pains to investigate the nature of this disease, and visited Scotland for the purpose, is of opinion that it is different, although approaching nearer to it than any other morbid poison with which we are ac- quainted. The primary ulcers of the two diseases have this difference, that the syphilitic are attended with a callous edge and base, and sivvens consists only in the clean phagedenic ulcer. In this parti- cular, as well as in several others, it appears to bear a very close resemblance to that form of venereal disease which I have termed phagedenic. The eruption is pustular, and hardens into a dark SIVVENS. brown crust. In syphilis we shall find that the eruption is scaly. Another circumstance universal- ly admitted, with respect to sivvens, in which it differs from syphilis, is, that it never attacks the bones but by the extension of an ulcer of the soft parts in their vicinity.* The primary symptoms of sivvens, we are inform- ed, usually take place on the lips and mouth, the disease being commonly communicated by drinking out of a vessel, or smoking with a pipe which had been previously used by a person infected ; and Doctor Adams remarks, that the ulceration can hardly be propagated, like syphilis, by the genitals, on account of the rapidity of the primary ulcers, which are attended with high inflammation. But, before we discard the supposition of its being dis- seminated by sexual intercourse, we should recol- lect, that phagedenic ulcers, attended with high in- flammation, are every day to be met with on the parts of generation. When we consider the constant communication that exists between the people of that part of Scot- land where the disease is most prevalent, and the inhabitants of the north of Ireland, it would be ex- traordinary to believe that the disease has not been communicated to this country : and, in fact, I am informed, by a medical friend, well acquainted with sivvens, that he met with many instances of it in the county of Antrim, but particularly in Belfast. It cannot be supposed, that the disease would re- * Adams on Morbid Poisons, p. 187. CANADIAN DISEASE. 7 main confined to the north of Ireland, if once admit- ted into it; and I long suspected, that cases of siv- vens were to be met with every day in the Lock Hospital of Dublin, as I had observed many patients whose symptoms strongly resembled those which were pointed out to me in the hospitals of Edin- burgh and Glasgow, as constituting that disease. These conjectures were afterwards verified ; for in the summer of 1812, Doctors Hamilton and Heenan, of Glasgow, visited the Lock Hospital with me, and recognised the disease as that with which they were well acquainted in Scotland. The disease w^as in its constitutional form, and exhibited a good number of ulcers about the size of a shilling, cover- ed by large brown irregular crusts, and accompanied by a few pimples and pustules. This eruption disappeared under the use of so- lution of corrosive sublimate, and decoction of sar- saparilla; but, the above-mentioned practitioners informed me, that though the disease may be sus- pended by mercury, it will return after the most pro- tracted courses of that medicine ; an event which I have myself witnessed in more cases than one in the disease, which these gentlemen recognised as sivvens. There is a very imperfect account of a disease nearly resembling sivvens, by Doctor Swediaur, which made its appearance in Canada, shortly be- fore 1785, and became so general in that year, that five thousand eight hundred persons were discover- ed to be infected with it, besides many who con- cealed the disorder. The disease, we are informed, 8 CAx\ADIAN DISEASE. from the statement of a Mr. Bowman, " first mani- fests itself by little ulcers on the lip, tongue, and inside of the mouth. These ulcers are of a very corrosive nature, and were observed in many chil- dren to have nearly destroyed the tongue. They first appeared in the form of little pustules, filled with a whitish purulent matter; the poison of which is so infective, that it communicates by eating with the same spoon, by drinking out of the same vessel, by smoking with the same pipe, na}^, it is even ob- served that it is communicated by linen, clothes, &c." We are also told that it seldom affects the genitals, and that, like the small-pox, " it is capable of being: communicated without immediate contact or coition." — " Children form a large proportion of the infected." The constitutional symptoms of this disease have a near resemblance to those of syphilis, sivvens, and the yaws, and chiefly consist of "buboes in the ax- illae, groin, or throat, which sometimes inflame and suppurate, and at others, remain hard and indolent." Also "tetters, itching crusts, and ulcers, which appear coming and going in different parts of the body." " Pains in different parts, which increase during the night time, or when the patient takes some violent exercise." — " The bones of the nose, palatum, cra- nium, clavicula, tibia, arm and hand, grow carious, or tophi appear in several parts of the bones ; at last, pains of the breast, cough, loss of appetite, sight, hearing, smell, and falling off of the hair, close the scene before death." The disease we are told is contagious in all its stages, and may continue to CANADIAN DISEASE. 9 harass the patient for many years ; but it is worthy of observation, that Mr. Bowman saw some children who recovered without the aid of medicine. The mode of treatment is very imperfectly de- tailed. We learn " that dock and burdock roots, sarsaparilla and spruce have been generally made use of, and with some appearance of success : most success, however, has been observed from a decoc- tion of the branches of hemlock spruce, (a tree so called on account of the resemblance of its smell to hemlock;) but we are afterwards informed, that none were cured radically without mercury, and that it is necessary to continue that medicine three weeks after all symptoms have disappeared."* From the whole of the information to be derived from the imperfect account of this disease in Doc- tor Swediaur's work, I should be inclined to infer, that, like the yaws and sivvens, it is capable of yielding to the powers of the constitution, and that mercury is only of service, when the disease is on the decline, and has begun to yield to those powers. For if that medicine was capable of curing the dis- ease, with the same certainty as attends its employ- ment in syphilis, we should not find those vegetable remedies resorted to in the first instance, which, ac- cording to Mr. Bowman's account, greatly forward- ed the recovery of the patients; yet it seems they were not radically cured without the assistance of mercury, although in another place, we are inform- * Practical Observations on Venereal Complaints,, p. 169, B 10 LEPRA SEPTENTRIONALIS. ed, that some affected with the disease, recovered without the aid of that medicine. However, the circumstances detailed, I conceive, afford sufficient grounds to conclude, that the Cana- dian disease is not syphilitic, but that it is another instance of a contagious malady which commences with ulceration, and is followed by bubo, eruptions, and ulcers of the skin, pains, nodes, and caries of the bones. A train of symptoms very generally supposed to appertain exclusively to the syphilitic poison, but which, as I hope to convince my reader,^ may derive their origin from primary ulcers which are not syphilitic, and are still more common in this country than syphilis itself. There is another disease similar, if not identical with sivvens and the Canadian distemper, which in- fests the maritime parts of Norway, some provinces of Sweden, and the northern parts of Russia. It is also found, as we learn from Callisen, on the shores of Iceland, in all the Feroe Islands and in some pro- vinces of Scotland. This disease, which is called radesyge by the Norwegians, and is denominated lepra septentrionalis by Callisen,* commences with the premonitory symptoms of lassitude, want of ap- petite, severe pains resembling those of rheuma- tism, rigidity of the limbs, dyspnoea, and violent headach; the face either assumes a singular shin- ing silvery appearance, or a deep red or livid colour. These feverish symptoms may continue for many * Systema Chirurgiae, torn. i. p. 490. LEPRA SEPTENTRIONALIS. 1 1 maiiths, before the formidable train of maladies to which they are the prelude, ensues. A dry branny efflorescence of the skin first takes place; the rege- nerated cuticle gradually becomes more rough and thickened. In many patients there occurs an erup- tion of small spots of various colours not larger than flea bites. These appearances are, however, but the precursors of copper-coloured tubercles or knots on the skin, and herpetic spots on the fore- head, nose, chin, lips, and eyebrows; afterwards they become scattered over every part of the body. The integuments of the forehead become thick- ened and corrugated, the eyelids swell and are everted, the bloated cheeks assume a livid colour, in fact the entire countenance becomes frightfully distorted. The spots afterwards degenerate into malignant ulcers, which even extend to the bones underneath, and render them carious. Every part of the fauces is also liable to be affected with simi- lar tubercles and ulcers which extend to the nares. The bones of the palate and nose soon become ca- rious. Frightful deformity ensues; and the patient, exhausted by so great an extent of disease, dies of hectic fever. Such is the account of a malady which has long ravaged the coasts of the northern peninsula. It has of course attracted the particular attention of the medical men of Norway. I have had the ad- vantage of conversing with a respectable member of that body. Doctor Hoist of Christiana, when he visited this city a few years since, on the subject, 12 LEPRA SEPTENTRIONALIS. and from whose accurate work* I have chiefly taken the above detail. It is not considered by him, or I believe by any of the numerous authors who have written on the subject, as arising from sexual intercourse, but is at- tributed to the mode of living followed by the north- ern Swedes and Norwegians, but more particularly by the fishermen inhabiting the coasts of these high latitudes. Indeed he draws a picture not very in- viting of rural life in this part of the world. Their houses or huts are low, damp, and rarely consist of more than one apartment, in which the entire fami- ly (with the smaller domestic animals of the esta- blishment) remain for many days and nights toge- ther, and in which they eat, drink, and cook their victuals. Into these wretched hovels the air is never intentionally admitted, the windows, which are scarcely pervious to the light of the sun, being always closely bolted down. The fishermen return- ing from their laborious occupations in these rainy and stormy regions hang their clothes soaked in wet, or embued with the filth of fishes, to dry in their smoky huts, which still adds to the impurity of the air. The food of the inhabitants is of the most rancid description, and consists chiefly of salt dried beef and pork, and too often semi-putrid fish. They have no esculent vegetables; and are fre- quently under the necessity of using in place of bread the pulverized bones of fishes, or the dried * Morbus quem radesyge vocant, kc. auctore Frederico Hoist, M. D. Christiana, 1817. LBPllA SEPTENTRIONALIS. 13 fish itself, mixed with the bark of trees or with Ice- land moss. Is it then to be wondered at that people leading such a life, living on the most rancid, indigestible food, breathing a pestilential atmosphere, and filthy in their persons, should suffer the necessary conse- quence of such habits in the attacks of the dreadful disease in question ? The chief part of Dr. Hoist's work is occupied with a consideration of the best mode of averting this evil, and it consists of course in recommending ventilation, cleanliness, bathing, and the cultivation and use of esculent vegetables. We learn from Callisen, that the disease admits of cure during the first stage, before the eruption occurs, and even afterwards, under favourable cir- cumstances. The methodus medendi consists in re- moving all the causes of the disease enumerated; the use of baths, and a milk and vegetable diet, with fresh animal food. With respect to medicine " ci- cuta, trifolium fibrinum, cortex ulmi, rosmarinus sylvestris, evacuentia leniora, et antimonialia," are those he recommends. As to mercury, he observes, that carried to the extent of salivation, it always proves injurious; and that all external repellents are to be strictly avoided, as they drive the disease from the surface to the more important internal or- gans. Doctor Hoist, from the circumstance that this disease begins with fever, which ushers in an erup- tion, conceives that we would be right in classing it with the exanthemata, were it not for its tedious- J 4 BUTTON SCURVY. ness; and therefore places it between the exanthe- mata and cachexiae.* I leave this objection for others to consider ; for my own part, since it pos- sesses the true essentials which characterize the ex- anthemata, — fever followed by eruption, — I should feel no hesitation in placing it amongst them. It appears to me extremely probable that sivvens is the same disease, rendered milder by the im- proved habits of the peasantry of Scotland, and the use of vegetable aliment ; and that this is the dis- temper to which Callisen alludes, when he says that the lepra septentrionalis is found in Scotland. There is an eruption, peculiar, I understand, to this country (Ireland,) termed by the natives the Button Scurvy. It has not, I believe, been men- tioned by any medical writer, and certainly has not been noticed by either Wilian or Bateman. It is so general that I am seldom without a case or two of it in the hospital ; but never yet saw an instance of it in the better ranks of society; nor even among the manufacturers or artisans who live in the city. In the instances I have seen, as far as my recollec- tion extends, it was only found among the peasantry" engaged in agriculture. The spots of this eruption are convex iubercles, varying from the size of a split pea to that of a shilling, seldom so large as half-a- crown ; they exhibit an appearance somewhat like the surface of a raspberry, and discharge a white tenacious matter, which forms thin yellow crusts, * Hisce expeditis abstrusi mali naturam adeo tamen perspec- tam cognitamque habemus, ut inter exanthemata cachexiusque idem referre audeamus. Hoist, p. 37. ON DISEASES RESEMBLING SYPHILIS. 15 that are in general rubbed ojff by tlie patient's clothes. The spots are seldom seen on the face, but are scattered over the trunk and extremities, and are almost always observable on the inside of the thighs, or close to the axillge. The general health does not appear disturbed ; but whether it is ushered in by pyrexia, I have not ascertained, not having witnessed any case at its commence- ment. This disease, which continues for months, nay, years, on the same individual, is generally cured by the use of the tepid bath, and the exhibi- tion of pitch pills, in as large doses as the stomach can bear, in the course of six or seven weeks. I notice the disease here, because the eruption might be readily mistaken by those unacquainted with it, for that which attends the phagedenic venereal dis- ease ; and because I believe that no account of it has as yet been published. As it is found only in one class of society, it is probably owing to the pe- culiar habits of that class ; and the smoky, unventi- lated, and filthy state of the habitations of the majority of the peasantry of this country, with inat- tention to personal cleanliness, may well account for the presence of any chronic cutaneous disease. Whether or not it is infectious I am ignorant ; but believe it is not, although it is generally thought to be so by the country people. The organs of generation are subject to a variety of ulcers, destitute of the characteristics of chancre — the hardened edge and base ; yet most practitioners look on them as chancres, and treat them as such, imagining that inflammation, peculiarity of consti- 16 GENERAL OBSERVATIONS tution, or some accidental circumstance, has de- prived them of the usual character of the primary syphilitic ulcer. To discover whether chancres may be altered by peculiarity of constitution, or accidental causes, we should look to the analogous symptoms of other contagious diseases, and inquire, whether the pus- tule of small-pox, or the vesicle of cow-pock is^ ever so altered, as no longer to display the charac- teristic marks by which they are distinguished the one from the other, and from all diseases with which they might be confounded. It must be admitted that these diseases are obe- dient to certain laws, from which there is seldom or ever any departure ; and if any deviation does oc- cur, it is not sufficient to deprive the disease of those characteristics by which it is distinguished from other disorders. Thus, small-pox is seldom so varied from its usual appearance, as to be mis- taken by any practitioner of experience for any other disease. It is the particular law and charac- ter of the small-pox poison, as Doctor Adams re- marks, to form a slough under every individual pustule, and this essential property of the disease is never wanting. We never find, says that accu- rate observer, the pustules running into phagedenic ulcers, or throwing up a callous edge and base like chancre. If the disease is in excess, as when the pock is confluent, the character of the poison is only more strongly heightened, and the sloughs be- come more extensive. Cow-pock is as strong an intanee of the same re- ON DISEASES RESEMBLING SYPHILIS. 17 gularity. If the vesicle of the cow-pock is broken, we often find a troublesome ulcer succeed, yet the areola is never absent at the usual period, which is looked upon by many as the most marked charac- ter of that poison. The yaws, sivvens, and other poisons mentioned, seem to have their appropriate laws and stated appearances, from which there is no departure. Why, therefore, should we suppose that peculiarity of constitution, or any adventitious circumstance, should prevent the syphilitic poison from producing its accustomed and characteristic effects? It is rational to think, that its laws are as invariable as those of small-pox, cow-pock, or any other morbid poison with which we are acquainted. But, in those ulcers which have hitherto been con- sidered as syphilitic, we should expect the presence of the hardened edge and base, if they were caused by the poison of syphilis; and, in the phagedenic and sloughing ulcers, whose ravages seem to have arisen to the very acme of virulence, we should naturally expect to find the hardened edge and base marked with the greatest strength of character; yet, we find, on the contrary, these peculiarities are to- tally wanting, from the mildest to the most destruc- tive of those ulcers. In an inquiry like the present, it should not be forgotten, that the very organization, secretions, and functions, of the genitals, dispose them to ulcera- tion beyond all other parts of the body. They are organized in the highest degree ; their secretions are various, their functions complicated with those of the urinary organs, they are at one 18 TESTIMONIES 0> THEIR EXISTENCE moment in a state of quiescence, and the next in a state of the highest excitement. Their secretions, particularly in the female sex, are liable to become vitiated, and consequently acrimonious and irritating, and the same effect may follow from inattention to cleanliness. The parts of generation must, therefore, be disposed more than others, to derangement in their functions, and, con- sequently, more subject to the ravages of ulceration. Since Mr. Hunter's work upon the Venereal Disease, it is very generally admitted, that not only certain modifications of animal matter, but the healthy secretions of one animal applied to a sus- ceptible or crude surface of another, is capable of exciting ulceration. It is unnecessary to add how frequently this occurrence must take place during sexual intercourse ; and, from the facts and obser- vations brought forward by Mr. Hunter, and Mr. Abernethy, it appears that this local ulceration may be followed by constitutional symptoms, resembling, in some degree, those of syphilis, viz. eruptions on the skin, ulceration of the throat, and affections of the bones. These facts are proved and elucidated by those diseases which are induced by the suckling of chil- dren, and the transplantation of teeth, as mentioned by Mr. Hunter, and which I shall consider more at large in its proper place. The frequency of ulcers on the genitals, not aris- ing from the poison of syphilis, is fully proved by the testimony of authors who wrote on the subject previous to the latter end of the fifteenth century, BEFORE THE INTRODUCTION OF SYPHILIS. 19 when syphilis was first observed in Europe, and who could not fall into our error of imputing every ulcer on the genitals to that source. Celsus describes eight species of ulcers to which the organs of gene- ration are subject;* three of which are at present as common as the syphilitic ulcer, viz : an ulcer which causes phymosis, but is readily cured by de- tergent washes : and the phagedenic and sloughing ulcers ; for the former of which he recommends the actual cautery, a certain proof of its obstinacy ; and the other he describes as beginning with a slough, and which is prevented with difficulty from spread- ing to the bladder. Other ancient writers, Greek, Roman, and Ara- bian, as Hippocrates, Galen, Paulus ^gninetae, and Avicenna, describe ulcers of the genitals as common and frequent occurrences. The indefatigable Astruc, not contented by ad- ducing a sufficient body of evidence to remove doubts from the minds of the most sceptical, in or- der to prove that syphilis was not known in Europe before the year 1494, also examines the writings of a number of physicians and surgeons, who lived before that time, which seemed to contradict these testimonies. The following are a few of those passages, and are confined to authors who flourished between 1270 and 1470 ; and by them Ave are distinctly in- formed of the infectious nature of some ulcers of the genitals ; — * Celsus, Edinburgh edition, 1809, p. 330 to 335, 20 TE5TI5IONIES OF THEIR EXISTENCE " Gulielnius de Saliceto. a physician of Placenza, obsen'es, in his chapter De apostemate in Ingui- bus. that a bubo sometimes comes upon a foulness of the penis, contracted by lying with a slovenly woman.'' " Lanfranc of !Milan states, that ulcers proceed from hot pustules growing upon the penis, which afterwards burst, or from sharp humours ulcerat- ing the part, or from coition \^*ith a foul woman, who had lately had to do with a man whose penis was ulcered." Bernard Gordon. Professor of Physic in the Uni- versity of Montpelier, states that the diseases of the penis are numerous as impostumes, ulcerations, cancers, inflation, pain, and itch." "Guido de Cauliaco, in his Chirurgia Magna, also treats of heat and foulness of the penis from lying with a foul woman." " Velescus de Taranta, Professor of 3Iontpelier, in his Chapter de Uiceribus et Pastulis Virga?, states, that ulcers break out upon the penis from coition with a woman who has an ulcer in the matrix." '• And, lasth', Peter de Argeleta, of Bologna, Doctor of Arts and Physic, has a chapter, entitled De Pustulis quae adveniunt Virgae, propter Con- versationem cum fosda 3Iuliere, quae albce sunt vel rubrae."* Astruc contends, that the difierent ulcers and buboes, mentioned by these authors, could not have * See Astruc, Book L p. 41. BEFORE THE INTRODUCTION OF SYPHILIS. 21 been syphilitic, because they were found to yield to external applications, and that internal medicines were not thought necessary. " Whence it is plain," he says, "they did not treat of venereal ulcers, w^hich are not so easily cured." He also adduces the testimony of John de Vigo, who wrote about the period in which syphilis first became known ; and who, as might be supposed, found it necessary to la}^ down diagnostics, by which the new disease, syphilis, might be distinguished from the ulcers to which the parts of generation were at all times subject. After describing the characters of those ulcers of the genitals, which were at all times known, John de Vigo proceeds (lib. v. cap. 1.) to detail the ap- pearances of the new disease, and states, " That ve- nereal pustules, from infectious coition, arise in the genitals : viz. in the vagina in women, and on the penis in men, and are sometimes of a livid colour, sometimes black, and sometimes whitish, with a cal- losity surrounding them^ It is satisfactory to remark how soon the sur- rounding callosity of chancre caught the observa- tion of practitioners, and how early it was esteemed the characteristic and distinguishing mark of the primary syphilitic ulcer; but the necessity of at- tending to this discrimination was soon forgotten, and has been, to this day, most strangely neglected by the great body of practitioners. Those other ulcers to which the parts of genera- tion were at all times liable, began soon to be con- founded with the new disease ; and we find authors 22 TESTIMONIES OF THEIR EXISTENCE stating, that it was only occasionally that the callo- sity surrounded venereal ulcers. Nicholas Massa, for instance, in the year 1532, observes, "that fre- quently obstinate ulcers on the penis appear, at- tended with surrounding induration, which are cured with great difficulty." And Aloysius Lobera, phy- sician to Charles V. about the year 1540, says, " that sometimes the patient is affected with ulcers on the penis, which are hard and callous, and that this ap- pearance is a certain mark of the French disease."* But to return to our subject, we learn from the authorities collected by Astruc, the prevalence of infectious ulcers on the organs of generation, long previous to any knowledge of syphilis. But the most curious document he produces on the subject, is a transcript of the statutes made by Jane I. Queen of both the Sicilies, and Countess of Provence, for the regulation of the public stews established at Avignon in 1347. He takes no small pains to con- firm their authority, but whether their truth, or the decorum of the high personage to whom they are ascribed, stand in the most questionable predica- ment, I shall venture to quote the fourth of these very salutary enactments, w^hich is as follows: "The Queen commands, that on every Saturday, the wo- men in the house be singly examined by the abbess, and a surgeon appointed by the directors ; and if any of them has contracted any illness by their w^horing, that they be separated from the rest, and not suffered to prostitute themselves, for fear the * See Astruc, Book I. p. 97. BEFORE THE INTRODUCTION OF SYPHILIS. 23 youth, who have to do with them, should catch their distempers.""^ In fine, there is scarce an authority collected by Astruc, which does not, directly or in- directly, point out the infectious nature of the ulcers in question, and inform us, that buboes were fre- quent attendants upon them : but, it must be acknow- ledged, that we do not find any intimation that con- stitutional symptoms were observed to follow the attack of the ulcers. With the view to ascertain this fact, I shall examine the writings of Mr. Wil- liam Becket. But even if we were without any tes- timony whatever, that constitutional symptoms were the consequence of these venereal complaints, which, as we have seen, infested Europe at all times before syphilis was known, it does not follow that such symptoms did not exist. For although the ancients may have had them before their eyes every day, yet they might not have had any suspi- cion of their origin, or a conception of the connex- ion that exists between the primary ulcer of a mor- bid poison, and the constitutional maladies which follow it. Even when syphilis first appeared, it was thought to be epidemical ; and, like other pestilen- tial distempers, to be owing either to " the malig- nant influence of the stars," — " an unwholesome dis- position in the air," — " a spontaneous corruption in the humours contracted by an error in diet, or the. abuse of the non-naturals." Of the latter opinion we find was Benedict Victorius ; who, in the third chapter of his book, De Morbo Gallico, published * Astruc, Book I. p. 61. 24 TESTIMONIES OF THEIR EXISTENCE ill Florence in 1551, protests, " that he is firmly per- suaded, that the infection itself is not absolutely necessary for producing the venereal disease ; but that the state of the air, together with that of the putrid humours, are sufficient." But, to put the matter beyond all doubt, he testifies, " that he hap- pened once to know some honest and religious nuns, who were confined in the strictest manner, unfor- tunately contract the venereal disease from the pe- culiar state of the air, together with that of the pu- trid humours, and the iveakness of their habit of body."* It was supposed for several years, that the in- fection of syphilis was conveyed, like the plague, from one person to another ; hence, those who were infected, were driven from society into the very forests ; and, in large cities, it was conceived neces- sary to provide for the public safety, by the most severe laws against these unfortunates. Thus, there is extant a decree in the acts of the parliament of Paris, dated the 4th of March, 1496, by which such as were infected with the venereal disease were prohibited, under pain of death, from conversing with the rest of the world, and obliged i6 retire in- to the suburbs of St. Germain's, to places set apart for their reception."! In the year 1717, Mr. Becket, the writer I have alluded to, presented a paper to the Royal Society, in which he endeavours to prove the antiquity of * Astruc, Rook II. Chap. I. p. 118. tAstruc, Book I. p. 110. BEFORE THE INTRODUCTION OF SYPHILIS. 2^ the venereal disease, and that it was known long before the discovery of the West Indies. He un- doubtedly fails in his prime object, but he suffi- ciently demonstrates the frequent occurrence, at the period in question, of gonorrhoea, and ulcers of the genitals, as also constitutional affections, which were esteemed to be symptoms of leprosy. In this enquiry, he confines himself entirely to those diseases as they occurred in England. He contends, that the term brenning, or burning, for many hundred years was used to signify the same disease which we now call a gonorrhoea. This he endeavours to prove in many ways. 1. There were licensed stews in those times, under certain rules. Among the regulations rela- ting to the lordship of Winchester in 1162, it is or- dained, that no stew-holder shall keep any woman who hath the perilous infirmity of burning, under the penalty of a hundred shillings; which was a very sufficient precautionary measure; for it has been ascertained that such a sum, in that day, was equivalent to seventy-five pounds of our money. 2. He quotes a passage from the manuscript of John Arden, surgeon to Richard II. in 1380, in which the brenning is defined to be an inward heat and excoriation of the urethra, and capable of being cured by local means. Among several passages which he quotes from old English authors, the fol- lowing is most deserving of attention. It is from a work written by Andrew Boord, Doctor of Physic and Romish Priest, printed in the reign of Henry Vm. in the year 1546. " If a man," he say$ "be 26 TESTIMONIES OF THEIR EXISTENCE burnt of with a harlot, and do meddle with another woman within a day, he shall burn the woman that he shall meddle withal;" and, as an immediate remedy against the burning, he recommends tbe " washing of the pudenda two or three times with white wine, or else with sack and water ; but if the matter have continued long, he prudently advises the patient to go to an expert surgeon, to have help." — " In another chapter, he gives advice what is to be done if the patient gets a dorser or two ; so called, from its protuberancy, or bunching out ; for, at that time, the word bubo was mostly made use of to signify that sort of swelling which usually happens in pestilential diseases." The subject is continued by Becket, in a second paper, inserted in the 31st vol. of the Philosophical Transactions, in which we find the following obser- vations. "John Arden, surgeon to Richard II., takes notice of those contumacious ulcers, which we now call chancres, and the great trouble our an- cient authors found in attempting their cure, suffi- ciently discover them to have had their original from a venereal infection." He afterwards pro- ceeds to give a quotation from a manuscript in Lincoln college, by Thomas Gascoigne, Chancellor of Oxford, dated 1430, who states, that he knew many men to die of a disease gotten by a connexion with women, which caused a putrefaction of the genital organs and of the entire body ; among whom was the celebrated John of Gaunt,* who, before his * Mortuus est ex tali putrefactione membrorum genitalium et Corporis sui causata per frequeDtationem mulierum. BEFORE THE INTRODUCTION OF SYPHILIS. 27 death, sent for his nephew, Richard II., to witness the ravages of his distemper, and receive a salutary lesson from his misfortunes. The remainder of Becket's paper is an endeavour to prove, that the venereal disease was constantly confounded with leprosy; and, indeed, he brings forward sufficient facts to evince, that diseases ac- quired by sexual intercourse, which afterwards af- fected the skin and the bones, were esteemed to be symptoms of leprosy. With this view, he gives a quotation from John Gadissen, a very learned and famous Physician, that flourished about the year 1340. In a work he entitles Rosa Anglica, speaking of the mode of pre- venting infection from connexion loith a leprous person^ he says, " sed siquis vult membrum ab omni corruptione servare cum muliere recedit, quam forte habet suspectam de immunditie, lavet illud cum aqua frigida mixta cum aceto, vel urina propria in^ tra vel extra preputium." "From hence," says Becket, " some of their leprous women, (as they called them) were capable of communicating an in- fectious malady to those that had carnal connexion with them ; which proves, that the pudenda of wo- men must be diseased, inasmuch as we are abso- lutely assured, that infections of that nature only happen where a sound part comes into contact with a diseased one ; for the symptoms always first dis- play themselves in those parts through which the virulency is first conveyed. Now, in a leprosy, we never meet tvith the mention of any disorder in those parts; which, if there be not, must absolutely se- 28 TESTIMONIES OF THEIR EXISTENCE cure the person from having that disease communi- cated to him, by coition with leprous women ; but, it proves, there was a disease among them, which was not the lepros}^, although it went by that name." These observations of Becket, I conceive, are un- answerable, if it is allowed that leprosy is a disease incapable of being communicated by coition. On this part of my subject the following passage, in Dr. Bateman's Synopsis of Cutaneous Diseases* is so apt, that I shall take the liberty of transcribing it. "Notwithstanding the care with which the se- paration and seclusion of lepers have been enforced, in compliance with the ancient opinion, there is great reason to believe, that elephantiasis is not contagions. M. Vidal long ago controverted that opinion, having never observed an instance of its communication from a leprous man to his wife, or vice versa^ although cohabiting for a long series of years. Dr. T. Heberden daily observed many ex- amples of the same fact, in Madeira ; and affirms, that he never heard of any one who contracted the distemper by contact with a leper. And Doctor Adams has more recently given his testimony to the same truth ; remarking, that none of the nurses in the Lazar House in Funchall, have shown any symptoms of the disease ; and that individual La- zars have remained for years at home, without in- fecting any part of their family." In those details we find strong reasons for be- lieving, with Becket, that disorders which com- menced on the organs of generation, and afterwards * Page 296. BEFORE THE INTRODUCTION OF SYPHILIS. 29 affected the constitution, were very general ; and that they ivere confounded with, and mistaken for leprosy. Becket mentions, that it was very much the practice, among physicians in England, to smear the ulcers, which they conceived to be leprous, with mercurial ointment. This, on account of the great number of the ulcers, frequently brought on saliva- tion ; and the ulcers, to their astonishment, healed. But he argues, that as it is universally acknowledged that mercury does not cure a true leprosy, it follows, that those ulcers which became well under the use of that medicine, were not leprous, but belonged to another disease. Venereal nodes on the bones, the same writer contends, were common before the time assigned to the introduction of syphilis into Europe; and " that they were termed by the old English writers, the Boon, or Bone Hawe; a name which gives us a perfect idea, not only of the part affected, but af- ter what manner it was diseased ; for the old Eng- lish word hatve, signified a swelling of any part. Thus, for instance, a little swelling upon the cornea was anciently called hawe in the eye; and the swelling that frequently happens on the finger, on one side of the nail, was called the white hawe, and, afterwards, white-flaw." Such are the facts stated by Becket ; from which we learn, that a running from the urethra, and ul- cers on the genitals, followed by diseases of the skin and bones, which yielded to mercury, but which were generally looked upon as symptoms of leprosy, were common in England before the period 30 TESTIMONIES OF THEIR EXISTENCE' when syphilis was first observed in Europe. We cannot conclude with him that these complaints were symptoms of a true syphilis, and that that dis- order was at all times prevalent in Europe; because there exists the strongest evidence, in the writings of all medical authors, about the year 1500, that syphilis was a new disorder, and baffled the skill of the most eminent physicians. On the whole, it will scarcely be disputed, that syphilis was first brought to Europe by the followers of Columbus ; and that, previous to that event, there existed, throughout the Old Continent, venereal disorders, both local and constitutional, which strongly resem- bled the new-imported disease, and, to the disgrace of our profession, (with two or three splendid ex- ceptions) have continued from that day to the pre- sent, more than three centuries, to be confounded with it by the general body of practitioners. It is to Mr. Hunter we are indebted for the first steps in an inquiry, which is of the greatest con- sequence to society, inasmuch as it is likely to pre- vent the indiscriminate and excessive employment of mercury, in diseases which do not require it, or are prejudiced, more or less, by its use. 3Ir. Hun- ter observes, "that diseases which resemble others, seldom do it in more than one or two of the symp- toms; therefore, whenever the nature of the disease is suspected, the whole of the symptoms should be well investigated, to see whether it agrees in all of them with the disease it is suspected to be, or only in part. This observation,*' he continues " seems to be more applicable to the venereal disease than INDEPENDENT OF SYPHILITIC INFECTION. 31 any other; for there is hardly any disorder that has more diseases resembling it in all its different forms than the venereal disease ; and when a disease re- sembles the venereal in some of its symptoms, but not at all in others, then those other symptoms are to be set down as the specific or leading ones of the disease to which it belongs, the resembling symp- toms to the venereal being only the common ones." " Other diseases," he says in the same chapter, " shall not only resemble the venereal in appear- ance, but in the mode of contamination ; proving themselves to be poisons, by affecting the part of contact ; and from thence producing, not only im- mediate consequences similar to buboes, but remote consequences similar to the leus venerea."* In elucidation of these opinions, Mr. Hunter re- lates some cases worth adverting to. The first case is that of a gentleman, who inoculated himself with the matter of yaws in his finger, while opening an abscess in the shoulder of a negro woman. In consequence, he was effected with tumours, which extended up the arm to the axilla ; nocturnal pains in his bones, scabby eruptions in different parts of his body, nodes on the tibia, and ulceration of his throat. From the beginning he took mercury in large quantities, which seemed to have no effect upon the disease. The next instance is that of a lady, whose milk being abundant, and her own child too weak to draw her breasts sufficiently, suckled a child, who, * Hunter, p. 567. '&2 TESTIMONIES OF THEIR EXISTENCE it was afterwards discovered, had the thrush, of which it died tabid, with many sores on different parts of its body. The lady, at first, had several small ulcers about the nipples, followed by swelling of the axillary glands ; the former healed, and the latter subsided in the course of three months. Im- mediately afterwards, the patient complained of shooting pains in different parts of her body, which were succeeded by eruptions on her arms, legs and thighs, many of which became ulcers. About two years afterwards, she was delivered of another child in a diseased state, the cuticle peeling off in various parts, and a scabby eruption covering the whole body. The child lived but nine weeks. The nurse to whom the child had been committed, com- plained of headach and sore throat, together with ulceration of the breasts; the bones of her nose and palate exfoliated, and, in a few months, she also died tabid, without having derived any benefit from mer- cury, with which she had been salivated. On the various remedies tried by the lady her- self, among which was mercury in a variety of forms, none succeeded so well as sea-bathing, and the Lisbon diet-drink, under which treatment the sores were healed. After having had another child, who died under the same symptoms, in the course of a month after its birth, the sores broke out again, and although internal medicines were given, remained for a twelvemonth, when they began to heal. This case demonstrates, that poisons are evolved similar to the syphilitic in many respects, though not in all. INDEPENDENT OF SYPHILITIC INFECTION. 33 It also evinces, that, notwithstanding the use of mercury, they will pursue their course, and that the means most capable of removing their effects, are those calculated to increase the secretions, and strengthen the constitution. Mr. Hunter gives an- other remarkable instance in the same chapter, which still farther elucidates those principles, but I shall refer the reader to his works, as the detail is too long to be introduced.* The several cases he relates of disease arising from transplanted teeth, which, I believe, no one of the present day will esteem to be syphilitic, offer corroborated evidence of the existence of dis- eases which closely resemble syphilis. Ulceration of the gum and jaw was the first symptom, and, in general, took place a month after the insertion of the transplanted tooth ; blotches on the skin, ulcers of the tonsils, and nodes on the tibiae succeeded. Two of the patients recovered without mercury; in others, the constitutional symptoms gave way to that medicine, but recurred several times, after the most severe courses. This is particularly obvious in the third of those cases ; the symptoms, we are told, yielded to corrosive sublimate, three years after the commencement of the attack, and Mr, Hunter remarks, " all who seemed to be cured by mercury, had not a treatment simi- lar to those who are indisputably poxed." Mr. Hunter was of opinion, that not one of the persons from whom the teeth were taken, had the leus ve- * See Hunter, p. 578, et seq. £ 34 TESTIMONIES OF THEIR EXISTENCE nerea. "When we consider that the girls from whom the teeth were taken, had not the least ap- pearance of disease at the time, and had none when the disease broke out in the person who received the teeth, it becomes strange that it should break out in the receiver, and not in the giver. " For," he says in another place, " I consider it impossible for parts to have the power of contaminating, which are not themselves diseased; and, in these cases, the parts contaminating were never known to have been contaminated themselves. " If it were asked, what is this disease, thepe would be more difficulty in answering what it is than what it is not. I should say, that a sound tooth transplanted, may occasion such an irritation as shall produce a species of disease, which may be followed by the local complaints above mentioned, and that undescribed diseases, resembling the vene- real, are very numerous; and what I have said, is rather to be considered as hints for others to prose- cute this inquiry farther, than as a complete account of the subject.'^'' This inquiry, which Mr. Hunter so happily com- menced, has been followed by Doctor Adams and Mr. Abernethy. These gentlemen, after a farther pursuit of the subject, are of opinion, that not only a certain modification of animal matter, being ap- plied to a susceptible surface of the body, will ex- cite an ulcerative disease, but that the healthy se- cretions of one animal, when applied to a crude wound, or denuded surface of another, will also ex- cite ulceration, of which Mr. Hunter's cases of INDEPENDENT OP SYPHILITIC INFECTION. 3 J transplanted teeth, afford strong evidence ; and that the ulcer thus formed, is capable of produc- ing constitutional affections, which bear a resem- blance to those of syphilis. Mr. Abernethy details several cases in support of this opinion, from which I shall select the first and third, as they are very brief, and elucidate sufficiently the subject under consideration. Case I. — "A gentleman was connected with a fe- male who was kept by another gentleman, and de- rived, from such connexion, several very irritable and foul sores, which broke out on the prepuce, but which, however, had not the syphilitic characters^ As neither the woman nor her keeper had any dis- ease, he had no wish to take mercury, nor had I, being consulted on his case, any desire to recom- mend it to him. The sores did not heal until be- tween two and three months, though a variety of local applications were employed. He at length, however, became perfectly well, and I cautioned him not be again connected with the same woman. But his inclination got the better of his prudence, and another crop of sores, equally irritable, foul, and tedious, took place, in consequence of a second con- nexion. These sores were treated in the same manner as before, and slowly healed. After some lapse of time he again erred in the same manner; and again received the same punishment. He had no constitutional disease from these sores." Case HI. — "A gentleman, lately married, com- plained to his surgeon of a running from the ure- thra, which so strikingly resembled a venereal go- 36 GENERAL OBSERVATIONS. iiorrlioea, that the latter could not but ascribe it to infection. He had afterwards a swelling of the prepuce, and sores on that part, which confirmed the surgeon in his opinion, and produced a kind of dissention between his patient and him ; the one affirming that the disease was venereal, the other, that it could not possibly be so, as his wife had no disease, and he had connexion with no other wo- man. The effect of this litigation was, that the surgeon would not urge the taking of mercury; nor would the patient require the administration of that medicine, though a bubo, sore throat, and eruptions succeeded ; which could not be distinguished from similar complaints of a syphilitic nature, but all of which spontaneously got well." Having, as I conceive, adduced sufficient evidence to prove, that ulcers on the generative organs, were at all times common before there was, in this part of the world, any acquaintance with syphilis ; and that these ulcers were frequently followed by con- stitutional disorders ; we must acknowledge the ne- cessity of discriminating them from those of true syphilis, and from each other, and not condemn all however unlike, to a similar mode of treatment be- cause they happen to be found on the same parts, and are produced by the same kind of communica- tion. We miorht, with as much consistency, treat all ulcers of the throat alike, whether arising from scrofula, scarlatina, or simple inflammation; yet, strange to tell, at this improved period of surgery, and notwithstanding the valuable observations of GENERAL OBSERVATIONS. 37 Mr. Hunter, Mr. Abernethy, and Dr. Adams, it is too generally the practice to treat every ulcer on the genitals as syphilitic, whatever may be its ap- pearance, character, or distinction.* * Notwithstanding the ingenious arguments adduced by the au- thor in this chapter, there is still reason to believe him essential- ly wrong in his principal conclusions. Circumstances of a very decisive nature, lead to a belief in the identity of the source, as well as the great antiquity of all the forms of syphilis, and the con- sequent overthrow of the original title so long urged in favour of America. That all the forms of syphilis are as ancient as the custom of promiscuous intercourse between the sexes, is by far the most probable conclusion. Contrary to the general opinion, which admits this disease to be communicated and disseminated only by infection from one person to another, there is perhaps no medical fact better established than that it is likewise spontane- ously generated by promiscuous venery. Our limits, however, will not admit of the proofs and arguments which might be ad- duced in favour of these positions. E. CHAPTER II. GENEILiL OBSER VATIONSON VENEREAL DISEASE S.-THEIR SPECIFIC DISTINCTIONS^ AND APPROPRIATE MODE OP TREATMENT. Since the first edition of this work was published in 1814, the treatment of venereal diseases without mercury, has been extensively tried, not only in Great Britain, but in all parts of the civilized world which have been visited by British troops. The office of the Army Medical Board is, I un- derstand, piled with volumes of reports on the non- mercurial mode of treatment ; and we have every reason to expect that a digest of this extensive mass of papers will be published, under the auspices of the gentleman who so ably presides over the army medical establishment. I do not pretend to antici- pate the precise conclusions which such a digest w^ill afford ; but this much I believe I may venture to assert, that ample experience has been afforded to prove, that every form and stage of venereal disease are capable of being cured without the aid of mercury; and that nodes and affections of the deeper seated parts seldom or never occur in those cases where mercury has not been employed. The cure, in those cases non-mercurially treated^ has been conducted chiefly by the aid of rest, cleanliness, astringent applications, antimonials, sar- GENERAL OBSERVATIONS, &C. 39 saparilla, and the antiphlogistic regimen. Collec- tively considered, recovery, it is thought, has been, in the cases thus treated, more slowly effected than when mercury has been employed. But even with this drawback, how important to medical science is a knowledge of the fact, contrary to all preconceived notions, that the venereal disease, in all its forms and stages, admits of being cured without the aid of mercury: — a medicine which, when employed with propriety, is one of the most useful and pow- erful instruments in the hands of the profession, but, when misapplied, is equally capable of produc- ing the most baneful and destructive effects. Even those who still continue to consider mercury as the only specific (as they term it) for the cure of ve- nereal diseases, may now fearlessly w^ithhold it in those cases, where a consumptive tendency, or a morbid state of the constitution, would render its exhibition dangerous to the life of the patient; and even, if nothing more than this had been gained by the investigation of the last ten years, the benefit which it has conferred on mankind has been of no trifling importance. This will be allowed when we consider the multitudes, who were, previously to this investigation, and the numbers who still are, doomed to undergo for the slightest venereal affec- tion, or even suspicion of such an affection, a regu- lar course of six or eight weeks of that powerful mineral ; under the superintendence, not always of the well-informed, but frequently of the most gross- ly ignorant pretenders to the profession. I have said above, that the non-mercurial mode 40 GENERAL OBSERVATIONS ON of treatment in the cases, collectively considered, has been more slow in effecting a cure, than where mercury has been employed ; but if we withhold that medicine when its employment may be dis- pensed with as useless, or avoided as dangerous, and if we have recourse to it when its adoption is likely to be attended with advantage, 1 shall ven- ture to assert that the cure in all cases, collectively considered, will not only be far more certain, but by many degrees more rapid than by following either of the sweeping systems of exhibiting or withholding mercury in every case. If I were obliged to follow either system ex- clusively, for which I see no possible necessity, I should certainly prefer the non-mercurial plan of treatment, as that which is fraught with far less dangerous consequences. Mr. Chevalier, in his excellent little work on gun- shot wounds, has shrewdly observed, on the prac- tice which prevailed at the time of his publication, of dilating every gun-shot wound, that " it seems absurd to make the rule to dilate so very absolute, that a man must inevitably be cut, because he has had the misfortune to be shot." An observation somewhat similar, may be applied to the venereal sufferer, who may well complain that it is a suffi- cient misfortune to be disordered, without being dosed to death, by a remedy that is worse than the disease. Mr, Chevalier sees nothing of obscurity in a gun- shot wound, which ought to prevent us from treat- ing it according to the general principles of surgery VENEREAL DISEASES. 41 applicable to contused and lacerated wounds ; and, therefore, restricts the use of the knife to the at- tainment of a precise object ; such as the extraction of an extraneous body, the suppression of haemor- rhage, or the division of a constricting fascia. And, on the same principles, let us restrict the exhibition of mercury to a precise object ; such as the general principles of medical science would authorize, for the cure of the symptoms of a morbid poison with- out considering mercury as a specific, or the dis- ease for which it is administered incomprehensible, and therefore only a fit object for blind empirical practice.* We have been long taught to believe that mer- cury was the only remedy for every form of vene- real disorder, gonorrhoea excepted. It was, there- fore, high time to commence an investigation into the most suitable mode of treating venereal diseases, when every practitioner, even of very limited expe- * The doctrine and practice here inculcated, may be regarded as a fulfilment of the prediction of the late Professor Rush, who, in his lectures, asserted it as his belief that the time would come when syphilis, like other diseases, would be treated upon general principles. It was formerly the case, nay, among some of our respectable physicians the practice still prevails, that every person with sores on the genitals following a suspicious connexion, was immediate- ly put under a mercurial course, without any regard to the na- ture or appearance of the primary ulcers. If the affection did not get well, or what was very commonly the case, became worse, it was considered as an evidence that enough mercury had not been used. The rubbings and the pills, the washes and fumiga- tions were consequently increased with diligence, and when all the evils were found to be aggravated, and the miserable patient died, or suffered mutilation, his fate was regarded as an incontes- table proof that he had not received enough mercury into his f=yst^m. E, 42 GENERAL OBSERVATIONS ON rience, must have met with circumstances to shake his faith in the powers of the remedy, from perplex- ing embarrassments and inextricable difficulties ac- cumulating upon him, as long as he persisted in the exhibition of his specific,^ But in order to preserve our faith unshaken, in- genious devices have been, from time to time, saga- ciously resorted to. By one of these we learned, that not only the new symptoms which arose under the most severe courses of mercury, but even the old ones which resisted its influence, were attribu- table to the remedy, and not to the disease. Hence we have descriptions of mercurial chancres, mer- curial ulcers, pains, nodes and swellings of the lym- phatic glands of the neck. But in ascribing those symptoms to mercury, we have entirely overlooked this obvious circumstance, that that medicine, when exhibited even to profusion for liver, or any disease which is not venereal, has never in any one instance produced those effects. With respect to the deteriorating influence of mer- cury, I am perfectly willing to allow that when it does not altogether supersede the actions of a mor- bid poison, it may so far alter or modify its symp- ^ In excepting gonorrhoea from the forms of the venereal dis- ease, for the treatment of which we have been taught to beUeve mercury unnecessary, our author has, perhaps, forgotten that even in this complaint some of our most able and orthodox medical au- thors, have inculcated the necessity of a mercurial course. Sy- denham Rotherham, in his Notes to Cullen's Practice, and even the popular and modern work of Thomas, recommend mercurials as the only means to be trusted for its radical cure. Such re- commendations are w6ll calculated to extend the evils ascribed to mercury, by leading to its unnecessary employment. E. VENEllEAL DISEASES. 43 toms, as to change, in a great measure, the appear- ance and natural progress of the disease ; but this is essentially different from an admission, that the remedy will produce symptoms which can scarcely be distinguished from those of the poison itself. Another device common to many arts and sci- ences, besides surgery, is an endeavour to conceal our ignorance, by the adoption of plausible and de- lusive epithets and appellations. The term syphi- loidal I cannot but regard in this point of view. It is usually applied to those symptoms, which con- tinue to linger after the patient has undergone full and repeated courses of mercury, and which that medicine was found incapable of curing. Those, therefore, who looked upon mercury as a certain cure for every form of venereal disease, found it ne- cessary to give those unaccommodating symptoms a name ; they therefore called them syphiloidal ; which, if it means any thing, insinuates that some- thing is present which resembles or appertains to syphilis, and which is not syphilitic. The coinage of this name, however, gave them an opportunity of relinquishing the further use of mercury, without making the mortifying acknowledgment, that they had been using, to a dangerous extent, a medicine incapable of curing the disease for which it w^as ex- hibited. These subterfuges were, however, useful, and, I will even say, reflected some credit upon those who devise them, as they obviated the injurious perseverance in the use of the medicine, which might otherwise have been considered a matter of necessity. 44 GENERAL OBSERVATIONS OiV Since, however, it is now well known, that cer- tain forms of venereal disease will pursue their course, whether mercury is employed or not, it is absurd any longer to retain words in our vocabula- ry which are calculated to mislead us from the truth. Nothing I am certain, would tend more to promote the present investigation, and the attain- ment of a perfect knowledge of venereal diseases, than to drop altogether those common, but arbitra- ry, terms syphilitic, syphiloidal, and pseudo-syphi- litic ; even the term mercurial should be restricted to designate those phenomena onl}^ which are known to arise from the use of mercury in other diseases besides the venereal, by which means we avoid the perplexity of confounding the symptoms arising from the poison w^ith the effects of the re- medy. In place of those arbitrary names which mean nothing, if surgeons would confine themselves mere- ly to terms descriptive of appearances and symp- toms, language would not be wanting to convey an adequate notion of any class of diseases. I have attempted,! trust, with some success, the adoption of this simple and natural mode of distinguishing vene- real diseases ; but though I by no means have the presumption to fancy that I have completed this dif- ficult task, yet I have met with very few cases which would not naturally fall under one or other of the classes I had formed. The difference which was found to exist in the appearance and progress of certain groups of symp- toms which usually went together, compelled me to VENEREAL DISEASES. 45 presume the existence of a plurality of venereal poi- sons ; but whether this opinion is right or wrong, can not, in a practical point of view, be of any con- sequence, if we confine ourselves to the more sim- ple inquiry into the circumstances and symptoms, for which mercury ought or ought not to be exhi- bited. These are questions purely practical, and to which I profess more particularly to confine my attention in the following Essay. But before I enter upon this task, I must observe, that I have not yet heard a satisfactory objection from those, who restrict their belief to the exist- ence of a single venereal poison, against the histo- ric evidence detailed by a multiplicity of authors, testifying that infectious venereal diseases existed at all times previous to the introduction of syphilis, towards the close of the 15th century. Are we to suppose that those old venereal poisons either sud- denly disappeared by one common consent, or were actually superseded by the introduction of the new one ? an opinion sufficiently refuted by the variety of characters exhibited in primary ulcers and vene- real eruptions ; the latter so numerous as to afford specimens of almost all the different orders of cu- taneous diseases. If we were to admit but one ve- nereal poison, we must conclude, that the regularity of the progress, and uniformity of the symptoms, which are observed in all other morbid poisons, do not appertain to this, and this alone ; thus making an unreasonable and unwarranted exception to a universal law of nature. But stiil this is met by another subterfuge not so easily answered, and the 46 GENERAL OBSERVATIONS ON difference of venereal appearances is ascribed to a difference in the constitution of patients. But whether the variety is owing to a diversity of poi- sons or a diversity of constitutions, is a question that can only be resolved b}^ a series of experi- ments, which it is not to be expected that any man will be so public spirited, as to submit to himself, or so unreasonable as to inflict upon others. If it were possible to guard against abuses, and were not contrary to the spirit of our laws, it would greatly tend to the advantage of society if criminals were sometimes permitted to commute a heavier punishment, by submitting to a series of experi- ments, for the purpose of ascertaining the truth in such questions as the present. I am perfectly aware, how much the state of the human constitution will modify local diseases ; and am willing to attribute, to a certain extent, the great variety of appearances we witness daily in venereal complaints, to this cause alone. But yet we observe that many of those primary ulcers evince from their very commencement such pecu- liar and distinct characters, that it would be quite an absurdity to believe that the virus is always the same, and the variety of characters dependent alone upon constitution. Thus nothing can be more opposite, even from the commencement, than the common chancre with its hardened base, like a piece of cartilage under the skin, and the sloughing ulcer. The first is slow and chronic ; the latter begins with a mortified spot, extends by alternate sloughing and phagedenic ul- VENEREAL DISEASES. 47 ceratioii, and often makes more progress in three days than the former in as many weeks. The phagedenic ulcer is equally distinct from chancre, as it does not evince, at any period, a hard- ened base, but gradually creeps from one part to another of the penis, leaving those parts to heal, which in the first instance it attacked. So that when the disease has existed for some months, the glans is seen to exhibit its entire surface furrowed over with ulcerations and cicatrices. There is a raised ulcer, also, with elevated edges, approaching the nature of the phagedenic ulcer, yet whose characters are sufficiently distinct to be considered as a separate species. But the most common venereal primary ulceration commences as a pustule, is excavated in the first week, and in the second becomes raised above the surrounding integuments, exhibiting a smooth fungous surface ; it may also be described by its negative qualities, and as an ulcer without induration, raised edges, or phagedenic surface. If the plurality of venereal poisons is supported by the variety of primary ulcers, it is more so by the multiplicity of constitutional eruptions. A pri- mary ulcer, which was not phagedenic or sloughing at first, may afterwards, like any other ulcer, become so by irritation, neglect, or inflammation. But I do not conceive that we have grounds for supposing that the state of the constitution can so modify morbid poisons, as to cause the same virus to pro- duce in one person the chronic scaly lepra, and psoriasis, and to assume in another a decided pus- 48 GENERAL OBSERVATIONS ON tular form, each pustule spreading rapidly into a deep ulcer. These two kinds of eruption may serve to illus- trate the subject, as in their nature they are so directly at variance. But I would be inclined to admit, that an eruption of papulae with acuminated heads containing matter, and approaching the pus- tular form, might be so affected by the constitution, as not to be distinguishable from the most regular pustules. The character of the disease may, how- ever, still be apparent, as their pustules, instead of spreading into extensive ulcers, will, like papulae, terminate in desquamation, but the scales will be larger; and in addition to this circumstance, the pustules will, throughout, be intermingled with papulae. These circumstances may serve to distin- guish, in doubtful cases, the form of disease, which is attended by the venereal lichen or papular erup- tion, from that which is much more formidable, and produces pustules which terminate in ulcers. This view may conduce to satisfy us, that the powers of the constitution are much more restrict- ed in modifying the symptoms of a morbid poison than is supposed by those who adhere to the gene- ral opinion, that the same virus may produce in one person the scaly lepra; in another, papulae that ter- minate in desquamation ; in a third, pustules, the precursors of malignant ulcers; and in a fourth, tubercles, — exhibiting a diversity, which does not occur in the eruptions of small-pox, measles, scar- latina, -and other morbid poisons — at the same time. VENEREAL DISEASES. 49 forgetting that all are equally subjected to the in- fluence of the constitution. From an attentive consideration of a vast num- ber of cases during many years, I find strong grounds for concluding, First. — That the syphilitic chancre is attended by the scaly eruptions, lepra and psoriasis, an ex- cavated ulcer, of the tonsils, and pains and nodes of the bones. Second. — That the simple ulcer, without indura- tion, raised edges or phagedenic surface, — gonor- rhoea virulenta, and excoriation of the glans and prepuce, are followed by a papular eruption, which ends in desquamation, pains in the joints resembling those of rheumatism, soreness of the fauces, and frequently swelling of the lymphatic glands of the neck; but that in a vast number, not a single in- stance was observed, in w^hich nodes were an at- tendant upon this eruption.* Third, — That the ulcer with elevated edges, in the few instances in which I had an opportunity of tracing it to its constitutional symptoms, was fol- lowed by a pustular eruption, which terminated in * In one instance of the papular eruption, in which there was considerable inflammation of the ankle, an appearance suddenly took place on the tibia, immediately above the inllamed joint, which at the time 1 considered as a node ; but as it afterwards disappeared with the inflammation of the joint, without the exhi- bition of mercury or any particular attentions, and as I have not from that period, eleven years since, witnessed any instance of node in the papular disease, I am certain that I was wrong in calling the appearance in question a node, and therefore feel my- self warranted in making the unqualified assertion on the subject, contained in the text. 50 GENERAL OBSERVATIONS ON mild ulcers, pains in the joints, and ulcers in the throat, but no appearance of nodes ; yet that the instances in which I had an opportunity of witness- ing distinctly the connexion between the primary and secondary symptoms of this poison, were too few to form a decided conclusion with respect to this particular. Fourth. — That the phagedenic and sloughing ulcers are generally attended by constitutional symptoms of peculiar obstinacy and malignancy, viz. pustular spots and tubercles, which formed ulcers that spread in general with a phagedenic edge and heal from the centre; extensive ulceration of the fauces, particularly of the back of the pha- rynx, obstinate pains of the knees and other joints, while nodes are frequently present, and the bones of the nose are occasionally affected. Fifth and last. — That, when an eruption, no matter what its character mav be, is on a surface which is opposed by another, as on the fossa of the nates, upper part of the inside of the thighs, or in the axilla, the spots, if they do not ulcerate, extend into soft, moist elevations of the cutis, which ought to be treated according to the nature of the disease to which they belong. Thus, if they are syphilitic, with mercury : or, if papular, pustular, or tubercu- lar, with the remedies recommended for the speci- fic disorder. According to the established practice, these condylomatous swellings, as they are called, are universally treated with mercury ; but I have, in innumerable instances, eured them, and the other VENEREAL DISEASES. 51 symptoms with which they are accompanied, with- out the exhibition of a particle of that medicine. These conclusions, it must be expected, will be doubted or denied by many who may possibly aver that they have seen a great variety of venereal ul- cers and eruptions, but have never observed the coincidence or correspondence here stated. I would ask, did they ever examine patients, when affected with primary and secondary symptoms, with a view to discover a correspondence between the one and the other ? — have they not, on the contrary, always been impressed with the belief that all venereal symptoms, however various or opposite their cha- racters, have sprung from one identical poison ; and that constitutional differences have alone produced this variety of character in the symptoms ; and witli such an impression on their minds, is it not natural to suppose, that they would scarcely examine the primary and constitutional symptoms with the same acumen as a practitioner who doubted the truth of the established doctrine ? But if an investigation surrounded by so many perplexing difficulties, is not carried on in the spirit of candour by persons more anxious to obtain truth than victory, we are not likely to make much use- ful progress. With regard to such an investigation, let it be recollected that, in any sore whatever, the various causes of irritation will considerably alter its appearance from its original or natural state ; and, therefore, that it must be difficult to decide upon the character of an ulcer arising from a mor- bid poison until rest and appropriate attentions have D'J, GENERAL OBSERVATIONS ON removed all extraneous irritation. Let it also be kept in view, that frequently a person will have on him at the same time the symptoms arising from more than one infection. If, therefore, primary and secondary symptoms exist together, before we de- termine in our minds that they stand in the relation to each other as cause and effect, let us enquire if the primary symptoms did not appear after the se- condary, or so near to each other in point of time that one could not be the occasion of the other. iVnd let us also recollect, that, although a phagede- nic ulcer in general spreads extensively, yet that it is capable of healing soon after its commence- ment, if not irritated by mercur}^ or other causes ; and that, therefore, a superficial observer may be led to ascribe the obstinate and malignant constitution- al symptoms which this ulcer occasions to a prima- ry ulcer of a very different character. These observations ma}' induce the rising gene- ration of surgeons to look with more attention into the characters of both primary and secondary symp- toms than is at present probably practised. The utility of doing so T have most ampl}^ experienced ; and I v/ill venture to assert that, after a little atten- tion and practice, there are few venereal cases, tlie result of which may not be prognosticated with as much accuracy as that of any other morbid poi- son to which the human body is liable. The attention which has, of late years, been given to the distinctive characters of cutaneous dis- eases, enables us to discriminate and describe, in the accurate language of Willan, the various eruptions wliich arise from venereal poisons : and this is an VENEREAL DISEASES. 53 advantage that our predecessors did not possess, and the want of which must have been a great im- pediment to the progress of the inquiry, and parti- cularly to the advances it would have made in the hands of such a man as Hunter. Before my observations on this intricate subject were submitted to the public, all venereal eruptions were described under the vague terms of copper- coloured blotches, scabb}^ spots, and other names equally equivocal and unsatisfactory with respect to their character. But a change for the better has already taken place, and in our late publica- tions on the subject, these eruptions are described in the exact and descriptive nomenclature of Willan. Great improvements are, however, still to be made, and among others, I would suggest the absolute necessity of observing with attention, w hether the scaly eruption (for instance) has been scaly from the commencement, as in the psoriasis and lepra syphilitia, or only in its declining, or desquamating stages, as is the case in the papular eruptions, — a circumstance which accurately distinguishes one from the other. f have in different publications brought forward sufficient evidence, that all primary ulcers, with the exception of chancre, will heal without the exhibi- tion of mercury. We learn from the testimony of Messrs. Rose, Guthrie, Thompson, and Hennen, that even this ulcer will also heal without its influence.* * This fact being now well established, the great criterion of Mr. Hunter, Mr. Abernethy and all others who believed in the constant progression and never retrogression of the symptoms of syphilis, unless checked by mercury, falls to the ground. E. 54 GENERAL OBSERVATIONS ON So that according to them, it would appear actual- ly unnecessary to exhibit mercury for primar}^ ul- cers, except with the view of protecting the consti- tution against the accession of secondary symptoms. On the point, however, whether or not mercury pos- sesses this power, there is a considerable diversity of opinion. In a question of this kind, reasoning can have no influence ; we must draw our conclu- sions from facts, and as yet we have not a sufficient number to decide upon. In Portugal, Italy, and the southern parts of Europe, Mr. Guthrie informs us, mercury is never etpployed for primary ulcers ; and I was informed by my late friend. Doctor Armstrong, who resided in Vienna for many years, and was well acquainted with the practice of the most emi- nent physicians and surgeons of that city, that they never give mercury for primary ulcers, from a knowledge that they will heal without it, and from a belief that it will not prevent the accession of constitutional symptoms. This important question must, however, remain undecided, until we have more evidence, upon which to form our judgment, but could, no doubt, be now satisfactorily answered by reference to the multitude of reports on the subject of venereal com- plaints filed in the office of the Army Medical Board ; particularly to those of Doctor Thompson, who, I understand, has not for several years given a grain of mercury for venereal complaints in the Military Infirmary of Edinburgh.* * To this testimony, from abroad, the editor is happy in having it in his power to add, that similar experiments made by American physicians have been attended with similar results. In Philadel- phia, the non-mercurial practice has been tried extensively by VENEREAL DISEASES. Db The question can only be settled by reference to the experience of many; that of an individual, how- ever extensive his practice, ought not to decide a point of this importance. In the absence, then, of documents so much to be wished for, I shall briefly state the practice I pursue for primary ulcers ; my reasons for adopting it, and the result of my expe- rience. Being now fully aware, as well from the experi- ence of others as from my own, that the true Hun- terian chancre will heal without the aid of mercury, the propriety may be questioned of exhibiting that medicine for its cure ; but it is of so very indolent a nature, and ihe surrounding callosity is so very slow in dispersing where mercury has not been em- ployed, that, notwithstanding my conviction of the fact above admitted, I always direct mercury for such cases, where there is nothing in the patient's constitution to forbid its exhibition, and I continue its use as long as the callosity remains. But pri- mary ulcers of this character are now so seldom met with, that I am not often called upon to direct Dr. Thomas Harris, Surgeon in the U. S. Navy. Having charge of the Philadelphia Navy Yard Hospital, Dr. Harris possesses an opportunity for making such investigations, far more ample and ad- vantageous than can be afforded by the range of private practice. For nearly six years he has discarded every preparation of mercury from his practice, and asserts that he has ever since found all the forms of syphilis more tractable, and what is of the utmost impor- tance, entirely exempt from secondary symptoms. He further declares that he has found that variety of ulcer described as the true Hunterian Venereal chancre, yield most readily to the non- mercurial treatment. The importance of the subject leads us to indulge the hope, that the Doctor will soon favour the public with a detailed account of his practice, and the results of his experience. E. 56 GENERAL OBSERVATIONS ON it on this account. I never order mercury for the primary phagedenic and sloughing ulcers, from the nio^t ample experience of the injurious effects of that medicine upon them. The pupils every day witness instances of mutilated persons applying at the doors of the hospital for admission, labouring inider ulcers of this description, their teeth dropping out of their heads, and their frames emaciated from repeated salivations; and I cannot but express my astonishment at the pertinacity of those who per- severe in a practice, the destructive tendency of which must be apparent to every man of experi- ence, who does not wilfully shut his eyes upon facts that must every day jostle with his prejudices.* With respect to all other primary ulcers, I never order mercury for them, except they continue long obstinate and chronic without showing any disposi- tion to heal. In such instances, I usually direct some preparation of mercury in alterative doses, watch- ing closely its effects on the sore ; and, if found to be injurious, instantly discontinuing its use. In fact, I administer mercury in such cases with the same views of altering the actions of the part, as in cases of chronic ill-conditioned ulcers of the leg, or any other part of the body. I do not, however, commence with mercury in such cases, or think of ordering it, except the sores should appear ob- stinate after the third or fourth week. * The worst picture which can be drawn of the worst form and stage of syphilis, cannot equal a sketch which might be made of the horrid and not unfrequent consequences produced by the improper use of mercurv. E< VENEREAL DISEASES. 57 This plan I have pursued for several years, and have not found that constitutional symptoms more frequently occur than where full courses of mercu- ry had been employed from the commencement; and I have always had the gratification of seeing my patient recover from his venereal complaints with an uninjured constitution. From reasoning a priori, it must appear to the most ignorant person injudicious to subject a patient to a full and debilitating course of mercury, with the view of protecting the constitution from the acces- sion of secondary symptoms, when we are really ig- norant whether or not it possesses such a power. But if, notwithstanding every means of precau- tion, constitutional symptoms should still make their appearance, the practice has been to subject the unfortunate patient to a second, or, perhaps, a third or fourth course of mercury ; but would it not be in such cases a more rational plan of proceeding to husband the resources of the constitution, and not waste them unnecessarily, until the attack shall have occurred, which, though apprehended, may never take place ? These observations are submitted to the conside- ration of inveterate mercurialists, or those who rely on nothing but mercury for the cure of venereal complaints. As to myself, I should consider it a sample of inconsistence and folly, were I to endeav- our by mercury to prevent the accession of those constitutional symptoms, for which I should not ex- hibit that medicine, had they even actually made their appearance. The best and surest means, in 58 GENERAL OBSERVATIONS ON iny apprehension, of preventing the accession of constitutional symptoms, are those which heal the primary sore with as little delay as possible ; and thus prevent the secretion of a morbid poison ca- pable of contaminating the system. In arranging, under distinct heads, the numerous appearances and symptoms produced by venereal complaints, I would follow the same rule which has hitherto guided the judgment of the profession in arranging and classifj^ing all other morbid poisons attended with eruptions. In other words, I would regard the eruption as the most proper basis of the arrangement; and, without neglecting such auxiliary evidence as other attending symptoms may afford, consider them as of minor importance in determining the nature of the disease. By following this method, it is truly gratifying to find how easily the numerous symptoms, both pri- mary and constitutional, of venereal diseases, which are so various as seemingly to bid defiance to any attempt at arrangement, can be disposed of in their appropriate places, under the name of the eruption which belongs to their respective species.* * In a practical point of view, it is of the greatest importance, that the physician should be aware of the almost infinite variety of appearances which cutaneous aflfections resulting from the ve- nereal poison may assume. Attempts to embrace all these varie- ties in classifications less extensive than those which include the whole range of cutaneous diseases, must, consequently, prove im- perfect The editor has seen many cases of the papular, scaly tuberculous and other forms, devoid of the usual concomitants of syphilis, though evidently produced by the insidious operations of that virus. Under these circumstances, it is the duty of the practitioner to investigate the case with great attention, in doing which, he will often be obliged to extend his inquiries several years back. E. VENEREAL DISEASES. 59 Next to the eruption, the symptom most to be regarded is the primary ulcer, whose characteristics are in general found sufficiently distinct to enable us to foretell, with tolerable certainty, what the ap- pearance of the eruption will be. But, as observed in its place, those primary characters may be de- stroyed by irritation, which often produces inflam- mation, and not unfrequently sphacelus; and not only the distinctive marks of the primary ulcer, but of the constitutional eruption, may be so modified by the exhibition of mercury, where that medicine is improperly employed, as to become altogether confused and indiscernible ; unless, indeed, the mani- fest ill effects of this mineral shall be esteemed a mark of distinction, and is to continue as at present the only means of discrimination, while in fact it seldom serves as a guide to the practitioner, but by leaving the track of its mischiefs behind it. He, indeed, discovers his error without finding his road, and sometimes blindly, sometimes desperately, flounders from mercury to sarsaparilla, and from sarsaparilla back to mercury again, without benefit- ing his patient or increasing the certainty of his own information. The affections of the throat are too indistinct to afford any certain diagnosis; and in forming our opinions, these appearances can only be esteemed as auxiliary to the characters of the eruption, and of the primary ulcers. But still this minor assist- ance is not to be neglected; for instance, the affec- tion of the throat which attends the papular eruption, and particularly if the disease has not been inter- 60 GENEtlAL OBSERVATIONS ON rupted by mercury, is not an ulcerated, but rather an excoriated or erithematous appearance of the fauces, very similar to that which attends measles, small-pox, or trivial cases of scarlatina. The ton- sils are often in this disease considerably swelled, as are also the other glands in the neighbourhood of the jaws. Mr. Hunter has stated, that the excavated ulcer of the tonsil is the characteristic appearance of syphi- lis in the throat ; but I have found it as frequently attended upon the disease which follows the pri- mary phagedenic ulcer. Extensive ulcers of the pharynx, and ulcers, and caries of the bones of the nose are also frequent attendants upon the phage- denic primary ulcer; but the same appearances oc- cur in those anomalous disorders which arise from derangement of the constitution, and are not of ve- nereal origin. Wherefore I must repeat, that we cannot ground our diagnosis on the appearances of ulcers in the throat, when unaccompanied by other symptoms. With a view to diagnosis, pains are a still more equivocal symptom, because in every species of venereal disease, they may affect the larger joints, and other parts ; but it is useful to know that the knees are more frequently subject to this symptom in the phagedenic disease, and the shafts of the tibiae in syphilis. Still it would be absurd to de- duce any conclusion from such circumstances alone. Nodes are equally equivocal and uncertain ; for syphilis and the phagedenic disease are alike capa- ble of producing them. VENEREAL DISEASES. 61 In a former part of this work I have mentioned my persuasion, that if all arbitrary terms were dis- continued in the nomenclature of venereal ailments, and if those alone were adopted in their place, which are descriptive of the characters of the dis- ease, that this change would in itself be productive of the greatest advantages. For as mankind are so much guided in their opinions by names, they woidd be less liable to be led astray by those which are merely descriptive of symptoms and appearances which are cognizable by our senses. As long as syphilis is the name attached to a certain form of vener^eal complaints, we shall never escape from the terms pseudo-syphilis, syphiloidal symptoms, and sequelae of syphilis. The first is an arbitrary term applied to a congeries of symptoms, upon the nature and extent of which scarcely two practitioners are agreed ; and therefore when one person calls a complaint syphilitic, another disease altogether different may be presented to the mind of the person he addresses. Pseudo-syphilis is equally objectionable, as it is too general a term for any useful purpose, inasmuch as it embraces not only all those venereal complaints which do not correspond to Hunter's description of syphilis, but also those spontaneous disorders which have no pretension to a venereal origin, and are solely at- tributable to some derangement of the constitution. The terms syphiloidal symptoms, and sequelae of syphilis, imply that there is but one venereal poison; an opinion which I conceive to be abso- lutely refuted, if the facts and arguments contained 62 GENERAL OBSERVATIONS ON in this and my former publications shall be consi- dered of any weight. Should these observations be thought to present sufficient grounds for adopting a radical change in the nomenclature of venereal diseases, it may be formed on the characters of the eruptions, which afford the most certain criterion, by which we are enabled to distinguish one species from another. Thus, I. That form of venereal disease which is the most prevalent of all others, and is attended with the papular eruption, may be termed the Pa- pular Venereal Disease, II. That which produces pustules that terminate in ulcers covered with thin crusts, and which heal like common sores from their margins — The Pustular Venereal Disease, III. That which is attended with spots that have less of the pustular character than the preceding class, and frequently with tubercles terminating in ulcers covered with thick crusts which extend with a pha- gedenic margin, and usually heal from their centre, may be termed the Phagedenic Venereal Disease, a term equally descriptive of the primary as of the secondary symptoms. IV. and lastly. That disease which I have hitherto distinguished by the name of syphilis (but which has been extended by other writers to every description of venereal disease, although it is probable that every other was known in Europe before it) may with much greater advan- tage be denominated the Scaly Venereal Disease, from the permanent scaly eruption which attends it ; and thus may we liberate ourselves from a whole VENEREAL DISEASES. 63 train of prejudices, which follow as the suite of the old appellations. It may, however, be objected to this classifica- tion, that the nature of the disease cannot be known until the eruption takes place ; and on a loose com- putation it may be regarded that nine cases out of ten of primary ulcers are not attended by constitu- tional symptoms; so that in a great majority of cases the disease has never arrived at the stage to which it is indebted for its name. To this objection I reply, that the primary ulcers afford a less deci- sive means of determining the nature of the disease than the secondary; yet from their characters, when unaltered by irritation or mercury, we may discrimi- nate their nature with sufficient certainty to decide on the precise eruption they would produce in their secondary state. For instance, 1st, The ulcer with- out callosity, raised edges or phagedena, in fact without any very peculiar characters, and which may, therefore, be termed the simple venereal pri- mary ulcer, produces the papular eruption which ends in desquamation : and the same effect is pro- duced by a patchy excoriation of the glans and pre- puce in men, and of the labia and vagina in women, and also by a gonorrhoea virulenta. 2nd, The ulcer with raised edges produces the pustules which ter- minate in small ulcers covered with thin crusts, and which heal from their margins, 3d, The phage- denic and sloughing ulcers produce the pustular spots and tubercles which terminate in ulcers cover- ed with thick crusts, which are accompanied with phagedena and heal in general from their centre. 64 GENERAL OBSERVATIONS ON 4th and lastly, The primary callous ulcer or chancre is attended with the well known scaly eruption — Lepra or Psoriasis, In this concise view of venereal diseases, we may perceive that they do not form an exception, as is generally imagined, to that uniformity of symp- toms and characters which marks the progress of all the other morbid poisons with which we are acquainted. But as the chief object of this work is not to sup- port peculiar doctrines, but to afford practical infor- mation, if any individual object to the division of venereal complaints into four distinct diseases, the difference between us is easily reconciled. Instead of four distinct diseases, let any one that pleases consider them as so many forms or modifications of the one disease, each requiring a peculiar mode of management, and under this view every practical object will be equally well obtained. Therefore, as names are of some consequence, let those who are of this opinion add the words form of to the appellation I have given to each species, and then we shall have the papular /orm o/" venereal disease, the pustulary form of venereal disease, &c. &c. Names and distinctions in nosology are most advan- tageous when they also serve the purpose of prac- tical utility, and I have little doubt but that it will be universally admitted, that the distinctions I have made of venereal complaints, formed on the basis of the character of the eruption, convey with them intimations of the greatest practical utility.^ * There is little doubt that those who avail themselves of this suggestion of our author will have adopted the most correct deci- VENEREAL DISEASES. 65 The foregoing observations, I trust, have render- ed it sufficiently convincing, how much may be learned of the nature of our patient's disease by a close attention to the character of his symptoms. I believe I am not wrong in asserting that practi- tioners at present form their decision as to the na- ture of the disease, and mode of treatment, chiefly from the history of the case. If mercury has alrea- dy been used in full courses, the disease is called mercurial or syphiloidal, and sarsaparilla is recom- mended. If, on the contrary, the patient has as yet used none, or but little mercury, the very same symptoms are pronounced to be syphilitic, and a mercurial course will be directed. I would by no means be supposed, by these ob- servations, to make light of the advantages to be derived from an attentive consideration of the his- sion of the question. The well known fact, that a person affect- ed with only one variety of the venereal disease, is capable of communicating the same or a different form to others, may be con- sidered as rendering nugatory our author's arguments in favour of a plurality of distinct venereal poisons. During the Peninsular war, the British soldiers, who had connexion with the Spanish and Portuguese women, contracted a form of disease which was comparatively rare among the natives. This was the phagedenic and sloughing ulcer, to which the Northern soldiers were proba- bly predisposed from change of climate, intemperate habits, and other causes, operating upon the constitution, and modifying the operation of the original virus, which might have been derived from any other species of ulcer. It happily occurs in this in- stance that the practical objects are not materially affected by this discrepancy of opinion. Notwithstanding the supposed error into which Mr. Carmichael has fallen, in describing as distinct diseases, what might more properly be regarded as forms or modifications, he is certainly entitled to great credit for the nice discrimination and accurate delineation which he has displayed in this treatise. ^6 GENERAL OBSERVATIONS, &C. tory of a case, and the effects of mercury upon it ; but still I contend that it ought not to engross the entire of our attention. The practitioner who forms his opinion of a disease, merely from its history, is under no necessity of seeing his patient ; he can as well determine on the case, if a written statement is laid before him. But even few of those who fan- cy that all information in venereal cases is to be derived from their history, would, I believe, ac^ cede to this proposition. I shall in the succeeds ing chapters consider each of the forms of venereal disease under the appellation which the character of its eruption suggests. CHAPTER m. PAPULAR VENEREAL DISEASE. I COMMENCE my particular description of venereal complaints with those which are liable to be attend- ed with an eruption of papulsB;* because they consti- tute the most simple^ most easily cured, and least dangerous of all the forms of venereal disease* The primary symptoms are either, first, a simple ulcer without induration, elevated edges, or phage- dena; but whose characters are not very remarkable. Secondly, a patchy excoriation of the glans and pre- puce, attended with purulent discharge. And, third- ly, gonorrhoea virulenta. The primary ulcer to whidi I allude^ has neither the indurated base which attends the true syphilitic chancre, nor the elevated edges which surround the primary ulcer of the pustular venereal disease ; noi* the phagedenic surface of the primary phagedenic ulcer; all of which will be considered in their pro^ per places. It is not often the surgeon has an op- portunity of seeing this ulcer when at its commence* ment ; but in the few instances within my experi- ence, it exhibited a small pustule, which continued one or two days, on the external prepuce or body of the penis ; and then formed a thin crusty which '*'See Plate I. figs. 1,2^3. 68 PAPULAR VENEREAL DISEASE. soon separating, exposed an excavated round or oval ulcer with a surrounding redness. This in the se- cond week began to fill up, and afterwards gradual- ly rose above the surrounding skin, exhibiting a smooth surface, having the colour of a healthy sore, but without granulations, and exhibiting somewhat of a fungous appearance. It is in this latter state that it usually comes under the observation of the surgeon ; and from its mild nature, when compared with others, I would propose to name it, the Simple Primary Venereal Ulcer. The process of ulceration, afs well as the sur- rounding redness, seem to cease as soon as the fun- gous stage commences, which may exist an indefi- nite length of time; but from three to six weeks may be mentioned as the averaged period of the continuance of this ulcer from its commencement. The appearance and duration of this, as of every other primary ulcer is liable, of course, to be modi- fied by the state of the constitution, mode of living of the patient, his exposure to various irritating causes, neglect and want of cleanliness. These ulcers, which are far more general than any others, to which the parts of generation are liable, are more frequently found on the glans and internal surface of the prepuce than elsewhere, in which situation they, in general, excite phymosis ; and it is, therefore, extremely probable, that it is the identical ulcer mentioned by Celsus,* as induc- ing phymosis, and readily cured by lenient reme- dies and mild detergent washes. They also occur * Celsus, p. 332- PAPULAR VENEIIEAL DISEASE. 69 on the external surface of the prepuce, body of the penis, and scrotum, in which last situation they are considerably raised above the surrounding surface, so as to resemble fungi or soft warts, and are rapid- ly cured by an application of a strong solution of muriate of mercury, in the proportion of two or three grains to an ounce of water. In women, they usually occur on the labia, perineum, and fossa of the nates. When phymosis has taken place, it is difficult or impossible to ascertain from what source the dis- charge proceeds, whether from these ulcers, or from the second primary affection I have mentioned, a peculiar excoriation of the glans and prepuce, by some called chancrous excoriation, and by others, spurious gonorrhoea; or whether the discharge flows from the urethra, and is a true gonorrhoea. The discharge, however, is frequently occasioned by these three affections, at the same time, a cir- cumstance which would a priori induce us to sup- pose, were there no other reasons for the opinion, that they all arise from the same poison ; but this supposition is almost confirmed by the fact, that the superficial ulcers which we are considering, even when situated so far back as the scrotum or body of the penis, are, in the majority of cases, ac- companied by one or both of the other two affec- tions. In the excoriation of the glans and internal pre- puce, the discharge does not proceed from the en- tire surface, but from irregular inflamed excoriated patches, leaving interstices of sound cuticle be- llO PXVVLAR VENEREAL DISEASE. tween ; and I find that Mr. Whately, in his work upon gonorrhoea, adduces some facts and arguments to prove, that the lining membrane of the urethra is affected precisely in the same manner in gonor- rhoea virulenta ; and asserts, that he has even been able to observe these appearances within the orifice of the urethra. He supports his opinions by the authority of Doctor Monro, who, in describing in his lectures, the manner in which the lining mem- brane of the urethra is effected in gonorrhoea, pro- ceeds as follows : " The application of the poison to the urethra, is seldom equal and universal. There is no great comparison between it and the catarrh upon the nose, where the membrane is every where affected equally ; for here, one part always suffers more than another, and it is seldom that we find external ulcers, occupying the glans uniformly, but it is affected in spots. It is in like manner, the same within the urethra, as particular spots of it are chiefly affected. We find eschars in few places, and an obliteration of certain of the raucous ducts ; and the patient, in making water, finds the pain more in one place than in another; so we are to compare the affection of the membrane of the ure- thra to the effects produced on the glans."* These observations of Dr. Monro and Mr. Whate- ly, on the similarity of appearance in the lining membrane of the urethra, and surface of the glans and prepuce, when secreting purulent matter, lead to an opinion, that the discharge from these sur- faces may be produced by the same poison, and is, * Wbately on Gonorrhoea, p. 20. PAPULAR VENEREAL DISEASE. 71 therefore, in both instances, the same disease affect- ing different parts : an opinion which we would na- turally be induced to adopt, on considering that both parts have the same continuity of surface, and that there exists a great similarity in the affections in question. From these observations, and from the very fre- quent occurrence of two, or even the three affec- tions, {viz. the simple primary ulcer, excoriation and gonorrhoea,) existing together on the same patient ; and from the fact that each occasions the same train of constitutional symptoms, we have strong grounds for concluding that they arise from the same iden- tical poison. That the ulcers in question, and excoriation of the glans and prepuce described, are frequently followed by the papular eruption, every practition- er, if his experience be not very limited, must admit; but that gonorrhoea alone may also produce it, is more questionable. In support, however, of this position, I beg to state, that I have repeatedly seen men affected with this eruption who asserted posi- tively, that they never had any primary symptoms, except gonorrhoea ; and I have also, in numerous instances seen women effected with the same erup- tion, who did not, on the minutest examination, ex^ hibit any other primary symptoms than a gonoi^ rhcea, and who asserted at the same time that they never had primary sores. I at first doubted their veracity, or supposed that ulcers might have exist- ed on the parts of generation, which had escaped their observation 5 but having met innumerable in^ 72 PAPULAR VENEREAL DISEASE.^ stances of the same eruption in persons affected with gonorrhoea, combined with a purulent discharge from the glans and prepuce, a little consideration led me to conclude, that it was the same disease affecting different parts. This papular eruption, which is occasionally observed to follow gonorrhoea, furnished a strong support to those practitioners who adopted the opinion, that gonorrhoea and chan- cre arise from the same poison. But the facts I have stated, and the analogies I have brought for- ward, will, I hope, dissipate at least some of the doubts and perplexities attending the subject, and, perhaps, set at rest this intricate and long disputed question. Notwithstanding these strong circumstances, it must be admitted, that constitutional symptoms after a gonorrhoea, is a very rare occurrence ; and therefore we can only esteem it as a natural, but not a very common consequence. Hunter, who supposed that chancre and gonorrhoea arose from the same poison, affecting different surfaces, does not, as well as I recollect, attempt to explain the infrequency of constitutional symptoms attending the latter. With the view of affording some clue to this hitherto unexplained and little fact, I beg to submit the following considerations. First. — When we wish to inoculate the matter of other morbid poisons, the vaccine and variolous, for instance, the earlier it is taken, and while the infec- tion is thin, limpid, and not purulent, the more cer- tain we are of communicating infection. In the latest system of medicine published, that of Dr. PAPULAR VENEREAL DISEASE. 73 Good, we find the following passage concerning small pock inoculation : " It is preferable to take the fluid before the pustule suppurates^ as afterwards it seems to partake of the nature of common pus^ and produces a larger circle of inflammation^ and on this account also it cannot so fully be relied o?2."* The same uncertainty occurs with respect to the inoculation of the vaccine virus, if not taken from the pustule until the twelfth or thirteenth day, a period when the virus has lost its limpid appearance and become thick and purulent, when we either fail in communicating a disease capable of affecting the constitution, or give one of a spurious and impotent nature. Secondly. — Mucous surfaces, when assailed by contagious matter, are excited into a state of inflam- mation, which rapidly passes into the suppurative stage. Thirdly, — It may be inferred from the preceding premises, that inflammation and suppuration are the bars which nature opposes to the introduction of morbid poisons into the system. These views will not only account for the infrequency of constitu- tional symptoms attending a gonorrhoea, but indicate a most important item in the laws which govern morbid poisons. It also adds another instance, to the many already observed, of a vis medicatrix naturae, or of those wise laws of the Creator, by which there ap- pears an inherent power in the constitution of ani- mals to resist injurious agents. The mucous sur- * study of Medicine, by J. M. Good, M. D. Vol. IL p. 636. K 74 PAPULAR VENEREAL DISEASE. faces necessarily unprotected by cuticle, are more exposed than others to be assailed by a variety of morbid poisons ; but they are more promptly than other textures excited to inflammation, which rapid- ly, and without breach of surface, passes on to the suppurative stage, which, from our knowledge of the vaccine and variolous inoculation, renders a mor- bid poison innocuous. Hence we have strong rea- sons, from the above facts and considerations, to conclude that the rapidity with which mucous sur- faces inflame and suppurate, prevents the admission of morbid poisons into the constitution. The frequency of catarrh and influenza ma}^ not (under these views) be always occasioned by changes of atmospherical temperature, but may be often owing to contagious matter floating in the air; which is thus prevented from doing farther mischief than exciting a troublesome affection of the mucous membrane of the nares and branches of the bron- chial tube. Surgeons in the army have opportunities of accu- rately investigating the laws of venereal diseases, which those in civil life do not possess; as the sol- diers are under orders to apply to them on the very first appearance of disease, and when cured, or ap- parently so, they still remain under surveillance. The females who infect a regiment are in general known, particularly in foreign stations, and much information into the laws of venereal poisons can be obtained, by comparing the disease in the fe- male with that of the male whom she has infected. I, therefore, with pleasure avail myself here of much PAPULAR VENEREAL DISEASE. 75 valuable information contained in the work of Mr. Evans, surgeon of the 57th regiment,* which evinces in the author much talent for observation, and af- fords some important facts that bear upon the ob- scure subject under consideration ; and I feel the more gratified in thus supporting the opinions I venture to offer, by the evidence of others rather than my own. Mr. Evans details three interesting experiments of inoculation of matter, taken at different periods from the simple primary ulcer under consideration ; which prove that the earlier the infection is taken, and while the sore is in its excavated or ulcerating state, and, as we may infer, before the matter is purulent, the more severe and obstinate is the ulcer which it produces. I shall refer to the work itself for the detail of the experiments, but the following passage contains the result. " From these and other experiments, I am inclin* ed to the opinion, that in this, as well as in the vac- cine disease, the secreted fluid varies, or is less certain in its effects in proportion to the duration of the disease ; for in the first of these cases, where the ulcer from which the matter was taken was of ten days' standing, the disease terminated in four- teen days ; in the second, where the sore was only eight days old, the inoculated disease continued eighteen days ; and in the third case, where the matter was taken before the cessation of the ulcera- tive stage, it continued twenty-eight days." * Pathological and Practical Remarks on Ulcerations of the Genital Organs, by James Evans, Surgeon of the 57th Regiment, 76 PAPULAR VENEREAL DISEASE. I shall also take the liberty of transcribing from Mr. Evans' work the three following cases, which decidedly prove that the matter of gonorrhoea is capable of producing the primary venereal ulcers we have just been considering. Case. — " Two gentlemen had connexion with a girl, the one shortly after the other; one of them contracted venerola vulgaris,* the other gonorrhoea; — the girl was examined, she had some discharge from the parts, but no ulceration.''^ Case. — " A gentleman in the habit of going with one particular woman, was occasionally affected with discharge from the urethra, sometimes accompanied with pain in passing his urine, but more frequently not; in the first case it usually remained upon him eight or ten days, in the second it generally went off in four or five. One day he applied to me for advice, under the impression that he had contract- ed chancres ; his disease, however, was herpes pre- putialis, finely marked, the vesicles being distinct, and placed in two parallel lines of three vesicles in each. The disease was explained, and the neces- sary directions given; he nevertheless, that night, paid the lady another visit, and three days after- wards came to me, with an ulcer, in the place where the herpes preputialis had been, and which turned out to be venerola vulgaris. The girl was examin- ed; there was some increased secretion^ hut no ul- ceration; the disease in him ran its course regular- ly in about twenty-eight days. No sooner was he * The term which Mr. Evans employs to designate the simple primary ulcer described in this chapter. PAPULAR VENEREAL DISEASE. 77 well, than he went again with the same woman, and a few days after, had virulent gonorrhoea. The woman was again examined, and found free from further disease than that degree of increased secre- tion^ which may be termed slight leucorrhcea, which she acknowledged to have been occasionally subject to for six months before. In this case, then, we see both venerola vulgaris and gonorrhoea take place in the same person from the same cause. " Whether or not in some cases ulceration exists beyond the reach of the eye, can only be decided by examination after death. I must acknowledge, no good reason presents itself to point out why it should not ; but as we have no proof that venereal ulcers do form so far within the vagina, as to be beyond discovery, I am no way disposed to argue upon the supposition that they do, particularly as this is one of the many matters of fact that cannot be demonstrated by reasoning." Case. — The following appears to me another strong case in support of the text. Captain contracted gonorrhoea, and a week afterwards em- barked for a foreign station. After being at sea for six tveeks, the gonorrhoea disappeared, but the next day a small ulcer was discovered, which proved to be venerola vulgaris : mercury was used, and the sore healed, but immediately afterwards another made its appearance near the scite of the former; it spread over the old cicatrix, and in spite of mer- cury, remained open for more than three months. In this -: ise, the first ulcer (for I shall take no no- t '^ t :^ ecvjiid) must have been the consequence 78 PAPULAR VENEREAL DISEASE. of the application of the gonorrhoea! matter ; for to suppose the application of the venerolic poison to have been coeval with the gonorrhoeal infection, and that it could lie dormant in the part for seven or eight weeks, is to go a little too much out of the road of common sense, and is contradicted by analogy." In another part of his work,=* Mr. Evans states three cases, in which the males exhibited the same description of ulcer on the genitals ; but on examin- ing the female from whom the disease was caught, no appearance of ulceration, or other disease was ap- parent; from which he infers, that these ulcers may be caused by " the application of an altered secre- tion, without any breach of surface, or discernible disease in the female organs." I have already, in my first chapter, given Mr. Abernethy's opinion, supported by two cases in con- firmation of the doctrine, that the secretions of one animal applied to the crude surface of another, are capable of producing an ulcerative disease ; and in further support of this opinion, we are informed by Mr. Evans, that he was frequently present at the examination of the public women, held at stated periods by the French surgeons at Valenciennes ; upon which he remarks, " I have always been sur- prised at the small portion of disease to be found among them : at one which I attended, no less than two hundred women of the lowest description, and of course, the most frequented by soldiers, were examined, and not one case of disease was found * Evans, p. 72. PAPULAR VENEREAL DISEASE. 79 among them; nevertheless, the military hospitals had, and continued to have, their usual number of venereal cases." And in a note he adds, " by vene- real' cases, ulcerations are alone meant." Mr. Evans might, however, have been in some respects deceived, although not one case of disease was found amongst them ; as we may presume, that on a general inspection of this kind, upon which the liberty of following their vocation depended, the women were particularly attentive to cleanli- ness, and may have removed all appearance of gonorrhoea! matter; but ulcers could not have been concealed, and no doubt, from the views we have taken, if they were affected with gonorrhoea, although free from ulceration, they were capable of exciting the latter in the males with whom they were connected.^ * That the various forms of the venereal disease can be com- municated by those who have no apparent disease of the genital organs, is a well established fact, and affords a strong argument in favour of the unity of the venereal poison, as well as the origi- nal manner of its production. It is an undeviating law of nature, that excesses are always followed with evil consequences. And what more suitable retribution could ensue to the unnatural vice of excessive and promiscuous copulation than that which attends it ? Could it be reasonably sup'posed that a female should have frequent intercourse with several men, and experience no incon- venience from thus transgressing the most important law of na- ture ? A different result might be naturally expected. Organs so exquisitely organized, would, from excessive excitement, and perhaps, laceration, become highly irritated, and subsequently in- flamed, whilst their secretions, converted into foul and acrimo- Kiious discharges, would be rendered highly virulent by intermix- ture with the most acrid of animal secretions. Inasmuch, therefore, as many are seduced into unlawful indulgence by appearances of security, it might, perhaps, be useful to society if it were gene- rally understood, that however favourable circumstances may seem, safety is never to be expected where either of the parties is ad- dicted to promiscuous intercourse. E. 80 PAPULAR VENEREAL DISEASE. Notwithstanding the preceding facts and obser- vations, which go to prove that the same virus will produce the simple primary ulcer described, a j)uru- lent discharge from the glans and prepuce, and a gonorrhoga virulenta, yet it is not likely that those who have formed their opinions respecting venereal complaints in the olden time will subscribe to these new heresies. Let them, however, recollect that the experiments of John Hunter, which go to prove that the matter of gonorrhoea will form chancre, and that the matter of chancre will reciprocally produce gonorrhoea, are directly contradicted by those decisive experimeuts detailed by Mr. Benja- min Bell, which were instituted by two gentlemen in Edinburgh, on their own persons, and witnessed bv him and Dr. Duncan. In one experiment, the matter of chancre intro- duced into the urethra, produced chancre, and in the other, the matter of gonorrhoea, placed between the"prepiice and glans, produced gonorrhoea of those parts, and chance rendered the experiment more perfect than was looked for, the matter in the last experiment having found access into the urethra, it affected it also with gonorrhoea. If these experi- ments will not enable us to decide on the fact, ar- guments can make but little impression. It is, however, too important a question to pass by with- out every illustration in our powder to give it. Independent of the total dissimilarity in the symp- toms, appearance, and progress of gonorrhoea and chancre, the following considerations could not but have decided our judgment, if they had not been PAPULAR VENEREAL DISEASE. 81 opposed by experiments intended to prove the identity of the poison in the two diseases, and which were promulgated by the most respectable authori- ty- It is exceedingly probable, that the matter of go- norrhoea introduced between the prepuce and glans, will, as in the experiments related by Mr. Bell, pro- duce gonorrhoea of these parts, unless, indeed, the matter should happen to be applied to a crude or abraded surface, and then, most probabl}^, ulceration will follow ; for even healthy secretions, applied to such a surface, is capable of exciting troublesome ulcers. Thus we are furnished with an obvious explanation of the mistake of those persons who inoculated the glans with the matter of gonorrhoea, and asserted that it produced a chancre. Gonorrhoea was not described as a symptom of syphilis till half a century after its introduction into Europe, and after chancre and the other symptoms of the disorder had been accurately described by the practitioners of the day. At the same time we are aware, that a running from the urethra is noticed by successive authors, from the earliest periods in which we have medical records. But although syphilis, immediately after its introduction, was ac- curately described, and discriminated from all other ulcers and symptoms with which it was liable to be confounded, yet, in a few years, all complaints of the genitals w^ere indiscriminately confounded to- gether and supposed to arise from one and the same poison. There is, therefore, no room for surprise, 82 PAPULAR VENEREAL DISEASE. that gonorrhoea should be included in the num- ber.* In support of the opinion that chancre and go- noiThoea arise from distinct poisons, I may observe (although I will be accused of begging the ques- tion) that the constitutional eruption which follows chancre, is of the order of scalr diseases belonging to the species lepra, or psoriasis of Willan, while that which attends gonorrhoea is papular, belonging to the species lichen, of the same author. The buboes which occur in this form of venereal disease do not exhibit any particular characteristic by which they are distinguishable from those which arise from other venereal primary ulcers, except that they partake of the original mild character of the disease. They are. however, probably from this cause, often remarkably indolent, occasioning no pain and but little inconvenience, except from their tediousness. The primary symptoms detailed in this chapter, are liable to be followed by a papular eruption, "^ Astruc is decisive on this point, as may be seen from the fol- lowing passage: — "In the fourth period, from 1540 to 1550, se- veral of the symptoms, which had shown themselres from the tirst eruption of the distemper, seemed daily to abate of their violence, such as pustules, srununafa, pains, erosions of the part*. &c. : but, on the other hand, there appeared a new symptom to make up for this abatement, never observed before, though from that time the most common, if not perpetual symptom in the begin- ning of the venereal disease. I mean a x'lvulent gonorrhcea. of which we have m-ention first made by Brassavolus. in hi? treatise De Ahrbo GalUco, which he wrote in l'>51. and published in 1553: by Fer- nelius in 1555. lib. 2. de abditis rerum cansis. c^p. 14. and lib. 6. de portium morbis el symptomatic, cap. 20. and by Fallopius in cap. 23. Tract de Morbo Gallico, which I imagine was written about the year 1560." See Astruc, book I. p. 98. PAPULAR VENEREAL DISEASE. 83 which terminates in desquamation. In all the in- stances but two which have occurred to me since I commenced the investigation, (a period of fifteen years,) this has been the case. In these two in- stances, which are detailed in p. 99, ct seq. of my first edition, the eruption was pustular. I may pos- sibly have been mistaken in the characters of the primary sores, the exceptions being so few to a very general rule. Let this be as it may, it is but candid to have them recorded. The utmost any individual can do in an investigation of the present magnitude, is fairly to state his experience ; for to determine the distinctive characters of morbid poi- sons, so closely related to each other as those of venereal origin, requires a field of observation be- yond the scope of any individual, no matter how extensive his experience. The CONSTITUTIONAL SYMPTOMS of thc papular vene- real disease consist of more or less of fever, attend- ed with pain in the head, shoulders, and larger joints ; and sometimes pain in the chest, with con- siderable dyspnoea, which ushers in an eruption that chiefly appears on the forehead, chest, and back, but also extends in a more scattered way over the ex- tremities. The fever does not subside on the appearance of the eruption, although it is at its height just pre- vious to that event. It exists as long as fresh crops of the eruption continue successively to appear, and is usually accompanied with jiaiiis of the several joints, which are most sev^ere at night. The papulse vary from a pale red to a deep crim- 84 PAPULAR VENEREAL DISEASE. son, as represented in Plate I. fig. 1, 2, 3. Some of them are simply pimples, while others are almost advanced to the pustular form. The time of the appearance of this eruption after infection is, pro- bably, as uncertain as the eruption in the scaly ve- nereal disease, or true sjphilis. In a few instances, I have observed it to occur in four or five weeks after infection. The papulae, in some patients, were numerous on every part, but particularly on the face, back, and bell}^: in others they were more thinly scattered over the surface of the body. They do not all make their appearance together, as in the eruptions of the exanthemata, but follow each other in succession; so that on the same patient some spots vAll appear in their commencement like small pimples ; others, which have arrived at maturity, form larger pimples, with acuminated tops, contain- ing pus or lymph : while others, on their decline, consist of exfoliations of the cuticle. Their colour, in their latter stages, becomes paler, and assumes a copper tint, while the exfoliation of the cuticle gives an appearance of scaliness, a state in which it is most liable to be confounded with the scaly erup- tion of sj^philis. But they may be readily distin- guished from each other: for when the papular erup- tion is on the decline, and has assumed a pale red or copper colour, on examining the patient, we shall find other spots in their papular or pustular form, which will at once point out the character of the eruption. But the ver\' appearance of the declining papulae will, to a discriminating eye, be sufficient for this purpose; for its copper-coloured scaly surface PAPULAR VENEREAL DISEASE. 85 is more raised in the centre than its circumference, while the reverse is the case in the scaly leprous eruption of syphilis ; as will be more particularly insisted on when treating of that eruption. In Plate I. fig. 2. is represented a form of the erup- tion less frequently met with than the appearances delineated in the other two figures. The spots are considerably smaller, and at the same time more numerous. Few of the papulae have acuminated heads containing matter; they are, in fact, minute red pimples clustered closely together. In some instances, papulae, similar to those delineated in this figure, are clustered together in separate patches, which are of an irregularly circular form. The pa- pulae, as exhibited in those figures, continue a week or two before they begin to decline, and two or three weeks elapse before the discolouration of the skin w^hich they produce entirely disappears. In all cutaneous eruptions, attended with any de- gree of fever, there is, as Dr. Bateman observes, " a general tendency to sore throat, and even to affec- tions of the eyes." We need not then be surprised, that the disease under consideration should have soreness of the throat as one of its most frequent constitutional symptoms. It is, however, widely different from that which takes place in syphilis, in V, hich there is a deep excavated ulceration of the tonsils, with little inflammation or difficulty of de- glutition. In this disease, on the contrary, the pa- tient complains of considerable soreness, and diffi- culty of swallowing ; and, on examination, the entire fauces, but more particularly the back of the pharynx, 86 PAPULAR VENEREAL DISEASE. exhibit an erithematous appearance, and not unfre- quently with considerable swelling of the tonsils, which assume, as they always do when swelled, an irregular appearance, that is often mistaken for ul- ceration. The cervical glands also frequently swell and ulcerate in this disease, but more frequently when the eruption is on the decline. These swel- lings have hitherto been esteemed scrofulous, it be- ing supposed, that the patient thus affected had scrofula lying latent in the system, which was brought into a state of activity b}- the mercury em- ployed. But this opinion is proved to be untenable by the fact, that the patient is equally prone to these swellings when mercury is not exhibited as when it is. This symptom is a common and every day occur- rence ; and, in fact, we only recognise in it an analo- gous affection to that which often takes place at the termination of small pox, measles, scarlatina, and all the exanthemata. The eruption, after having wholly disappeared, will, in some few instances, return again and again, at uncertain intervals of from one to several weeks, each successive crop, however, being less than the former, and attended with less constitutional de- rangement. The intervals between those attacks are also greater, as the disease exhausts itself, or yields to the powers of the constitution. But if the progress of the disease has been interrupted by mercury, before it has arrived at its latter stages, it becomes more obstinate and complicated than it would otherwise have been. PAPULAR VENEREAL DISEASE. 87 If that medicine be exhibited on the first appear- ance of the eruption, and while there exists consi- derable fever, with severe pains of the joints, which often demands the use of the lancet, the patient is, in general, rendered much worse, his fever is in- creased, and the pains become more severe. But if the exhibition of mercury is postponed until the fever has subsided, the eruption will in most instances disappear under its use, and the pains, though not removed, will be alleviated. How- ever, as soon as the mercurial irritation has ceased, a fresh crop of the eruption will, in general, make its appearance, together with an increase of pains in the joints, and, perhaps, with soreness of the throat. Under these circumstances, another mercurial process is in general recurred to, and the symptoms yielding to that medicine, as in the first instance, induces a firm belief that the right path has been pursued, and that the former failure was owing to the employment of an insufficient quantity of mer- cury. The patient is, therefore, doomed to a se- vere and protracted course of that medicine, and while he is under its full influence, the symptoms will often return w4th additional severity, to the great perplexity of the surgeon, and disappoint- ment of the patient. The return of the symptoms under these circumstances demonstrates that the mercurial irritation on the constitution is no longer capable of suspending that of the poison; a fact which is probably owing to the effects of habit; for the constitution having now become accustomed to 88 PAPULAR VENEREAL DISEASE. the mercurial irritation, no longer feels the same impression or is excited to the same actions as for- merly, under its influence. When the symptoms of the disease re-appear, at a time when the mercurial action is at its height, it is found to be absurd to persevere any longer in its use. It is, therefore, at length discontinued, from a belief that the symptoms under which the patient labors are not the effects of the poison, but of the antidote. He is, therefore, directed to adopt a plan, under which he might probably have recovered in the first instance. The mercury is discontinued, and sarsaparilla, or other vegetable tonics, which, without weakening the constitution, promote the several secretions, are directed. Under this plan, if his constitution has not been irreparably injured by the courses of mercury to which it was subject- ed, he in general recovers with a rapidity that even surprises his medical adviser. If the advanced stages of this disease, but parti- cularly if the eruptive fever, have been injudicious- ly superseded by the early use of mercury, or if the eruption has been repelled by imprudent exposure to cold, inflammation of the iris of each eye is a very common attendant. This affection is now so well known, and so accu- rately described in all elementary works upon dis- eases of the eye, that it is only necessary for me to warn my junior brethren to be on their guard against an attack that occurs in the most insidious manner ; but which rapidly destroys vision, if not energetically opposed by appropriate means. PAPULAR VENEREAL DISEASE. 89 Intolerance of light, and defect of vision, are in general the first symptoms which induce the pa- tient to seek for advice. On examination, a want of the usual transparency of the aqueous humour is observable, and is caused by a deposition from the inflamed vessels of the iris : the pupilar edge of the iris at the same time exhibits a thickened and puckered appearance, which usually causes an irre- gularity in the circular form of the pupil, most ob- servable at its upper part. A change of colour may be discerned in the iris, on comparing it with that of the other eye, if it has not been affected; and although the conjunctiva partakes in a slight degree of the general inflammation of the eye, yet the ves- sels of the schlerotic coat surrounding the cornea will be seen obviously enlarged, and deeply engaged in the inflammation, which we have no reason to suppose is strictly confined to the iris, but extends more or less to every part of the eye, as is indeed rendered sufficiently obvious by the pain excited from pressure on the eye-ball. As the disease advances, adhesion takes place be- tween the iris and capsule of the lens; the pupil be- comes contracted, and portions of lymph not only plug up its orifice, but are deposited on the surface of the iris. Pus or lymph is seen lying at the bot- tom of the anterior chamber, the humours of the eye become more opaque, and vision more defec- tive. The pain is sometimes intense and lancinat- ing, but in general less considerable than might be expected from the extent of the disease affecting the delicate structure of the eye. Suppuration at M 90 PAPULAR VENEREAL DISEASE. length ensues, and the eve becominc: disorojanizeci, the matter either makes its way through the scle- rotic coat, or transparent cornea, but more frequent- ly through the latter. In a former publication, I stated that with a sin- gle exception, throughout tlie whole of my then ex- perience, the eruption if any was present, which ac- companied venereal iritis, was papular : and after six years' additional experience in attendance upon a large hospital, containing wards for the reception of venereal patients, as well as for those labouring under diseases of the eyes, and also an extensive eye dispensary attached to the institution, I have to confirm the above statement, by declaring that, among the numerous cases of iritis which have been during this latter period under my care, there was not a single instance of the disease accompanied by eruption, in which that eruption was not papular.- And yet so guarded am I in my conclusions, that with all this experience, I did not, nor do I at pre- sent venture to assert, that this venereal affection of the eyes is only attendant upon the papular eruption. This cautious observance, I should think, might have protected me from the uncandid observations of one of those puny aspirants after fame, who are contented to convert, by force of hammering and wire-drawing, the solid discoveries of others into an ostentatious display of their own tawdry tinsel : thus, in this author, the twenty pages of that ever-to-be- regretted original writer, John Cunningham Saun- ders, the first describer of iritis, are expanded into a PAPULAR VENEREAL DISEASE. 9 I portlj-sized octavo volume, that does not contain one fact of any practical utility, originating in this aiitlior's own experience. But the passage in ques- tion modestly runs thus : " Some species of erup- tion most commonly attends it (iritis.) and is usually either of the papular or scaly kind ; we are not, however, to credit the statement of a recent specula- tive loriter, who would have us believe, that it is only joined with the papular, &c." Although my name is not brought forward on the occasion, yet it is obvious that this sneer is intend- ed for me, because it was only from my publications that he could have learned that iritis is a common attendant upon the papular venereal disease ; a cir- cumstance which, with some others of minor impor- tance, he has thought proper to borrow from me without acknowledging the obligation. I am in- clined to believe, however, that the scaly eruption he mentions was actually the papular in its declin- ing stage ; for the scaly or true syphilitic eruptiop has been but seldom met with in this city during the last eight or ten years, which probably com- prises the space of this author's observations. But to return to the other symptoms, I may ob- serve that in many hundreds, I might with truth say thousands, of cases of this the most common form of venereal disease, I have not met with a sin- gle instance of decided nodes, or of those affections of the deep-seated parts, which are common in some of the other forms of venereal complaints ; so that the absence of nodes may be considered as one of the characters of the papular disease. 92 PAPULAR VENEREAL DISEASE. It must be admitted, that, in a few cases, swell- ings occurred over the tibiae, and these might by some be denominated nodes. They differed, how- ever, from nodes, in possessing much more of the inflammatory character, and in effecting obviously the integuments covering the bone, and not the bone itself, for they appeared suddenly, and after continuing a few days as rapidly disappeared with- out the exhibition of mercury. I have in this outline sketched the leading cha- racters of the venereal disease, attended with the papular eruption, and have purposely omitted some circumstances detailed in my first edition, which my increased experience has taught me to consider more as accidental occurrences than its usual and common attendants. It is not to be expected that a writer or lecturer shall detail every appearance which may possibly take place in any disease ; all that ought to be demanded from him is, that he de- scribe the usual and characteristic symptoms which are scarcely ever absent, and this I think I have accomplished in respect of the form of venereal disease under consideration. The TREATMENT OF THE PRIMARY SYMPTOMS of the papular disease is extremely simple. It consists in keeping the patient as quiet as possible ; and if in- flammation, with swelling and phymosis should be present, strictly confining him to a recumbent posi- tion. His diet should under every circumstance be very light; but in the latter case the antiphlogistic rules ought to be rigidly observed. The internal medicines I employ are cathartics, combined with PAPULAR VENEREAL DISEASE. 93 antimonial preparations ; for instance, a couple of pills containing equal parts of the compound ex- tract of colocynth and antimonial powder each night, and repeated in the morning if necessary ; or a so- lution of sulphate of magnesia in plain water, or in- fusion of mint, with the addition of as much tartar- ized antimony as the stomach can bear, twice or thrice daily. When there is a disposition to inflammation and phymosis, and that a patient has a good appetite, which he is not inclined to disappoint, the exhibi- tion of this medicine is particularly advantageous. If the ulcers are at all irritable, confinement to the house will be almost as necessary as if the patient were undergoing a full mercurial course; and unless the ulcer is very inconsiderable indeed, the gentlest exercise will excite irritation. These ulcers will heal under the use of any simple astringent washes, or mild ointments; if, however, they should continue long obstinate in an indolent chronic state, mercury in alterative doses will indubitably hasten the cure: and an ulcer which, under different treatment, might not heal for several months, may thus be cured in a few weeks. This may be ascribed to the excitement of a new action in the part; and, with this view, I am in the habit of putting those affected with chro- nic indolent ulcers of the legs, arising from any cause whatever, on alterative doses of mercury, by which means the most obstinate of them are healed in a comparatively short period of time.^ * This remark the editor thinks he has often seen corroborated. Mercury should, however, be rarely given ^n such cases, in alter- 94 PAPULAR VENEREAL DISEASE. With respect to local applications, I employ such as are most likel}' to heal the ulcers as rapidly as possible, from a belief in this maxim, that the sooner an ulcer which secretes a morbid poison ca- pable of infecting the constitution, is healed, the more likely is the constitution to escape contamina- tion. We have seen from the analogy of this to other morbid poisons, as well as from the decisive experi- ments of Mr. Evans, that the earlier the stage of the ulcer from which infection is taken, the more active or virulent is the poison; and that in proportion as the ulcer advances to the secretion of pus, in place of lymph, its contagious properties diminish. Influenced by these facts and considerations, when a patient applies to me with an ulcer in its 6rst stage, while it is yet excavated and secreting lymph, I instantly endeavour to destroy its entire surface by a free application of lunar caustic ; and when the eschar separates, I have often the satisfac- tion of finding a simple sore instead of a poisonous ulcer. Not, however, confiding altogether to the first application, I direct the patient to keep lint ative doses, before the system is well prepared for it by the aati- phlogistic measures above recommended. The hydrargyri oxy- murias in such minute doses as will hardly be sensibly felt by the patient, namely, the one-eighth or one-tenth of a grain in pills or solution twice a day, frequently acts like a charm in healing ulcers of a very indolent character. Hence the reputation of certain Rob's, Panacea's and other nostrums, of which this preparation of mercury is the concealed basis, and which are most frequently resorted to in the declining stages, after the use of other mea- sures may have paved the way to their successful administration. This lucky application of them is the grand secret of those tniracu- lous cures which astound the public, and frequently perplex and even put to the blush our most able physician?. E. PAPULAR VENEREAL DISEASE. 95 moistened in a solution of nitrate of silver, (in the proportion of three or four grains to an ounce of distilled water,) constantly to the ulcer; which so- lution I gradually diminish in strength as the sore assumes a healing disposition. An opinion has prevailed, owing, I believe, in a great measure to the writings of Mr. Benjamin Bell, that the application of caustic to primary sores ex- cites bubo. It may possibly do so by partially irri- tating, in place of wholly destroying the ulcer; but for my part, I have by no means found that bubo is apt to follow the application of caustic to the ulcers under consideration, when it is applied at the period that they are alone fitted for the experiment, viz. at their commencement, when they are in their exca- vated state, secreting lymph, and of small extent compared to that which they may afterwards at- tain. In the second stage of the sore, however, when its surface is either on a level with the surrounding skin, or raised above it, and that pus and not lymph is secreted, it would be folly to apply caustic with the object of cutting off infection, or altering its nature. It has already existed too long to afford a chance of the former, and the latter is unnecessary, as the ulcer is already approaching the nature of a common sore. The applications I employ in this stage are those most likely to accelerate the healing pro- cess, such as a solution of nitrate of silver in the pro- portion of one or two grains to an ounce of distilled water, or the blaxik or yellow mercurial washes; the 96 PAPULAR VENEREAL DISEASE. lint with which any of these are applied ought to be changed thrice a day. When these ulcers become-very much raised, ex- hibiting a fungous appearance, touching them daily with sulphate of copper will hasten their cicatriza- tion. In some instances, particularly when the sores are on the external prepuce, or body of the penis, ointments are most suitable ; among these I have found the zinc ointment either alone, or blended with a third or a fourth of the nitrated mercurial ointment, the best application.* Whenever a disposition to phymosis occurs, the patient should be confined strictly to the recum- bent position, and desired to inject warm water fre- quently between the glans and prepuce. Poultices of bread and water may also be applied with advan- tage to the entire penis ; and the antimonial solution given in such doses as will excite slight nausea: but when the inflammation is violent, the penis consider- ably swollen, and attended with acute pain, if the most active measures are not immediately adopted, the inflamed parts will fall into a state of mortifica- tion. In these cases, the symptomatic fever runs so high, that the pulse is from 110 to 130, with thirst and restlessness. Cnder such circumstances, I im- mediately direct blood to be taken from the arm, in proportion to the urgency of the symptoms and strength of the patient, and repeat the venesection * The healing of these sores may likewise be greatlv expedited by the daily application on a piece of lint of a saturated solation of the sulphate of copper in water, with dressings of simple ce- rate or red precipitate ointment. E- PAPULAR VENEREAL DISEASE. 97 every six or eight hours, until the inflammation be- gins to yield It is as necessary to have recourse to the lancet in those cases, as in pleurisy, or in the most acute ophthalmia. However beneficial local bloodletting may be in inflammation of other parts, it is scarcely admissible in this; for if the matter which flows from beneath the prepuce should come in contact with the wounds inflicted by leeches, troublesome sores might ensue, which would still farther add to the inflammation it was intended to subdue. By active measures of this kind, if employ- ed in time, we shall avert the usual result, viz. mor- tification of the prepuce, or suppuration of the body of the penis under its investing ligament. In some cases, a portion of the prepuce will slough in such a manner, as to leave an opening through which the glans penis passes out; and the remainder of the prepuce lying behind, or at the frenal side of the glans, forms a useless appendage when the parts are healed. When the other attend- ant upon inflammation of the penis, viz. the for- mation of matter under its ligament, takes place, the pain is excessive, from the unyielding nature of the ligament; and the entire penis acquires a state of constant tension, and becomes indurated in an ex- traordinary manner. The integuments are of that red colour which indicates the presence of matter underneath, but no fluctuation can be felt, on account of the thickness, and unyielding nature of the invest- ing ligament of the penis. This circumstance can only be discovered by the previous symptoms, the pain and tedious obstinacy of the disease, the cal- 98 PAPULAR VENEREAL DISEASE. lous state of the penis, and the discolouration of its integuments. The matter at length, usually makes its way through that part of the dorsum penis near- est the pubis, where the ligament is found less dense than elsewhere ; and a probe will freely pass into the small round opening through which it flows, and may be moved, in any direction, under the li- gament. But instances sometimes occur, where the matter points over or above the pubis ; and, in this case, a deep abscess is always formed. In the pro- gress of the complaint, the ligamentous covering of the penis will occasionally ulcerate and slough away ; in which case, a foul and extensive ulcer, with averted edges, will occupy the dorsum penis, closely resembling, in appearance, that produced by a deep-seated paronychia, a day or two after a free incision has been made on the anterior part of the finger. Nor can we adopt a more certain mode of arresting the progress of the disease under consider- ation, than by a free incision of the dorsum penis, longitudinally through the ligament, before ulcera- tion takes place ; for if we wait for this event, the organization of the penis may be destroyed. But the matter, once allowed an exit, the pain, tension, and other symptoms, in general soon give way under the use of emollient applications. In some instances the matter finds a passage at the corona glandis, and the probe introduced into this opening will pass under the ligament of the penis,- often as far as the pubes, at the upper part of which sinus it will be necessary to make an open- ing; this will sometimes succeed, and the cavitv PAPULAR VENEREAL DISEASE. 99 will gradually close. In other instances, however, amendment will not follow this step; the openings will contract, notwithstanding every attention, so as to prevent the discharge from flowing off, and the confinement of the matter will occasion much pain, and an appearance of pointing on the dorsum penis between the two openings. These tedious, painful, and embarrassing circumstances may be prevented by the timely use of a seton passed from one open- ing to the other, which occasions a free exit to the matter. As the discharge diminishes, the threads of the seton may be gradually reduced, until it is withdrawn altogether ; laying open the entire ex- tent of the abscess with the knife is too severe an operation, and would probably, in the swollen and diseased state of the parts, be followed by sloughing of the ligament, and disorganization of the penis ; enlarging the original openings in general only affords temporary relief. But in the mode of treating those cases by seton, I have, in many instances, perfectly succeeded in removing the disease, leaving the state of the parts uninjured. The preceding observations respecting the formation of matter under the liga- mentum penis, and the mode of treatment, of course, equally apply to the other forms of venereal dis- ease, as well as that which produces the papular eruption. The simple venereal primary ulcer, as well as every other description of primary ulcer, is liable to be followed by warts ; when they are numerous, and their bases comparatively broad, they will, in some instances, almost conceal the surface of the 100 PAPULAR VENEREAL DISEASE. glans and prepuce, and it has long been a desirable object to possess an application capable of destroy- ing them. Practitioners agree that mercury does not affect them, and the common caustics, savin or verdigris, will, under the circumstances in question, require in the most favourable instances months for their removal; and, perhaps, fail after the most patient and continued perseverance in their use. But I have had the satisfaction of introducing an application which I have never knov/n to fail in any instance, however numerous and extensive these untractable excrescences. The idea of applying acetic acid to warts, was first suggested by a know- ledge of its extraordinary effect upon those well- known indurations of the cuticle called corns, which it will in general remove in one or two applications -, and, if not carefully managed, all the surrounding cuticle which it may happen to touch. But how- ever efficacious this remedy, I would only recom- mend its application to large warts with broad bases, on which it should be rubbed daily by means of lint on the end of a probe. Where they have nar- row necks, the most expeditious way, and one which is perfectly safe, is to cut them off with scissors, and afterwards, if it is thought necessary, apply lunar caustic to the wound, after the oozing of blood has ceased. Having considered the treatment of the simple primary ulcer, and its consequences, I shall proceed to make a few very brief observations on that of the patchy excoriation of the glans and prepuce, and also on gonorrhoea virulenta. PAPULAR VENEREAL DISEASE. 101 Of all venereal complaints, the patchy excoriation, or chancrous excoriation, as it was formerly term- ed, is the most easily cured ; any mild astringent lotion, injected five or six times daily between the glans and prepuce, will remove it in a few days. That I usually employ is the yellow mercurial wash above mentioned; but weak solutions of acetate of lead or sulphate of zinc, or even simple ablutions, may answer equally well. It is so easily cured, even under common attentions to cleanliness, that I cannot conceive how some practitioners can have the conscience to subject their patients to a five or six weeks' course of mercury, for a complaint that simple water may remove in a few days.* This excoriation is, however, very generally accompa- nied with gonorrhoea ; and so commonly is this the case, that many have very judiciously given it the appellation of external gonorrhoea. We have now to say a few words on the treat- ment of gonorrhoea virulenta, the only remaining primary affection of the papular venereal disease to be considered. During the early or inflammatory stage of this affection, we observe that the discharge, though purulent, is thin, and stains the linen of the patient with a greenish hue; and that during this period, which corresponds with the first stage of * It might puzzle a moralist, or a phrenologist, to decide whe- ther in some medical heads the auri sacra fames ^ as to himself, or the hydrargyri sacra fames, as to his patient, forms the most pre- dominant propensity. But where both are combined, he would soon discover that their power is irresistible, and that poor co7i- scieniiousness would be allowed to remain in a state of perfect re- pose. 102 PAPULAR VENEREAL DISEASE* the simple primary ulcer in its excavated state, when it secretes thin ichorous matter, the disease is in its most virulent and infectious state. But as this specific inflammation of the mucous membrane of the urethra subsides, the secretion from it becomes thicker, more purulent, and we may add, without much assumption, less infectious. During the first, or inflammatory stage, nothing farther can be done than to lessen the inflammation ; this sometimes runs so high as to excite sympathetic fever, and demands the use of the lancet; but it must be acknowledged that general blood-letting is sel- dom necessary, except rendered so by the impru- dence of the patient. In this stage I usually have recourse to my favourite solution of tartarized an- timony, with or without sulphate of magnesia. This medicine prevents the patient from indulg- ing a good appetite, lessens inflammation, and is the best preventive against painful erections or chor- dee. During its exhibition the patient is directed to dilute largely, which by causing frequent passage of the urina potus, washes off" frequentl}^, without irritation, the virulent matter secreted by the ure- thra.* * This useful intention may be promoted by frequent draughts of Gum Arabic water, infusion of Marsh Mallows, Linseed Tea, and Orgeat Sirop and water. One of the best drinks is prepared by dissolving 3J of Gum "rabic, and 9ij of purified Nitre, in a quart of Flaxseed tea. Of this the patient may drink plentifully during the existence of the ardor-urinae or other inflammatory symptoms. Painful erections and chordee are often very troublesome at- tendants on gonorrhoea. By the use of warm fomentations these are generally most quickly relieved, although the opposite plan PAPULAR VENEREAL DISEASE. 103 I have been informed by several surgeons, that during the first stage of gonorrhoea, they have suc- ceeded in curing it almost instantaneously, by in- jecting into the urethra a strong solution of the ni- trate of silver ; for instance, ten or twelve grains to of bathing the parts in cold water, and applying it in a bottle or bladder between the thighs, occasionally better answer the pur- pose. A grain or two of opium with four or six of camphor, taken at bed-time, will often prevent the occurrence of these unpleasant symptoms during the night, but their permanent cure can only be expected from the employment of those general and local mea- sures best calculated to subdue the main disease, Chordee is supposed to be occasioned by an effusion of coagulable lymph into the cells of the corpus spongiosum, producing adhesion in its cells and preventing distention. When, therefore, an erection takes place, to which, owing to the excitement commonly present in gonorrhoea, the penis is exceedingly prone, the cavernous portion enlarges, but the undistended spongy portion acts upon it like a chord and bends it downwards. The hardness which sometimes remains after the inflammation and other symptoms subside, may be removed by the application of camphorated mercurial oint- ment. During the acute stages of gonorrhoea, bleeding from the urethra occasionally takes place, which, although it generally contributes to the relief of the patient, occasions him considerable alarm. Pressure made upon the canal with the hand, and con- tinued 15 or 20 minutes, will often be sufficient to arrest the haemorrhage. Sometimes, however, it is requisite to apply a roller over the whole penis, and pass a T bandage under the pe- rineum. The practice of introducing bougies for this purpose, is calculated to do mischief, by removing the clot and aggravating the inflammation. The sudden stoppage of the discharge in gonorrhoea, instead of affecting the testicles or other parts, sometimes produces a watery effusion into the prepuce, which becomes more or less distended like a bladder. The treatment which the editor has pursued in such cases, with unvaried success, consists, first, in the prompt removal of the exciting cause, whether this be exercise, an external irritant, or an internal stimulant, and afterwards the ob- servance of rest, with the use of cooling aperients and diuretics, arid more particularly frequent bathing the part affected in a watery solution of opium (3ss to ^viij) applied warm. Venesection is often highly necessary. The running generally recommences on the reduction of the excitement, and should not be suppressed by any means before the complete subsidence of the local and general in- jflammalion.. E 104 PAPULAR VENEREAL DISEASE. an ounce of distilled water; that this injection caused at the moment great pain, but that no dis- charge afterwards followed its use, and the further progress of the disease was thus summarily stopped. Now although this information came to me through so many respectable channels, that I cannot doubt the fact, yet the practice is attended with such risk of exciting severe inflammation of the en- tire urethra and bladder and all the immediate as well as secondary train of e\'41s attendant upon this calamity, that I have no hesitation in saying that it is a practice that cannot be too strongly deprecated. However, we perceive that the success which has in numerous instances occurred, is analogous to that which follows the application of the same remedy to the simple primary venereal sore, during its first or excavated stage.* In the second stage of gonorrhoea the discharge is thicker and more purulent, and the disease be- coming milder, gradually loses, like the simple pri- * Warm fomentations applied to the penis during the inflammato- ry stage, will, in most cases, be found eminently serviceable. Simple water, or milk and water, made of a pleasant temperature, answers every purpose. The applications should be frequent, and continued for at least 10 or 15 minutes each time. The inflammatory attendants of gonorrhoea, viz: painful swel- Hngs of the glands and parts adjacent, and even of the testicles, are not always to be regarded as interdicting the use of the Balsam Copaiva, or other terebinthinate medicines. When the pulse and other signs indicate that the general action of the system does not correspond with the local excitement, these medicines may be often administered so as speedily to remove the disease with its local inflammatory symptoms. The result of this practice does not accord with the commonly received theories. In fact such a practice is only to be adopted at^ter the most careful consideration of the habil and narticular circumstances of the patient. E. PAPULAR VENEREAL DISEASE. 105 mary ulcer, its specific or infectious properties. The purulent discharge at length ceases altogether, and the urethra returns to its former state, or to one of an increased mucous secretion, constituting the affection termed gleet, which may remain a very indefinite time. During the second stage, such medicines are found beneficial as seem to possess most power over the altered secretions of the mucous membrane in all parts of the body. No specific or anti-venereal powers are esteemed necessary in the remedies em- ployed even by those who consider gonorrhoea and chancre to arise from the same poison. Among these terebinthinate medicines have been long re- sorted to as affording the best means of curing go- norrhoea ; and balsam copaivse is the remedy upon which, with justice, most reliance is placed, when given in as large doses as the stomach can bear.* Cubebs, in some instances, has answered my ex- * The following formula will be found a highly advantageous mode of using this medicine: — R. Bals. Copaib. Spts. Nitri Dulc. aa ?j. Tinct. Opii Spirit. Camphorse, aa 5j. M. Of this, the ordinary dose may be a teaspoonful three times a day. The Balsam when thus administered, will, in general, be found less nauseous and oppressive to the stomach than when given in the more usual modes. To some stomachs, however, this medi- cine proves extremely oifensive in every shape, so that the whole system participates in its disagreeable effects. In such cases, it has been fonnd a good plan to omit the morning dose of the above mixture and substitute a moderate portion of some neutral aperient salt, after the operation of which, the Balsam may be taken libe- rally in the after part of the day. E. 106 PAPULAR VENEREAL DISEASE. pectations; but, in the majority of cases, has disap- pointed them altogether.* If the discharge should continue obstinate, not- withstanding the above measures, recourse may be * Cubebs, to be used with advantage, require a nice discrimina- tion into the circumstances of the case, and even with every pre- caution on the part of the practitioner they will often disappoint his expectations. Being of a highly stimulating nature, their em- ployment is countermanded by the presence of much inflamma- tion, fever, or even a febrile or inflammatory diathesis, except these conditions be considerably on the decline. When the in- flammation is entirely confined to the mucous surfaces, they may be exhibited with more success than when it involves the neigh- bouring parts. From comparative observations made in the East Indies and elsewhere, there is reason to believe that they are best adapted to the gonorrhoea's occurring in the relaxed and less phlogistic constitutions of warm climates. To derive their full advantage, they should be administered in large doses, that is to say, from six to eight drachms of the powder per day, or as much as the stomach will bear. The following prescription unites the powers of the Balsam and Cubebs, and though deficient in elegance. has often made rapid cures. R. Pulv. Cubebae, Spts. Nitri Dulcis. _^ Bals. Copaibae, aa. 5ss. Pulv. Gum Arab. Sacch. Alb. aa 5ij' Tinct. Opii. gtt. xxx. vel. 5j. Aq. Fluvialis, 5vj. M. The dose may be a table spoonful every third or fourth hour. One of the best and safest injections adapted to gleet or the se- cond stage of gonorrhoea, is a solution of the Sulphate of Zinc, the strength of which should not at first exceed a grain or a grain and a half to the ounce of plain water or rose water, but may be gradually and safely increased to five or ten grains to the ounce, should the discharge continue obstinate. The remedies for Go- norrhoea ought not to be left off as soon as the discharge is arrest- ed, but continued for at least ten days longer, during which time they are to be gradually diminished. No case of gonorrhoea can be considered as cured until after the runninj^ and concomitant symptoms have disappeared for that length of time at least. It is to be regretted that the popular injection of Lead-water used in all stages of the disease, is so frequently followed by unpleasant consequences, of which gleet swelled testicle and stricture are the most common. E. PAPULAR VENEREAL DISEASE. 107 had to astringent injections of a mild description, such as half a grain to a grain of the oxymuriate of mercury, in six or eight ounces of lime-water ; or from two to four grains of the sulphate of zinc, or sulphate of copper, in the same quantity of rose or distilled water, beginning always with the smaller proportion. When there is much irritability of the urethra, injections of any description are inadmissible; for it is far better to trust to time and internal remedies, than to tamper with stimulating applications, which may irritate the parts in their state of increased sen- sibility. Some are inimical to the use of any injec- tions whatsoever, and lay to their account the differ- ent unpleasant consequences which are so frequent- ly attendant upon gonorrhoea; such aschordee, in- flammation of the neck of the bladder, of the testes, and strictures of the urethra. There is no doubt, that the imprudent use of in- jections (which are most frequently irritating, though intended to be astringent,) may induce the com- plaints alluded to ; but at the same time, those com- plaints occur every day in patients who have not employed an injection. Strictures are more gene- rally attributed to the use of injections, than any other attendant of gonorrhoea ; but I have as fre- quently witnessed their occurrence where injections have never been used ; so that I am more inclined to ascribe these affections to the irritation of gonor- rhoea than to any other cause.* The sooner such ir- * During several years practice, in vvhicli the solution of Sul- phate of Zinc has constituted a favourite astringent injection, the editor has never had a single case followed by stricture or swell- ed testicle. E. 108 PAPULAR VENEREAL DISEASE. ritation is removed, the more likely is the patient to avoid those unpleasant visitations, which are far more to be dreaded than the original disease. I have therefore no hesitation in putting as speedy a termination to the discharge as I can, by the use of the injections above recommended, if the internal remedies mentioned disappoint my expectations.* Should buboes attend any of the primary symp- toms detailed in this chapter, I have not learned from experience that mercurial frictions will discuss them; on the contrary, the trials I have made incline me to believe that this medicine tends rather to increase their inflammation, and, consequently, their tenden- cy to suppurate. But even under suppuration, they will heal much more readily than if the patient were subjected to a strong mercurial irritation. The ap- plication of leeches and cold lotions, with attention to rest and quietness, will often succeed in dispers- ing them. But buboes, in this form of venereal disease, are often remarkably hard and indolent, evincing neither a tendency to disperse or to sup- purate. In such cases, the greatest advantage may be derived from the repeated application of blisters to the indurated bubo ; which soon either cause the dispersion or the suppuration of the tumour, and thus free the patient from a troublesome symptom, which might otherwise continue many months to torment him. If suppuration takes place, it is my practice to allow tlie tumour to break spontaneous- ly, except the patient should suffer much pain be- * For further information relative, to strictures, swelled testicle^ <^c. see the supplement to this Chapter. E. PAPULAR VENEREAL DISEASE.. 109 fore this event occurs, which often rentiers it neces- sary to use the lancet as a means of relief.* At the time of my former publication, when it was the general opinion that mercury was indispen- sably necessary for the cure of all venereal com- plaints, I deemed it incumbent on me to support my doctrines by adducing a host of cases that oc- curred in public hospitals under the eyes of numer- ous spectators : but now that it is almost universal- ly acknowledged that every form of venereal dis- ease can be cured without mercury, it is no longer necessary to overwhelm my reader w^ith the display of some thousands of cases, which might be brought * The treatment of buboes here recommended by the author, deserves particular attention, as it varies from the practice com- monly followed in this city, not less in form than in efficacy. The objections to rubbing in mercurial ointment are numerous and formidable. In the first pluce, the operation is dirty and disagree- able, rendering concealment almost impossible, and undoubtedly tending, as the author remarks, to encourage the disposition to suppuration. The only method, in which the editor has appUed the Ungt. Hydrarg. to buboes, apparently with good effect, has been as a dressing, to promote the discharge from blistered surfaces, and prevent their healing. Where mercurial frictions are em- ployed for the discussion of buboes, most, if not all, the benefit which may arise, should, perhaps, be ascribed to the action of fric- tion rather than to the virtues of the ointment. Indolent enlarge- ments of the inguinal glands may often be dispersed by applications of a stimulating kind, such .is the soap, volatile or camphorated lini- ments, which are far from being unpleasant. The editor would further observe, in relation to the application of leeches, that they are too often resorted to for the reduction of this and other spe- cies of inflammation, before they have a chance of doing good, for, Should the inflammation be high, and the pulse active, little bene- fit can be expected from their application. The smaller vessels may, indeed, be relieved for a short time, but the vigorous circula- tion in the larger vessels soon distends them again. To produce permanent effects the general increased action of the system must be previously reduced. E. 110 PAPULAR VENEREAL DISEASE. forward to supjDort this doctrine. I shall therefore pass on to the consideration of the treatmbnt of THE CONSTITUTIONAL SYMPTOMS of the papular venereal disease. The papular eruption, and its accompanying symptoms, will yield, I firmly believe, in every in- stance to the powers of the constitution; but it sometimes requires several months to overcome the disorder, which will disappear and recur again and again in successive crops of the eruption, until at length, to use a familiar expression, it has entirely worn itself out. The cure, no doubt, will be considerably hasten- ed, when the disorder is on its decline, by the exhi- bition of alterative doses of mercury. These doses, as I can aver from very extensive experience, being quite sufficient for the purpose. The eruption is usually ushered in by consider- able fever, pains in the different joints, and frequent- ly with dyspnoea and pain in the chest : symptoms which often demand the repeated use of the lan- cet; and I have always observed that great relief is obtained by these depletions, and that the blood betrays the usual signs of the inflammator}' state. During this stage, the other means belonging to the antiphlogistic plan should not be neglected, but particularly the exhibition of antimonials. These afterwards, when the inflammatory diathesis is re- moved, I combine with decoction of sarsaparilla, and this treatment seldom fails to remove the symp- toms. But if the eruption and pains continue to linger. I usually direct j)ills of antimony and calo- PAPULAR VENEREAL DISEASE. 1 1 1 mel, — for instance, the compound calomel pill, (Ph. Lond.) — in small alterative doses, together with the decoction of the woods, which, in the declining stage of the disorder, can be exhibited with safety, and has in no instance disappointed me in removing this form of disease, which is indeed the simplest and most manageable of these diversified complaints.* May we not presume, that the ease with which this disorder is cured, in some degree, arises from the fever or re-action of the system which attends it. In this respect it bears a close analogy to the exanthemata — poisons which the constitution over- comes by its own unassisted powers. And should we not, therefore, be careful, not unnecessarily to interfere with the powers of the constitution, which we have now sufficient evidence to assure us, are in every instance adequate to overcome the poison which induces this form of venereal disease ? If Hunter's account of the progressive, and never retrogressive symptoms of syphilis, when mercury is not employed, be true, may we not ascribe this * In such cases the oxymurias hydrargyri in such minute doses as will occasion no inconvenience to the stomach or system, will be found the most advantageous form in which mercury can be administered. Of nearly equal efficacy is the Plumber's pill or powder, 8 or 10 grains of which may be given as a dose, night and morning. The Plumber's powder is thus prepared. R. Sub. Mur. Hydrarg. Sulph. Aur. Antimon. aa 9j. Sacch. Alb. 5ij- M. The dose for an adult may be eight or ten grains, morning and evening. In this form the calomel undergoes such a chemical change, that its action is rendered much milder, and directed to the skin, and lymphatic system generally, rather than to the sali- vary glands or other organs. E. 112 PAPULAR VCNEREAL DISEASE. circumstance to the want of that fever which attends the exanthemata, and the virus which produces the papular eruption. These observations were published in a former work, and it was only lately I discovered that the re- vered Linnaeus — that close observer of nature, who threw off the trammels of authority, and made use only of his own sound intellect and penetrating ob- servation, in ascertaining the properties and pheno- mena of organized beings, from the simplest vegeta- ble production to man himself — Linn^us, in his Ge- nera Morborum, places the venereal disease in the class of exanthemata, i. e. fevers attended with erup- tion on the skin. His English translator observes, " Our author stands alone in bringing syphilis (every form of venereal complaint is termed sjphilis) into the exanthematic ; and he considered himself justi- fied by its being attended, in the advanced state at least, by fever and eruptions.'** Linnaeus was per- fectly justified in doing so; for if the term exanthem is intended by nosologists to designate " a conta- gious disease beginning with fever and followed by an eruption on the skin," the various forms of vene- real disease, but in particular the one under consi- deration, have as strong a claim to be included in the class as either small pox or measles. I shall make so bold as to add, that venereal dis- eases ought to be treated on the same principle; and that, when we quit the plain dictates of gene- ral pathology, to follow those of mysticism, if not of * Pulteney's Linnaeus, by Maton, p, 144. PAPULAR VENEREAL DISEASE. 113 empiricism, we only embroil ourselves in inextrica- ble errors, — rashly driving the eruption from the skin, heedless of the axiom of the philosopher Jen- ner, " that eruptions on the skin are the safeguards of the constitution;" and the consequence too fre- quently is, that the periosteum, bones, and deeper seated parts, become affected; and thus the disease, instead of yielding in a few weeks, requires months, nay, sometimes years, to restore the patient to his former state of health. This position is supported by the treatment found most beneficial for the other exanthemata. Who ever dreamed of such an ex- ploit as repelling the eruption of small pox or measles ? If this event should unfortunately occur, the most alarming symptoms ensue, in consequence of the lungs, or other internal organs, becoming affected. I have already mentioned, that the use of mercu- ry in the yaws, (a disease which deserves also to be placed among the exanthemata,) is abandoned, because it is found to drive the distemper from the skin to the periosteum and bones. Other diseases might also be adduced of the same character, in which this mal-treatment is equally dangerous. Cal- lisen, in the treatment he lays down for the northern leprosy, or radesyge of Norway, (and, as I have mentioned, probably the sivvens of Scotland,) states, that mercury, carried to the point of salivation, is always found to be injurious ; that repellant appli- cations should be decidedly shunned, as certain dan- ger is incurred by driving the acrimony of the dis- p 1 14 PAPULAR VENEREAL DISEASE. temper upon the interior and more important parts.* The papular venereal disease is of such frequent occurrence, that I am within moderate bounds when I assert, that at least three-fourths of all the vene- real complaints which are prevalent in these coun- tries, are of that species, which gives birth to the papular eruption — a form of disease whicji I am bet- ter pleased to encounter than any other, as I am al- ways certain of seeing it yield without trouble to the mode of treatment I have detailed, unassisted by the disgusting and injurious process of a full mercurial course. Confinement, however, is necessary, and in cold weather should not on any account be dis- pensed with. The rapid amendment which takes place among hospital cases, in this species of vene- real disease, is a sufficient proof of the utility of confinement. I am, however, always better satisfied, in this form of disease, of the permanent safety of my pa- tient, where mercury has not been employed, than where it has ; for my experience enables me deci- dedly to affirm, that if the papular eruption, or its accompanj'ing symptoms, do not return in a patient tvho has not used mercury after a lapse of a few weeks, he may be considered as perfectly well ; but on the contrary, if he has employed that medicine, the disorder may return after an interval of many * Mercurium ad salivationem fortiorem usque porrectum semper nocuisse compertum est. Remedia externa reprimentia qua^que omnino ernnt evitanda, dum ab acrimonia ad interiores atque no- biliores partes delata certum periculum inducatur. — SystemaChi- rurg-. torn. i. p. 194. PAPULAR VENEREAL DISEASE. 115 months, unless exhibited when the disease was manifestly on the decline ; and therefore I always consider a patient who has been treated without mercury, as much more secure against a relapse, than one who has employed it. Mr. Guthrie, in his observ^ations upon those cases which he treated without mercury, remarks that "it appears singular, that in the secondary cases, the symptoms should all have been of a mild nature ; in two instances only affecting the bones;" — and we should recollect that this was the small propor- tion which occurred in upwards of five hundred cases.* Mr. Rose also observes the same circumstance ; his words are, " it is now generally admitted, that the majority, and certainly by far the most serious diseases of the bones, as well as many other most distressing symptoms which are met with in all these diseases, are to be attributed to the injurious or excessive use of that remedy."t I shall take this opportunity of observing, that in the many hundred cases I have noted of the pa- pular eruption, which I have treated in the Lock and Richmond Hospitals, and in private practice, since my present views first occurred to me, I have not met with a single instance in which it was at- tended with nodes. But whether this was owing to the nature of the poison, or to the circumstance that mercury was not exhibited (except in a very small proportion of cases, when the disease w^as on * Med. Chirurg. Transactions, y. viii. p. 561. t Ibid. p. 425.- 116 PAPLfLAR VENEREAL DISEAhli. the decline,) remains to be determined by future ex- perience. It is an undoubted fact that. ccBteris paribus, hos- pital patients recover more rapidly than private pa- tients, from their venereal complaints. This ap- pears to me to be evidently owing to the state of quietude in which the former remain in the warm air of their wards, not exposed to the cold, moist, and var3ing atmosphere of our climate, which our private patients, notwithstanding every exhortation to the contrary, have too often the fool-hardihood to encounter. The necessity of confining a patient to his apartment, when affected with an eruption which is usually attended with pains and consider- able constitutional derangement, few will be dispos- ed to denv, even althouorh mercurv should not be employed. The importance of this measure is, in my opinion, so great, that I have not a doubt but that a considerable share of the benefit which results, when a patient is put on a mercurial course, has arisen from his confinement to his room, which, ex- cept under the use of this medicine, is seldom thought necessary. A circumstance of an opposite nature, and which gives rise to an analogous mistake, is ine improve- ment that alwavs ensues, when scrofulous children are sent from crowded towns to the sea-side to bathe. The amendment is entirely attributed to the sea- water ; while the removal of the young patient from a vitiated to a pure atmosphere, together with an increase of exercise, and, consequently, of appetite and health, are in fact, the chief, though unnoticed PAPULAR VENEREAL DISEASE. Il7 agents which effect the favourable chaii2;e that al- most always takes place in such cases. The general treatment of this disorder should be the same as that which has been found most service- able for the yaw^s, in w^hich mercury is injurious, unless emploj^ed at a late period, after the disease has nearly yielded to the powers of the constitution; because its exhibition, as I have elsewhere observ- ed, merely suspends the influence of the poison of this disease for a time, but does not supersede its action altogether, as is too certainly evinced by a re- turn of the symptoms, as soon as the mercurial ac- tion subsides, when it becomes more severe and te- dious than before. In fine, our object in the treat- ment of the constitutional disease under considera- tion should be, — 1st. To moderate the action of the system, if the fever which attends and accom- panies the eruption should be violent. — 2dly. After the fever is considerably lessened, or subdued, the exhibition of sarsaparilla, either alone or combined with antimonials, affords the most safe and effica- cious mode of treatment. The action of sarsaparil- la, particularly when assisted by antimonials, is to increase all the secretions ; and these must not be checked, particularly that of the skin, by imprudent exposure to cold. The diet of the patient may be light and nourishing, but not heating or stimulating, and he ought to increase the quantity of mild dilut- ing drinks he is in the habit of taking, which will assist the action of sarsaparilla on the skin and kid- neys. The practitioner himself should be observ- ant that this medicine is carefully prepared, and of 118 PAPULAR VENEREAL DISEASE. a good quality. Not only boiling water extracts the virtues of sarsaparilla, but lime-water is supposed, by acting on the cortical part, to be equally effica- cious.* 3dly. When the eruption has declined, no new spots appearing, and those that remain all desqua- mating or scaly, while the patient still complains of lingering pains in his head, elbows, hips, or knees, the disease being obviously on the wane, it may now be subdued altogether by alterative doses of mercury conjoined with antimony, for which object the compound calomel pill of the London Pharma- copoeia affords an excellent example: and with this medicine the sarsaparilla may still be continued. either in the form of decoction or infusion. "^ * The red sarsaparilla. «o named from the col r,r cf the inner bark, has been lately introduced into practice, and is t\iv superior to every other description. The decoction, according- to the London Pharmacopceia. is that I am in the habit of employing. The in- iusioD ot' sarsaparilla in lime-water may be made accordiag to the following formula. R. Sarsaparillas Rad. incisae, xiv. Glycyrrhiz3B Rad. contusae, ^i. Aquae Calcis. lb. iv. macera per horas xxiv. in vase lente c]aa«Ov dein cola. If we substitute the bark ot^ the root in place of the root itself, we shall have, of course, a more powerful infusion. A pint daily is the medium dose. ' In doses of the eighth or tenth of a grain in the torm of pill or solution, repeated two or three times a day. the oxymurias hy- draro^yri operates very favourably in these cases. It is not the least recommendation which tbis preparation possesses, that it is capable of performing a cure without producing those unpleasant effects which often prevent that concealment which is in general so highlv desirable. The ?rand rule to be otsers ed in the ad- ministration of this, and all other preparations of mercury, in al- terathe dose^. is. never to be2"iii with them until fever, indamma- PAPULAR VENEREAL DISEASE. 1 19 It may be useful to insert three or four cases, by way of example, of this form of venereal disease, and of the mode of treatment recommended. I shall, therefore, select out of the numerous cases already published, the following brief statements. Case 1. — Thomas Trainer admitted, December 23d, 1812. His complaints were phymosis and pu- rulent discharge from the glans and prepuce, an ul- cerated bubo in the right groin, and an incipient bubo in the other. There was also considerable swelling and thickening of the scrotum, but the tes- ticles were of their natural size. He stated, that he was four months disordered, and that the first symptom with which he was affectedwas gonorrhoea, and that the other complaints shortly afterwards succeeded. I direct the antimonial solution,* and the lotion of calomel and lime-water. 28th. — The discharge and swelling of the penis were entirely removed ; on retracting the prepuce the parts were free from ulceration. The ulcerat- tion and all other increased excitement or action of the system has been subdued. This rule not only applies to the treatment of the forms of syphilis, but should be kept in view whenever a mercurial is prescribed more as an alterative than as a prompt evacuant. E^ * The following is the formula of the antimonial solution em- ployed in the Richmond hospital. R. Antimonii Tartarizati, grana quatuor, Aquae distillatae septem uncias, Tinct. Cardamomi comp. drachm, tres, Tinct. Opii drachm. M. Syrupi Cort. Aurant. drachm, quatuor. sumatur cochi, ampl. ter quaterve quotidie. 120 FAl^ULAR VENEREAL DISEASE. ed bubo was healing, and that of the other was de- clining fast. The swelling and thickening of the scrotum were also considerably lessened. He com- plained, however, of severe pains in his joints, par- ticularly at night. January 12th, 181'3. — The swelling of the scrotum had again increased, and he complained of soreness in his throat. On examination, the back of the pha- rynx appeared raw and excoriated, and the velum and uvula swelled and relaxed. I directed the dococ- tion of sarsaparilia, in conjunction with the antimo- nial solution. 15th. — An eruption of papulse broke out all over his body, attended with high fever, pain in his chest, and difficulty of breathing. The scrotum and penis were very much swelled, and the prepuce so much swollen as to resemble a bladder of water. The soreness of his throat was increased, and tlie pains of his joints had become more severe. I directed that he should be blooded to sixteen ounces, and the antimonial solution to be continued without the sarsaparilia. On the following day his fever seem- ed to be considerably diminished, and his breathing was free. There appeared numerous small ulcers on the scrotum, which were probably the papulae, altered in their appearance by the friction to which they were exposed on this part during locomotion. 21st. The swelling of the penis and scrotum had disappeared, and the eruption had entirely declin- ed, and on the 25th he was discharged the hospital well. The speedy termination of the constitutional symptoms in this case was probably, like those of PAPULAR VENEREAL DISEASE. 121 the exanthemata, owing to the acuteness of the fe- ver, which was so high as to require the use of the lancet. The eruption closely resembled that repre- sented in Plate I. fig. 1. Case 2. — Michael Dunn, admitted December 31st, 1812. His complaints were phymosis, with puru- lent discharge from the glans and prepuce, and a deep foul ulcer of the right groin. He stated that he was disordered two months before his admission, and that he had not used mercurv. I directed him to take the nitrous acid mixture dail}^, and to use the lotion of calomel and lime-water. January 6th, 1813. — An inflammatory red sw^ell- ing, the size of a dollar, appeared suddenly over the right tibia, to which I directed him to apply sa- turnine lotion, by means of folded linen. 12th. — The discharge from the glans and pre- puce was stopped, and he could retract the latter. The tumour over the tibia w^as nearly dispersed, and the ulcer of his groin looked healthy, and was granulating. 17th. — He was discharged the hospital well. Case 3. — Patrick Gordon admitted February 20th, 1813. His complaints were phymosis, purulent discharge from the glans and prepuce, and an erup- tion of small red papul£e on every part of his bod}'. He complained of pains in his shoulders, arms, hips, and in the small of his back, Avhich were most se- vere at night. He stated, that he was five months disordered ; that six weeks before his admission he was attacked with pains in his joints, attended with feverishness, and that three weeks afterwards the 122 PAPULAR VENEREAL DISEASE. eruption appeared. He had taken mercurial pills, which did not produce any beneficial effect upon his complaints. I directed him to take the nitrous acid mixture, and to inject the lotion of calomel and lime-water between the prepuce and glans.* 22d. — The discharge was stopped, but the pains were more severe. On this day the drawing, as represented in fig. 2. Plate I. was taken of the erup- tion. March 1st. — The eruption had declined, and its vivid red colour was changed to a pale copper hue : the pains were more severe. I therefore discon- tinued the nitrous acid, and directed in its place, de- coction of sarsaparilla, and antimonial solution. 4th. — The pains still continued to increase, with thirst, fever, and head-ach, pulse 110, difficulty of re- spiration, and severe cough. I directed that six- teen ounces of blood should immediately be taken from his arm, the decoction to be omitted, and the antimonial solution continued. The blood taken was highly buffed, and the following day he stated that he received the most decided relief by the de- * The author having omitted his formula for the preparation of this mixture, it may be well to mention the most convenient methods of administering the Acid. The simplest plan is to add ten or twelve drops of the Acid. Nitric. Dilut. to a small tumbler of water, which, when swallowed, will be so weak as not to injure the teeth. This dose ma}^ be repeated three or four times a day. But a more^agreeable method is to blend ^ij of the Acid. Nit. Dilut. with gviij of thick mucilage of gum arable, to which ^ss of lemon, ginger, or simple sirop, may be added. The dose of this is a table-spoonful, repeated three, four, or five times a dav. E. ^ PAPULAR VENEREAL DISEASE. 123 pletion. His pulse was reduced to 90, and his thirst and fever were considerably lessened. 15th. — He no longer complained of pains, the eruption had disappeared, and he was discharged the hospital apparently well. But he was re-admit- ted on the 26th of April following, on account of a fresh crop of the papular eruption, which had made its appearance since he quitted the hospital, attend- ed with pains in his joints as before. There were also swellings over the tibise, near the ankle joints, which were painful upon pressure ; and he called my attention to a small hard tumour, the size of a hazel nut, situated on the right testicle. I directed the antimonial solution, and venesection to twelve ounces. April 30th.— The pains and eruption continued as before ; the tumour on the testicle was, however, considerably reduced. Twenty grains of the com- pound powder of ipecacuanha were directed to be taken in the evening. May 1st. — The pains had become more severe, with oppressed breathing and cough; pulse 106. Venesection was directed to sixteen ounces, and the antimonial solution. The blood, as was the case in the former depletion, exhibited the usual in- flammatory characters, and was followed by consider- able mitigation of the severity of the pains, and re- lieved his chest altogether ; however, as I conceiv- ed that the most likely means to prevent a recur- rence of these symptoms, were to persevere in the plan from which he had derived so much relief, I directed that the venesection should be repeated on the 3d, from which he felt still farther relief. 124 PAPULAR VENEREAL DISEASE. 10th. — The eruption was declining rapidly ; he scarcely felt any pain ; and he was discharged the hospital, perfectly well, on the 20th instant. Case 4. — Henry Scully was admitted March 24th, 1813. His complaints were a superficial ulcer on the prepuce, without induration, and papular erup- tion, which extended to every part of his body ; in some places the spots, when on the decline, ran into each other, so as to appear true syphilitic blotches to a superficial examiner. The papulae on his scrotum were larger than elsewhere, and were moist on their surface. He complained of pains in his shoulders, hips, and other joints. x\s there was not any febrile symptom in this case, I directed for him, on his ad- mission, the decoction of sarsaparilla, conjoined with the antimonial solution; he was also desired to keep lint, moistened in the lotion of muriate of mercury and lime-water, to the sores on the penis. 29th. — The eruption was of a less vivid red colour, and his pains were considerably alleviated. April 5th. — The eruption had nearly disappeared: he scarcely felt any pain in his joints, and the sores on the penis had healed. 13th. — His complaints being all removed, he was discharged. Case 5. — Cornelius Leary, admitted April 1st, 1813, on account of small superficial sores on the corona glandis, excoriation and discharge of the glans and prepuce, gonorrhoea, and a bubo in the right groin. There was also an eruption of papulae on his breast and belly. He stated that he was dis- ordered six months, and that he underwent several PAPULAR VENEREAL DISEASE. 125 courses of mercury, which had no effect whatsoever on his complaints. I directed him to use frequent- ly every day, an injection of a scruple of calomel, suspended by means of mucilage, in six ounces of lime-water, and to keep lint, moistened in the same, constantly applied to the surface of the glans and prepuce ; also the antimonial solution. 7th. — The sores and excoriation of these parts were healed, the bubo was lessened, and the eruption was declining. 13th. — The discharge from the urethra had ceas- ed, and the eruption had disappeared. He was dis- charged the hospital well. Case 6. — ^Michael Whelan was admitted April 19th, 1813. His complaints were superficial ulcers on the corona and glans ; a large ulcerated bubo in the right groin, of a projecting fungous appearance, and a papular eruption on his breast, back, and face, nearly similar, but not of so deep a colour as those represented in Plate I. fig. 1. He complained also of pains in his shoulders, elbows, and ankles; the last were swelled, red, and painful on pressure. The lotion of muriate of mercury and lime-water, the antimonial solution, and the decoction of sarsa- parilla, were directed for him. May 3d. — The ulcers of the penis were healed, and the pains lessened. 10th. — The eruption had declined, and the pains no longer remained. The ulcer of his groin was healing, and he was discharged the hospital well, on the 23d of the same month. Case 7. — James Corrigan, admitted September 126 PAPULAR VENEREAL DISEASE. 9th, 1813. His complaints were excoriation of the glans and prepuce, with purulent discharge ; a small superficial ulcer on the prepuce, without induration; a thick eruption of papulae on his face, arms, and neck ; a dry excoriated appearance of the posterior part of the pharynx; superficial ulceration and en- largement of the tonsils, accompanied with difficul- ty of swallowing ; and he complained of pains in his shoulders and elbows. He stated that he was six months disordered, and that he had been repeatedly salivated under differ- ent courses of mercury. I directed the same medicines as were employed in the preceding case, under which his complaints gradually amended, and he was discharged the hos- pital well, on the 18th October following. Case 8. — Michael O'Neil admitted into the Rich- mond Surgical Hospital, on the 25th November, 1813; His symptoms were phymosis, and purulent discharge from the glans and prepuce, gonorrhoea, and ardor urinse, and a bubo in the right groin. His throat was inflamed, raw, and excoriated, and there was an eruption of papulae, of a paler colour than usual, scattered over the entire surface of his body. The drawing, Plate I. fig. 3, was taken on this day, and exhibits the eruption as it appeared on his belly. He complained of severe pains in his shoul- ders, elbows, knees, and legs. I directed the decoc- tion of sarsaparilla, antimonial solution, and the lo- tion of muriate of mercury and lime-water. 28th. — The eruption had declined, but many fresh PAPULAR VENEREAL DISEASE. 127 spots, nearly approaching the form of pustules, ap- peared on his face. He complained of severe pains in his heels, but those of his joints were much alle- viated. Dec. 13th. — The discharge from the glans and prepuce was stopped, the eruption and pains were almost dissipated, and he was discharged the hospi- tal on the 2d of January, 1814, apparently well. I saw him in about a fortnight afterwards ; he was complaining of a return of the pains, but they were not so severe as at first, and there were a few pa- pulse on his face and breast ; they were removed in a fortnight under the use of the antimonial solu- tion. I HAVE stated that inflammation of the iris is a very common affection in the papular disease. Mr. Travers, to whom modern surgery is so much in- debted, observes, that the occurrence of this disease during the use of mercury, is so well established and familiar a fact among persons who see much of ophthalmic diseases, that their first enquiry of a pa- tient, labouring under inflammation of the iris, is not whether he has recently contracted syphilis, but whether he has been taking mercury." And again he says, " It appears to me impossible to pro- nounce whether the iritis, so frequently presented after sores on the genitals, and accompanied by eruptions, is the effect of a morbid poison, or of the mercurial poison, or, thirdly, the casual effects of exposure to an exciting cause in a state of predis- 128 PAPULAR VENEREAL DISEASE. position from the mercurial impregnation of the sys- tem."* One good effect of treating venereal complaints, without mercury, is, that we are enabled to remove that accumulation of doubts, which are eternally arising, while that medicine is employed, and which so often embarrass us to decide whether we ought to attribute the occurrence of new symptoms to the disease or the remedy. This remark is well illus- trated by the above quotation from Mr. Travers ; for the symptom under consideration, actually be- longs to a disease that will run its career, as I have seen in a multitude of cases, in opposition to the most extensive courses of mercury. It is, therefore, not unreasonable to suppose that Mr. Travers, in the majority of cases of iritis, may have met with that symptom in persons who had been extensively under the influence of mercury; and we cannot be surprised at his attributing iritis to the mineral and not to the morbid poison. But this candid writer will scarcely adhere to this opinion, w^hen he is as- sured that iritis is frequently found in those who have not used mercury ; and I believe it is equally certain, that it has never been observed in a patient who w^as salivated for any disease that was not ve- nereal. But inflammation of the iris, whether it originates from venereal infection, or from any other cause, will readily yield to mercury and the antiphlogistic means ; and the reason why mercury is so useful in those cases, is admirably well explained in Dr. * Surgical Essays by Cooper and Travers, p. 60. PAPULAR VENEREAL DISEASE. 129 Farre's valuable letter to Mr. Travers, in which he observes, that he has uniformly regarded the mer- curial action as one of the most effectual means of ar- resting the disorganizing process of adhesive in- flammation, whether of the iris or of any other tex- ture of the body." Thus, by means of the mercu- rial action, the inflammation is arrested, and the de- position of coagulable lymph prevented. If,* how- ever, it has already taken place, instead of becom- ing organized, which would render the iris immove- able, it is absorbed through the influence of this me- dicine ; and the other stages of the adhesive inflam- mation are also prevented. Thus we find an explanation for the seeming anomaly, that the symptom of a disease should be cured by a medicine, which is incapable of arresting the progress of the disease itself; as must have been the case in those instances of iritis detailed by Mr. Travers, in which, it seems, the patients were un- der the influence of mercury, either before, or dur- ing the attack of this symptom. Mercury, however, though a powerful auxiliary in the cure of venereal iritis, is not absolutely necessary for its removal ; for we learn from the authority of Doctor Thompson, that seven cases, under his care, became well with- out its exhibition.* Dr. Thompson, in those cases, cured the disease by bleeding, blistering, and the antiphlogistic plan of treatment carried to the utmost extent ; and I understand from good authority, that he perseveres * Edin. Med. Journal, No. LIII. R 130 PAPULAR VENEREAL DISEASE. in the same line of practice, with a success that authorizes him to continue it: and I believe, the profession at large will be more inclined to attend to the representations of this distinguished patholo- gist, than a recent author already alluded to, who announces with a ludicrous affectation of authority, that "the patient may be saved the inconvenience of blood-letting or blistering, as ttiey do not afford the smallest benefit, nor will they allay a single dis- tressing symptom." With respect to my own practice in this disease which threatens so rapidly to disorganize the eyes, and cause total blindness, I feel myself called upon to adopt every measure without delay calculated to check so dangerous an affection. While mercury is thrown in as speedily as possible, with a view of stopping the adhesive inflammation, I do not neglect to put in practice both local and general blood-let- ting, the application of blisters, the use of belladon- na, and the antiphlogistic regimen. In ninety-nine cases out of a hundred, these mea- sures will succeed if adopted in time, and I have met with one case only, which however, came un- der my care in the advanced stage of the disease, that resisted tiiis plan of treatment, and terminated in loss of vision. I shall not fatigue my reader by detailing cases, illustrating the success of the practice recommend- ed ; therefore, shall merely add the conclusions af- forded by the cases detailed in my work on the symptoms and specific distinctions of venereal dis- eases, published in 1818, since which period the P/VPULAR VENEREAL DISEASE. 131 same treatment has been pursued, in several hun- dred cases, with the same happy result. "From those cases we learn many important facts; and, in the first place, that iritis is an attendant upon the papular eruption. By cases 1 and 5, it is ascertained that the papu- lar eruption will occur either after alterative or full courses of mercury. By cases 1, 8, 9, 10, and 1 1, that gonorrhoea alone is sufficient to produce the papular eruption. By cases 7, 8, 9, 10, 1 1, that iritis will occur where little mercury or none at all has been employed, and therefore that it cannot be attributed to that medi- cine. All the cases prove the utility of combining th€ depleting with the mercurial plan, for the cure of iritis. But the mercury was in every instance discon- tinued as soon as the mouth became affected. It is of moment to add, that I have met wnth a considerable number of instances of iritis, that viere not attended by any eruption whatsoever, which yielded to the same plan of treatment." I trust that I have, in the preceding observations on the first class of venereal diseases, adduced suf- ficient evidence to satisfy any reasonable mind, that the same virus may produce the three primary af- fections described in this chapter: that these prima- ry affections are all liable to be follovv ed by the same train of constitutional ailments, and that all the symp- toms of this disease, both primary and constitution- al, may be easily recognised and distinguished a^ 132 PAPULAR VENEREAL DISEASE. to their external characters, by those who will en- deavour to discriminate one disease from another. When all venereal complaints were treated nearly alike, such discrimination may not have been thought necessarj^ for practical purposes ; but now that the baneful effects of this mal-practice is universally felt and acknowledged, the student, if he hopes for success, must learn to discriminate appearances, in order that he may judge of the true nature of the disease, and whether it is likely to be mild or malig- nant, brief or tedious, in its duration. And finally he may acquire a knowledge from those characters and appearances, which will enable him to deter- mine with promptitude and decision the mode of treatment best adapted for the case committed to his charge. It will scarcely be credited, that before I drew the public attention to these matters, all our profes- sional powers of discrimination exercised v»ith a view to ascertain the nature of a doubtful disease, were almost exclusively confined to two simple points, the history of the disease, and the effects of mercury upon it. ' As to the consideration of the external characters and symptoms of the disease, which, we should naturally suppose, would form the basis of our diagnosis, it was scarcely esteemed ne- cessary to throw away a thought upon the subject. Mr. Hunter, as I have already observed, was the first in later times w^ho suspected the existence and frequency of diseases resembling, but differing from, true syphilis. He does not, however, attempt to discriminate them by the appearance of their symp- PAPULAIi VE^EREAL DISEASE. J 33 tomS, but by their history and progress under the use, or in the absence of mercury. For instance, if symptoms spontaneously disappeared before its^ adoption ; or if others arose while the patient was under its influence, he concluded that the disease was not syphilitic. His reasoning, however, on those doubtful cases, will be better understood by a perusal of the following case from his works : — "A gentleman had for some time blotches on his skin ; the face, arms, legs, and thighs were in many places covered with them; and they were in their different stages of violence. In this situation he applied to me ; and I must own they had a very sus- picious appearance. I asked him what he suppos- ed these blotches were ; he said he supposed them to be venereal. I asked him when he had a recent venereal complaint; he told me not for above twelve months. I then asked him how long he had had the blotches ; and the answer was, above six months. As this was a sufficient time for makins; observations upon them, that might ascertain better than the mere appearance what they were^ I asked him if any of the blotches that came first had disappeared in that time ? and he said many. I desired to see where those had been; and on examination I found only a discoloured skin, common to the healing of superficial sores. I then declared to him that they were 7iot venereal, for if they had arisen from that source, noiie of them would have disappeared. He now informed me, that he had been taking mercury ; and this information obliged me to hav^e recourse to further enquiries; and I therefore asked him. 134 papUlaJi Venereal disease. whether while he was taking mercitry, many of the first got well ? The answer was, Yes. And was the cure of those imputed to mercury? The answer was again in the affirmative. I then asked him, if while he was taking the mercury^ which appeared to have cured some, those that now remained^ arose ? Yes^ My next question was, how long had he taken mercury ? He said for six months. I then declared they were not^ nor never had been, venereal. I ask- ed him, what was now the opinion of his surgeon } He said, that his opinion still was, that they were venereal, and that he should go on with the mercu- ry. I advised him to take no medicines whatever ; to Mye well, avoiding excess, and to come to me in three weeks, which he did, and then he was per- fectly well, only the skin was stained where the blotches had been. He now asked me, what he was next to do } I told him he might go to the sea and bathe for a month. This he did, and returned well and healthy, and has continued so."* If Mr. Hunter had lived some time longer, he would most probably have persevered in, and en- lightened this obscure and intricate subject; but this case entitles him to the merit of pointing out to his successors, the necessity of discriminating between syphilis and the resembling disorders. His Commentator, Dr. Adams, has added many useful observations ; and Mr. Abernethy has prose- cuted the inquiry with great advantage. He is of opinion, that the pseudo-syphilitic diseases cannot * Hunter on the Venereal Disease, p. 436. PAPULAR VENEREAL DISEASE. 135 be distinguished from true syphilis by their appear- ances, but that we must trust to their history alone, A very simple fact, he says, has enabled him in most cases to distinguish between the two diseases^ which is, " that the constitutional symptoms of sy. philis are generally progressive, and never disap- pear unless medicine be employed ; and it may be added," he continues, " that they are as generally relieved under an adequate effect of mercury on the constitution."* The criterion by which Mr. Abernethy decides on the nature of those diseases, is that which guided Mr. Hunter's judgment in the case which I have just extracted from his works ; but however excellent this criterion, which should never be neglected, I do not hesitate to say, that in the great majority of eases, these disorders may not only be distinguished with ease from true sy- philis, but from each other, by the eye alone, and that whether the symptoms be local or constitu- tional. In the papular venereal disease, the eruptive fever is more strongly marked than that of syphilis ; and, in many cases, is so acute as to require repeated blood-kttings. The eruption is not scaly, like that of syphilis, but papular, disappearing and recurring repeatedly. The affection of the throat is not a deep ulceration of the tonsils, but an inflammation and superficial excoriation, or rawness of the fauces, but particularly of the posterior part of the pharynx. The pains do not affect the centre of the long bones. * Abernethy on diseases resembling Syphilis, p. 46, 136 KiPULAR VENEREAL DISEASE. but the large joints. This disease is not attended by nodes, but iaiiammatoij swellings of the integu- ments have been mistaken for them, which occur suddenly, and as suddenly disappear, without the assistance of mercury. But although the actual appearances of the symptoms thus point out the nature of the disease, yet I would not l3y any means neglect such assistance as an inquiry into the his- tory of the case may afford. On the contrary, when instances occur of doubtful character, we should endeavour to ascertain whether the primary ulcers have healed spontaneously, or by the aid of medi- cine; or, while they healed in one place, if they broke out in another. If the eruption disappeared without the use of mercury, and afterwards recur- red. If it has happened, that mercury has been exhibited, its effects will also assist our diagnosis ; nothino; can be more certain or more decided than the improvement that follows the use of this mine- ral in all cases, either local or constitutional, which are truly syphilitic. Its effects in the other vene- real diseases are by no means similar. Sometimes it flatters with an early amendment ; sometimes the mischief is immediate, and an increase of ulceration the consequence ; but whether, in spite of the mer- cury, its progress continues, or, suspended for a lime, again resumes its ravages, the disease we may be certain is not syphilis, but one of those disorders so constantly and unphilosophically confounded with it. In the middle of a full course of mercury, the practitioner is often perplexed by the appearance i»APULAR rENEREAL DISEASE. 137 €f a constitutional ulcer, or eruptioia, and he re- doubles his efforts to conquer the disease, by the exhibition of more mercury. But if that mineral is capable of superseding the syphilitic poison, it is absurd and contradictory to suppose, that while it is operating with sufficient energy to cure the symp- toms for which it was directed, it is possible for the poison to contaminate new parts; but there is little absurdity in acknowledging, that a poison of another nature, over which mercury does not possess any certain influence, may contaminate new parts while the constitution is under the fullest operation of that medicine. As the powers of the constitution are, in many instances, found competent to the cure of these dis- eases, we should make use of every means capa- ble of increasing and strengthening these powers. Therefore when the attending fever is subdued, generous diet and country air should be particular- ly recommended, if the chronic nature of the symp- toms, and the means of the patient will admit of their adoption. It frequently happens, that the se- condary symptoms of a disorder which was consi- dered to be syphilis, whether eruption, ulcers of the throat, or nodes, have disappeared unexpected- ly, during an accidental journey or excursion ; and most practitioners have been acquainted with, and surprised at the circumstance; but there can be little doubt, that in every such instance, the disease has not been syphilitic. I trust that the facts I have detailed will be the means of removing some of the most glaring obsta- 1 38 PAPULAR VENEREAL DISEASE. cles which opposed a true knowledge of venereal diseases. The variety of symptoms, both local and constitutional, hitherto attributed to the syphilitic poison, not only baffled all attempt at description, but seemed to set at defiance every rational arransje- ment, and rendered the disease an exception to all other morbid poisons : a class of disorders which are remarkable for the uniformity of their symptoms, and obedience to laws known and determined. But syphilis, according to the received opinion, unlike to other poisons, assumed every possible shape and appearance, both in its local and constitutional symptoms. To awaken the readers attention to this point, L shall transcribe the following passage from Dr. Bateman's most accurate and useful work on Cutaneous Diseases: — -In the course of this Synopsis I have made only cursory allusions to a very important class of cutaneous eruptions, which are often the source of considerable embarrassment to the practitioner: I mean those which are the re- sult of the venereal poison. The subject indeed is difficidU and ?iot as yet sufficiently investigated; for these eruptions assume such a variety of forms, that they bid defiance to arrangement according to their external character; and. in fact, they possess no common or exclusive marks, by which their nature and origin are indicated. There is perhaps no or- der of cutaneous appearances, and scarcely any ge- nus or species of the chronic eruptions already de- scribed, ichich these secondary symptoms of syphilis do not occasionally resemble. Dr. Willan pointed out. among the papular, scaly, and exajithematous PAPULAR VENEREAL DISEASE. 139 iiffedions, several species to ivhich the resemblance was most obvious; and the pustular and tubercular eruptions would furnish still more accurate examples of similarity. Nevertheless, there is, in many cases, a difference, which a practised e3^e will recognise, between the ordinary diseases of the skin, and the syphilitic eruptions, to which the same generic ap- pellation might be given; this is often observable in the shade of colour, in the situation occupied by the eruption, in the mode of its distribution, and in the general complexion of the patient. Hence, to a person conversant with those ordinary diseases, a degree of anomaly in these respects will immediate- ly excite a suspicion, which will lead him to inves- tigate the history of the progress of such an erup- tion, and of its concomitant symptoms. And it will frequently happen, that the most experienced ob- server can only arrive at a satisfactory conclusion, by comparing the cutaneous appearances with these concurring symptoms, and with the previous history of the disease."* This uncertainty, of which Dr. Bateman so for- cibly and, in the recent state of our knowledge, so justly complained, I believe n,ever existed; and I trust I have offered strong grounds to infer, that the appearance of the venereal eruptions is far from ir- regular, but that the embarrassment of the practi- tioner has arisen, not from any want of uniformity in the effects of those poisons, but in the circum- stance of his ascribing to one the diseases which arise from several poisons, * Bateman on Cutaneous Diseases, p, 329 J4(> PAfl/LAR VENEREA t DISEASE^ The papular, pustular, and phagedenic venereal diseases, have hitherto beeft attended with more danger than the scaly or true syphilis; not because they are^ from their nature, in reality more formi- dable, but because they have not been distingmsh- ed from that disease, and have been subjected to an inappropriate remedy. Thus it happens, that the symptoms of those disorders recurring after the use of mercur} , that medicine is again resorted to, and the mercurial irritation is alternated so often with that of the disease, that the patient at length falls a victim to their combined effects, and in this way numbers are annually destroyed. When once known and discriminated from syphilisy they are no longer formidable. The powers of the constitutionj^ assisted by simple remedies, are sufficient for their cure ; they may be tedious, but they will not be de- structive. As the treatment of strictures^ swelled testicle^ and sonje other affections omitted by the author, constitutes a very important part of venereal practice, the editor will attempt to supply the defi- ciency with as much brevity as the subjects admit. Strictures. The symptoms indicating the existence of these obstructions in the urethra are — frequent inclination to urinate, generally first noticed by the patient, from the circumstance of his being often obliged to rise at night ; the stream forked or twisted, occasioneilly without, but more frequently with, an evident diminution of its size ; sometimes he is troubled with incontinence of uniic, but mostly discharges it in drops and sudden gushes. Nocturnal emissions constitute a frequent symptom. The most common seat of stricture is about six or seven inches from the ori- fice, at the union of the membranous and spongy portions of the urethra. The existence of one, if it is not soon removed, often leads to the formation of others. When this occurs, there may generally be found two or three thus distributed : one about three or four inches from the end, another at about five inches, and the StPl'LEMENt TO CIIAPTER Ml. 141 ihird at six or seven inches : sometimes they are even more nume- i'ous, A gleety discharge ustfally attends the disease, together with dull heavy pains in the loins. The exciting causes of strictures are various, and for the iriost pai't, such as occasion considerable local and general excitement. The proximate cause appears clearly to be inllaromation, which thickens and contracts the memhranotrs coats of the urethra, so that it sometimes appears as if a strmg had been tied round it j at other times the contraction would seem to have been made by a broader band. Although the treatment of strictures is for the most part a me- chanical process, still great care is necessary in their commence- ment to subdue all local and general excitement by bleedings saline cathartics, diuretic and cooling draughts and abstemiousness. The importance of these general measures may be inferred from the circumstance that strictures are always aggravated and often brought on by dissipation or high living, whilst they are almost as certainly benefitted by an opposite course. Plain bougies will generally be found entirety sufficient for the safe and complete removal of these obstructions. Those made of waxed linen, if well prepared, are perhaps to be preferred, al- though the metallic and hollow elastic bougies are very good. The largest which the stricture will admit, is to be first introdu- ced well oiled, and the size must be subsequently increased as fast as the dilatation will permit. The time of introducing and retaining the instrument should be short at first, and afterwards prolonged, as the urethra becomes reconciled to its presence. The bougie is to be steadily and firmly pressed against the stric- ture, which in due time Avill certainly give way. To provide against relapses, an instrument of the largest size the urethra will easily admit should be passed every week or two, for man}^ months after the obstructions are removed. The patient may be taught to do this for himself. These observations, though chiefly applicable to permanent strictures, will generally prove equally adequate for . the cure of the spasmodic varieties. Sometimes the inflammation of gonorrhoea extending backwards becomes violent, and affecting the accelerator and other muscles, gives rise to paroxysms of extreme pain, attended with a suppres- sion of urine. This affection is most commonly met with in irri- table habits, and has received the name of the inflammatory stric- ture. The remedies for it are, copious bleeding, the warm bath or long continued spunging with warm water, leeches to the pe- rineum, anodyne enemas, the internal use of opium and camphire, with or without the addition of extract of cicuta. When the bladder is distended, we should wait for the violent irritation and inflammation to subside before we cautiously attempt the intro- duction of the catheter. 142 SUPPLEMENT TO CHAPTER HI. To prevent inflammation of the testicles, patients with gonor- rhoea should have them supported by means of bag or hunting trusses made of silk or cotton netting. This preventive measure is likewise useful in the treatment of the disease when it ensues. The most frequent exciting causes are, the irritation of gonorrhcEa, acrid or stimulant injections and bougies, strictures and external violence. The usual premonitory and attendant symptoms are, a feeling of irritation and uneasiness far up the urethra, as if caused by the presence of a drop of urine laying in that part ; shooting pains along the course of the spermatic chord, extending through the abdominal ring and passing down to the epididymis, which is the chief seat of the inflammation, although the body of the tes- ticle becomes much afi'ected, painful and swelled to a considerable size. Energetic antiphlogistic measures are generally called for ; such as bleeding, purging with calomel and the neutral salts. A hori- zontal posture should be strongly enjoined on the patient. The local treatment may consist of lotions, the best of which are either the Liquor. Ammon. Acetat. or warm vinegar and water, applied by means of soft linen cloths; — sometimes poultices are useful. Leeches will be found serviceable after the reduction of the ge- neral excitement. A chronic and indolent enlargement of the testicle sometimes proves very obstinate. This affection the editor has seen cured by a mild course of the oxymuriate of mercury, aided by the ex- ternal application to the gland of camphorated mercurial ointment, gently stimulating embrocations, and suspension in a bag truss. Little danger results to the procreative powers from the hardness which often remains in the epididymis after the subsidence of the general enlargement, especially if only one is thus affected. If, however, suppuration has ensued, the danger is much greater. Fistula in Ferinoeo^ is another attendant on gonorrhoea, or rather on stricture. Though comparatively of rare occurrence, it is a formidable affection, and therefore the more deserving attention. In consequence of the inflammation and ulceration of the coats of the membranous portion of the urethra, the urine finds its way into the cellular substance of the perineum, penis and scrotum, where it extravasates, excites inflammation, suppuration, and ultimately gives rise to a fistula. A hard, but not very painful tumour is perceived opposite the bulb of the urethra. Most pain is felt in it at the time of urinating. Sometimes the patient's life is placed in great danger from the extension of the inflammation, not only to the parts enumerated, but throughout the integuments of the anterior and lower parts of the abdomen. In this case it is re- commended by able surgeons not to rely upon attempts to discuss the inflammation, but to provide against the danger from suppu- ration, sloughing &c.. by an early opening into the part. The SUPPLEMENT TO CHAPTER III. 143 mode of performing this operation is thus described by Astley Cooper. — " Pass a catheter as far as the stricture will allow, then make an incision an inch beyond it ; after which pass a staff into the urethra, and cut directly upon it through the stricture ; by this means, present relief is not only afforded, but it may effectu- ally relieve the stricture by introducing an elastic hollow bougie, and suffering it to remain two or three days. The scrotum should always be opened at different parts, by means of incisions, to admit of the urine being evacuated by means of them, but not so as to endanger the wounding of the tunica vaginalis : by this method, and by this only, will sloughing be prevented. The application of a vinegar poultice to the scrotum, will be found extremely beneficial. Whether the extravasation is anterior to the scrotum, in it, or in the perineum, the early opening is always to be adopt- ed." When, by the adoption of these measures the dangers of sloughing and suppuration are surmounted, the original stricture is next to be attended to, as without its removal the fistula can never be completely cured. For this purpose the practitioner just referred to prefers the caustic to the common bougie. An instrument of a size which the urethra will readily admit, armed with the lunar caustic, well secured and scraped to a point like a pencil or crayon, must be dipped in oil and passed down to the stricture as quickly as possible. In general, half a minute will be long enough to keep the caustic applied to the stricture, and that the slough should have ample time to separate, the operation need not be repeated oftener than every second or third day. But although strictures have undoubtedly been removed by a few applications of the armed bougie, instances can be adduced to show that retention of urine, and other distressing symptoms, have been occasioned by the severe irritation which it often produces. It has even happened that false passages have been made, giving rise to fistula in perinaeo when it did not previously exist, the ar- tery of the bulb destroyed, alarming hsemorrhage consequently produced, and spurious aneurism formed. For these reasons it must appear evident, that, for the destruction of all kinds of strictures, the plain unarmed bougies are to be preferred, as long as any prospect remains of their effecting the object. The treatment will perhaps in most cases be considerably prolonged by adopting this more safe and less severe plan, but as the other frequently fails, even in the best hands, and may be highly mischievous in those of the rash and unskilful, we think there are sufficient grounds to justify our preference. Even after the removal of the stricture, the fistula has been found to remain uncured. Under such circum- stances, it has been recommended to keep the patient in the hori- zontal posture, introduce a flexible metallic catheter into the bladder, and suffering it to remain there three or four days, replace it with a new one. This last precaution is found necessary in 144 SUPPLEMENT TO CHAPTER III. coneeqyenee of the action of the urine upoa the metal, by which the instrument has been so corroded as to break — an accident which exposes the patient to an operation similar to that for Li- thotomy. Perhaps the hollow elastic catheters would answer the purpose equally well, and as they are also corroded by urine, the same precaution relative to changing them should be attended to. Another affection, which originates from gonorrhoea, especially when it has been improperly treated, is what has been termed an irritable state of the bladder. The most prominent symptoms are, a very frequent inchnation to void urine^ all attempts to restrain which desire produce ex- treme pain in the regio pubes ; considerable discharge of mucus along with the urine, which is sometimes tinged with blood ; dis- tressing tenesmus^ The symptoms frequently bear so striking a likeness to those of stone, as to make it difficult to tell which dis- ease they belong to. This affection oiay, however, be distinguished by the patient's heing mo^t exempt from pain and uneasiness when the bladder is empty, at which time he can even bear to jump and exercise with a degree of freedom which would be attended with violent effects if he laboured under stone. The same exer- cise taken when the bladder was full, would occasion great pain. Dissections have shown the mucous coat and even the whole structure of the bUidder inflamed violently, and so contracted as not to be capable of containing more than from two to six or eight ounces. The inflammation has sometimes produced adhesions to the anterior parietes of the abdomen, and caused the patient to be curved forward. The treatment may be divided into the palliative and curative measures. Among the first are anodyne enemas and the intro- duction of opium and cicuta into the rectum ; injecting into the ■urethra a watery solution of opium — for which purpose ^j may be rubbed down with 5vj or §yiij of gum arable water, or flaxseed tea, and injected warm. When the urethra will bear its presence, a hollow bougie is to be passed down, and the injection forced through it into the bladder. But sometimes the irritation is so great, that the attempt to pass an instrument occasions excruciating and long continued pain, for which reason it will be better to close the orifice of the urethra, and rub it in such a manner as to direct the injection into the bladder. As remedies of a more curative nature, we may enumerate the following. Diluent and mucilaginous drinks, particularly in the first stage, such as gum arable and water, orgeat and water, flaxseed tea, infusion of marsh mallows, &,c. Soothing laxative enemas should be frequently resorted to. Leeches may be often usefully applied to the perineum. When ulceration has ensued, it has been recommended by Astley Cooper to introduce an elastic catheter into the bladder, which is to be jeft for the urine to pass through, varm bath, should not be neglected. When nodes occur, (and I am not certain that they ever do in this species of venereal disease when mercury has not been employed) leeches, fol- lowed by a repetition of blisters to the part, will generally relieve the pain, and diminish those swell- ings. But if, notwithstanding these means, the nodes should continue obstinate, and the pains se- vere, recourse must be had to mercury, although it was originally, perhaps, the very cause of those nodes : not indeed by producing a mercurial disor- der, but by driving the venereal disease from the surface to the interior. These affections of the bones, it is to be hoped, will in time become more and more rare, according as the inveterate practice by which they are occasioned, gives place to the modern improvements so obviously necessary. — Periostitis, no matter from what cause it may origi- nate, is powerfully combated by the mercurial irri- tation, which acts by checking the adhesive inflam- mation. The preparation I prefer, is calomel com- bined with opium, given to such an extent as to af- fect the gums ; but if the stomach or bowels are delicate, mercurial frictions must be employed. If all these means fail, our only resource lies in a free 208 PHAGEDENIC VENEREA!^ DISEASE. division of the inflamed periosteum covering the node, which seldom fails to afford relief. ' Enlargement of the testes is also a frequent symp- tom of this form of the disease, but I do not recol- lect to have seen it in any case where mercury had not been previously employed. I always treat it on the same general principles applicable to nodes, — viz. leeches, counter stimulants, antimony, and sarsaparilla. If these fail, then calomel combined with opium or cicuta will be necessary, in altera- tive doses. In fact, the treatment recommended for this, as well as every other form of venereal disease, is founded upon general pathological principles, and the success which has attended these views, suffi- ciently proves that venereal complaints are neither ©bscure or incomprehensible ; but that they yield to that treatment which a plain sound pathology points out, and which is available against the other diseases to which they bear an analogy. Notwithstanding the length of time which has elapsed since the ill effects of mercurial courses in the phagedenic form of venereal disease was first urged upon the public, and although the inordinate use of mercury has considerably diminished since that period, I regret that I am in this edition oblig- ed to repeat the observation, that there is scarcely a day in which I do not see some fresh instance of a constitution broken down b}^ reiterated and pro- tracted courses of this mineral, for this species of venereal disease ; yet the faith of the practitioner is still undiminished in his specific : and the patient PHAGEDENIC VENEREAL DISEASE. 209 is, year after year, assailed by some new symptom, for which he is again to submit to a remedy more destructive than the disorder. The phagedenic and sloughing ulcers, probably present the most unfavourable form of venereal dis- eases, the most uncertain in their progress, and the most fatal in their result ; but they have been ren- dered still more destructive by the manner in which they have been hitherto treated. The constitution- al disease which they produce, may be retarded, or suspended, but cannot be superseded altogether by the mercurial action on the system. It may yield to the powers of the constitution, but will not to mercury, which in this complaint deserves the character of a ready and valuable instrument in our hands, well calculated, under peculiar circumstances, to check the progress of a dangerous ulcer, or to alleviate the severity of the pains of this species of venereal disease. One of the great errors in prac- tice, arises from an inference that all ulcers or pains which are relieved by mercury, must there- fore be syphilitic; and consequently that a full course of mercury is required for their cure. If we esteemed mercury merely as an instrument, by which we have it in our power to raise an action artificially in the system, capable of superseding that of some poisons, but only of suspending that of others, we should avoid a source of inextricable error, and might then more usefully direct our at- tention to discriminate those which may be super- seded or cured, from those which can merely be suspended or alleviated by its influence. 2d ^1<^ PHAGi;DENIC VENEREAL DISEASE. lii: relinquishing the hope of curing this disease!, lijte syphilis, by a full mercurial action, and of leav- ing it in a great measure to the powers of the con- stitution, we certainly resign the too often disap- pointed expectation of the eclat which the rapid recovery of our patient might produce; but we shall probably have the satisfaction, in the end, of guiding him through a most difficult and perplexing i^alady, and of escaping the mortification of seeing his complaints rendered more inveterate by our efforts, to remove them, and of the unpleasant feel- ings that must result when we are conscious that those very efforts have tended more to subvert his constitution, than the poison which they were in- tended to subdue. I shall now proceed to give a few cases of the con- stitutional symptoms of the phagedenic disease, many of which also afford instances of the existence, on the same individual, of the primary symptoms. I shall, in the first instance, detail those cases which exjemplifyihe injurious consequences attendant upon the too early exhibition of mercury, and the train of difficulties, embarrassments, and disappointments, wliich the practitioner entails upon himself by con- tinuing this line of practice. And these cases may be considered as the stepping stones by which 1 advanced to that mode of treatment, w^hich has an- swered my most sanguine expectations. I shall af- terwards subjoin cases that may be contrasted with the former, which were treated, from the time they came; under my care, according to the views I have above unfolded. PHAGEDENIC VENEREAL DISEASE. 2^11 It was not at first my intention to burthen this work with the detail of any cases, but I am inclined to believe, that my views of the phagedenic disease would be very imperfectly understood, without the minute and faithful details which these records pre- sent to the mind. Cases exemplifying the injurious consequences at- tendaiit upon the early exhibition of mercury for the constitutional symptoms of the phagedenic dis- ease ; but many of them also illustrating the bene- Jicial effects of that medicine ivhen the disease is on the wane. Case 22. — Martha Lloyd was admitted Septem- ber 10th, 1813, on account of a discharge of an acrid excoriating matter from the vagina, but from the swelling and excoriation of the parts, it was impos- sible to ascertain the nature of the surface from which it proceeded. There were pustules scattered over her body, but more numerous on her back than on any other part, which were of a large size, and as distinct as those which occur in a case of mild small-pox. There was also an ulcer on the outside of the left leg, extending from the ankle upwards, a^ large as the palm of the hand, and of a black sloughy appearance. A white superficial ulcer was situated on each tonsil, and she was affected with ptyalism, although, as she asserted, she had not used any mercury. She also complained of pains in her shoulders, and her strength and constitution seemed to be greatly reduced. 212 PHAGEDENIC VENlTREAL DISEASE. She stated, that she was affected with the dis- charge and soreness of the pudenda, three months before her admission, and that about the middle of that period, the constitutional symptoms had begun to appear. I directed her to take the antimonial solution and decoction of sarsaparilla. The symp- toms were not, however, in the smallest degree checked by these medicines ; the pustules became more numerous : those that at first appeared, had become dark brown crusts, concealing ulcers, the largest of which, formed on the sacrum, and was, at least, six inches in circumference. The ulcer of her leg also increased, and the ulcers of the tonsils extended to the back of the pharynx, and engaged the velum and uvula in their progress. On the 21st of September, a drawing was taken of the appear- ance of the eruption and ulcers on her back. (Plate III. fig. 1 and 2.) I did not any longer delay the exhibition of mercury, but directed that she should take a pill, containing one grain of calomel and half a grain of opium, three times a day. 28th. The greater number of the pustules had changed their appearance into dark-brown conical crusts, which were, in general, at their bases, about the size of a sixpence. The ulcer of her leg look- ed somewhat better, as did also those of her throat. Oct. 12th. She was evidently affected by the mercury, and her swallowing was easier, but I could not examine the state of her throat, as from the number and extent of the ulcers on her back, she was obliged to lie upon her face. The crusts on the smaller ulcers closely resembled, in appearance, PHAGEDENIC VENEREAL DL-EASE. '2115 the common limpet shell. No fresh pustules had appeared, and many of those on her limbs had form- ed crusts, which, falling off, left the parts underneath cicatrized; an evident indication, that the disorder was giving way to the means employed. She was, however, greatly reduced, and her legs became (Edematous. These circumstances induced me to discontinue the mercury, and the rather, as the pro- gress of the disease was decidedly checked. She was now ordered bark and wine, which, however, with every attention to diet, were insufficient to support her declining strength, although such ulcers as were exposed by the falling off of the crusts, exhibited a granulating appearance. The great extent of ulcerated surface so harassed a debilitated, broken down constitution, that she did not survive longer than the 2d of November following. If this patient had continued on the use of sarsa- parilia, which might have been advantageously combined with opium or cicuta, in doses sufficient to mitigate the state of irritation caused by extensive and painful ulcers ; and if mercury had not been employed, I have little doubt, from my present ex- perience, that she would have recovered. Case 23. — The eruption of the phagedenic dis- ease, in its scabbing stage, frequently forms conical crusts resembling the limpet shell in appearance. (See Plate III. fig. 2. and Plate IV.) I have, how- ever, met with a few instances, in which one or two of the crusts rose into projecting hard cones, re- sembling horns. My attention was called to a remarkable instance 214 PHAGEDENIC VENEREAL DISEASE. of this description, on the 26th of October, 1813, by one of the surgeons of the hospital, under whose care the patient, Patrick Kenny, was placed. He had three spots at that time on his face, formed by large brown conical crusts, one of which, in par- ticular, projected like a horn from his forehead, and is delineated in Plate III. fig. 3. He complained of pains in his shoulders, elbows, knees, and ankles, which last were red and swelled. On examining the penis, I discovered the cicatrix of a deep ulcer which had excavated the corona and superior surface of the glans penis. I learned that this ulcer had made its appearance in October, 1812; and that it healed with difficulty towards the conclusion of a severe course of mer- cury of two months' continuance, during which period he had taken pills and rubbed in six ounces of ointment. He had, however, scarcely finished the course, when a frill of soft warts, or fungi, sub- ject to frequent bleeding, sprouted up round the corona glandis. For this complaint he was again put upon a mercurial course of several months, during which he took pills night and morning, and rubbed in eleven ounces of ointment. On the 10th of March, 1813, he was seen by an intelligent pupil of the Hospital, Mr. Adams,^ who has attended my lectures on these diseases, and seen my practice in the Hospital, who favoured me with the following history of his complaints from the time he first saw him, until he came under my observa- tion. * Now a member of the College of Surgeons, and Lecturer on Anatomy and Surgery. PHAGEDENIC VENEREAL DISEASE. 215 He found the patient labouring under severe ptyalism, and at the same time affected with exces- sive inflammation of the penis, owing in a great measure to some corrosive application which had been applied to the fungi. He directed him to dis- continue the mercury, took blood from his arm, con- fined him to low diet, and ordered him antimonials. In a few weeks, under these means, the inflamma- tion was reduced, the fungi disappeared, and the patient considering himself well, returned to Jiis business. But on the 23d of May following, he was again taken into the Lock Hospital, on account of pains in his arms, and an ulcer which had formed on the back of the pharynx. . For these complaints he was again submitted to another full course of mercury, under which the ulcer of his throat healed ; but while he was affected with ptyalism, even to a quart daily, he was attacked with severe pains in all his joints, and his wrists and knuckles became red and swelled. At the same time an eruption of pustules, which formed ulcers covered with crusts, appeared in different parts of his body. In consequence of the appearance of these symptoms in the midst of a course of mercury, that medicine was properly discontinued, the pains were considered to be rheumatic ; and he was ad- vised to leave the hospital for the benefit of pure air, and for the purpose of recruiting his shattered constitution. But in the beginning of the September following, he was admitted for the third time into the hospital. 216 PHAGEDENIC VENEREAL DISEASE. for the symptoms described in the beginning of his case. From the 26th of October already mentioned, though he was not under my immediate care, I saw him daily. The medicines he took were decoction of sarsaparilla and solution of muriate of mercury, under which he perfectly recovered from his pains, and the conical crusts already described fell off, leaving the surface underneath perfectly healed. On the 24th of December, he was discharged the hospital w^ell. He was desired to return if any re- lapse should occur, but he has not since returned. I need scarcely observe, that if a similar case were now to come under my care, I should treat it with sarsaparilla and antimonials^ and not give a grain of mercury. Cas& 24. — Thomas Dunn, admitted Sept. 3d, 1814. An extensive phagedenic ulcer of the glans penis formed a deep cleft that almost divided it into two parts ; there was also an ulcer on his forehead covered with a thick crust, and a similar one on his side. He had been using mercury three weeks pre- vious to his admission, under which the ulcer had extended. At this period, circumstances which I then misunderstood, but which I have since been able to unravel, and which I shall have occasion to advert to, induced me to think that the phagedenic primary ulcer would be benefited by the use of mercury, if the patient was at the same time affect- ed by constitutional symptoms. Under the influence of this opinion, which I have long since relinquish- ed, I determined to give a trial to mercury in this PHAGEDENIC VENEREAL DISEASE. 217 and two or three other cases, and accordingly I or- dered the muriate of mercury, conjoined with the decoction of sarsaparilla, for the patient soon after his admission. Under this plan the symptoms im- proved for a time, but they soon began to relapse to their former state, with the accession of new ones, as observable in all similar cases, unless the exhibition of mercury is postponed till the disease has nearly exhausted itself. In the present instance, about a month after the patient had entered upon the use of mercury, and while his gums were affected, he was attacked with severe pains in his different joints^ but particularly in one knee ; and a great number of pustular spots, which soon formed crusts, and ulcers appeared on different parts : — at the same time the old ulcers extended with a phagedenic edge. In December they were at their utmost extent, several the size of a dollar; one on his neck was as large as the palm of the hand. There were also very extensive ulcers on both thighs. According as these ulcers began to mend they healed from their centre, and frequently, while heal- ing in the centre, were extending with a phagede- liic margin at their circumference. At length, un- der the use of the muriate of mercury, blue pill, calomel with antimony, cicuta and sarsaparilla, the ulcers healed before the 4th of March, and he was discharged the hospital. He was, however, re-admitted on the 17th of the following April, on account of an extensive ulcer of phagedenic appearance, which engaged the left 2e 218 PHAGEDENIC VENEREAL DISEASE. tonsil and the entire velum, a great part of which it had destroyed. This ulcer it was necessary to check as rapidly as possible, and, therefore, re- €Oiirse was had to mercurial frictions, and the solu- tions of the muriate of mercury.^ Under this course the ulcer rapidly amended, and he was dis- charged the hospital well on the 28th of May, since which time I have not seen him. Many will argue, that if mercurial frictions had been resorted to at the commencement, instead of the other preparations of mercury, the disease would have been subdued at an early period ; and if I myself were to draw my conclusions from this case alone, I should be of the same opinion ; but I have met with so many similar cases in which the effects of full, or even the gentlest mercurial action on the system was highly injurious at the com- mencement of the constitutional disease, that I have not the slightest doubt of the inutility and danger of its adoption until the disorder is on the wane. Case 25. — Mary Fitzgerald, setat. 25, admitted Feb. 25th, 1815, on account of a small ulcer of foul appearance and phagedenic character on one of the labia, and an eruption of pustules on her face and body. She also complained of pain in her right arm. She stated that she was but four weeks dis- ordered previous to her admission, and that she had not used mercury. Decoct. Sarsap. — Solut. Antim. — Lot. Hydrarg. Flava. As no amendment was apparent under this plan, * If a similar case were now to come under my care, I should content myself by ordering fumigations of the red sulphuret ot mercury to the throat, and decoction of sarsaparilla. PHAGEDENIC VENEREAL DISEASE. 219 on the 3d of March she was directed to take a grain of calomel night and morning, which on the 20th had affected her mouth severely. At this time the eruption had assumed the form of ulcers covered with conical crusts, and a white apthous ulcer had appeared on the velum and uvula. The mercurial pills were discontinued, and she was or- dered two grains of opium at night to allay the irri- tation arising from her complaints, particularly the soreness of her mouth. April 10th. — The ulcers had extended, and on her face presented the appearances depicted in Plate IV., which was engraved from a drawing taken this day, and exhibits a most accurate re- presentation of this form and stage of the disease. There were four or five similar spots on her neck and back; one of them had thrown off the crust and exposed a pale unhealthy ash-coloured surface. 17th. — All the spots had so far extended, that her lip and nose were nearly covered by the crust which had formed on those parts. The ulcer of her throat had also spread in so great a degree as to engage the velum, right tonsil, and back of the pharynx, in one extended white slimy ulceration. Every attempt to swallow was attended with re- gurgitation through the nose. From constant irri- tation and want of nourishment she was greatly re- duced. The ptyalism continued to three pints a day; but conceiving that this was in a great mea- sure owing to the irritation of the ulcer in her throat, I directed the frequent use of cinnabar fu- migations, and such nourishment as she was capa- 220 PHAGEDENIC VENEREAL DISEAsiE. ble of swallowing. She sunk rapidly, and died on the 23d of April. This case closely resembled in its symptoms that of Martha Lloyd, the first detailed of this series of cases. And the observations which I had occasion to make respecting the mode of treatment I should now adopt for the symptoms with which that pa- tient was affected, apply with equal force to the present instance. Case 26. — James Heney, admitted Sept. 27th, 1815. An ulcer about the size of a sixpence, exhi- biting a white sloughy appearance, was situated on thje body of the penis, the integuments of which, were undermined to som-e little extent. There was also an ulcer situated on the upper lip, covered by a large conical scab. He had been about two months affected, and had rubbed in two ounces of ointment, and taken 20 pills, which affected his mouth, but did not produce any beneficial change in his complaints ; on the contrary, the ulcer on his lip occurred, as he stated, while he was under the infliience of mercury. — Decoct. Sarsap. — Solut. An- tim. On the 15th of October, the crust separated from the spot on his lip, exposing an ulcer covered with white tenacious matter. The ulcer on the penis was healing at one end, w^hile it w^as extending at the other (that next the pubes,) by burrowing un- der the skin. 29th. — He complained of severe pain in his knee. After hot fomentations had been used for some days, the ointment of tartarized antimony was rub- PHAGEDENIC VENEREAL DISEASE. 221 bed on his knee, and produced a large crop of pus- tules, which evidently relieved the pain. In the beginning of November he was put upon the use of nitrous acid, and about the middle of the month the ulcer of the penis and that of his lip were nearly healed. In the beginning of Decem- ber, his amendment seemed to cease, and some new symptoms appeared, viz. raised spots on his fore- head and at the root of his nose, of a copper-colour and firm consistence. It was difficult to say whether they presented a scaly or a scabby appearance, but they did not, like the preceding spots with which he was affected, show any disposition to ulcerate. These symptoms, such as I have described them, always convey to me at present an indication that the disease is on the decline; and that mercury may be used not only with safety, but effect : but when this case was under my care I had not arrived at this point of information ; yet on their appearance I deemed it prudent to resort to a course of mer- cury, under the impression that the means I had employed were insufficient to subdue the disease, and that these very symptoms were indicative of this fact. I accordingly ordered him mercurial frictions, al- though I confess my hopes were rather stronger than my expectations of deriving any advantage from them. They were continued near two months, and his complaints gradually disappeared. He was discharged the hospital well in the beginning of February, leaving me in no small perplexity at an anomaly I was then so little able to explain, but w^hich at present I find of such easy solution. 222 PHAGEDENIC VENEREAL DISEASE. Case 27. — The following case, although not under, 7ny care^ I had an opportunity of observing during its entire progress. The notes I give were taken by my pupil, Mr. Farrall, and the case is instruct- ive, inasmuch as it affords another instance of the connexion which exists between the phagedenic primary ulcer and the pustular eruption which forms secondary ulcers, and at the same time evinces the injurious effects of mercury both on the primary and constitutional symptoms of this peculiar disease, unless it has begun to decline. John M'Mahon, admitted 27th May, 1816, with considerable inflammation of the penis, phymosis, and profuse discharge. On retracting the prepuce as far as its inflamed condition would admit, the entire glans was discovered to be in a state of pha- gedenic ulceration. Severe pain; high symptomatic fever. He had been disordered two months, and had taken eighteen mercurial pills. He was ordered a bolus, to be taken at night, containing six grains of calomel and two of antimo- nial pow^der, which, on the 29th, was increased to ten grains of calomel, with the same quantity of antimonial powders, and a grain and a half of opium. This bolus was repeated every night until the 16th of June, with but four omissions, and on these intervening periods, he took some opening medi- cine, which was continued as required until the 30th. The ulcer on the penis all this time was making progress, and on the 1st July, ulcers were apparent on the tonsils. He was now put on the use of PHAGEDENIC VENEREAL DISEASE. 223 mercurial frictions, which he continued until the 9th of July, when he had rubbed in seven drachms of ointment. However, as the disease was still tinchecked, the ointment was laid aside for pills of calomel and antimony, with occasional doses of the compound powder of jalap, and the fermenting poultice was applied to the penis. These medicines were discontinued on the 12th of August for the solution of the muriate of mercury, and an anodyne draught at night. On the 19th of August, it was noted that a number of large brown scabs had made their appearance on his forehead, chin, arms, legs, and body, at a time that he was under the influence of mercury. From tKis period until the beginning of Septem- ber he did not use mercury in any form ; the only medicine he was ordered was a pill every night, con^ taining two grains of ipecacuanha and one of opium, under which his throat improved, but the scabs en- larged, and he became affected with pains in his joints. The primary ulcer continued its ravages, until the entire penis was destroyed, which occurred about the middle of August, when a cicatrix formed close to the scrotum. On the 4th of September he was ordered the so- lutioi; of muriate of mercury and decoction of sar- saparilla, which soon affected his mouth. The scabs shortly afterwards began to drop off, leaving the parts underneath healed. The pains of his joints daily diminished, and he continued the medi- cine until the 3d of October, when he was discharg- ed well. 224 PHAGEDENIC VEINEREAL DISEASE. This case was managed in every respect contra- rary to the plan of treatment I have recommended. The patient, it is true, recovered from the disease under the use of mercury, but in a mutilated state, and with a shattered constitution. Case 28. — William Kelly, admitted September 6th, 1816, with a phagedenic ulcer extending from the corona glandis, more than half way along the body of the penis, and nearly round its circumfer- ence. It was attended with imflammation, pain, and symptomatic fever; — pulse 120. It commenced at the frenum, and spread rapidly under the exhibition of mercury, which the patient informed me had been given to so great an extent as six pills a day, which he persevered in a consi- derable time before his admission. Under my di- rections he was bled twice, (sixteen ounces each time,) and took purging and antimonial mixtures, which he persevered in till the 20th September; when the ulcer not improving, he was directed to take five grains of the extract of cicuta every fourth hour ; but the ulcer still continuing its ravages, this medicine was laid aside, on the 6th of October, for the muriate of mercurj and decoction of sarsaparii- la. Still the ulcer extended, until the entire pre- puce, and a great portion of the glans, including part of the urethra, were destroyed. About the mid- die of November the ulcer began to put on a more favourable appearance, but at the same time, and while he was under the influence of mercury, he was attacked with pains in his ankles and in- steps. The mercury was now laid aside, and he PHAGEDENIC VENEREAL DISEASE. 225 was ordered, on the 25tli November, a scruple of Dover's powder every night, with the decoction, and the frequent use of the warm bath. Under this plan, the pains lessened and the ulcer improved, and finally healed before the 10th of January, 1817. Still the pains were lingering in his joints, and in compliance with his desire, I allowed him to rub in ^ss. of mercurial ointment every night, which about the end of January, excited con- siderable ptyalism, under which the pains were greatly relieved, but at the same time a large red tubercle appeared on the back of the right leg. The mercury was still persevered in, but the pains be- came more troublesome, and in the middle of Feb- ruary a large scabby ulcer had formed on the right arm below the elbow, and towards the end of the same month, his knee became swelled and inflamed. Under these circumstances, it was obvious that the mercurial plan was of little advantage to him ; it was therefore discontinued on the 28th of Febru- ary, and he was put upon decoction of sarsaparilla, with which he was directed to take five grains of gum guaiacum every forth hour, and to rub the knee with the ointment of tartarized antimony, which ex- cited as usual a crop of pustules on the part. The pain of his knee, as well as all the other pains, gradu- ally lessened under these medicines, and the fre- quent use of the tepid bath. The tubercle on the back of his leg did not ulcerate until the beginning of April. The same medicines were still continued, with little variation, and under their use all his com- 2 F 226 PflAGEDENIC VENEREAL DISEASE. plaints at length disappearing, he was discharged the hospital on the 19th of May. This case affords a good example of the phage- denic disease, both in its primary and secondary symptoms ; of the inutility of mercury for their cure; and of the advantages derivable from sarsaparilla and guaiacum, after mercury had been exhibited without success. Case 29. — The following case, though long, so well exemplifies the distress and danger to the pa- tient, as well as embarrassment and mortification to the surgeon, from the early exhibition of mercury in the phagedenic disease, that I cannot refrain from giving it, as I am certain it will be esteemed by the juniors of the profession a very useful and impress- ive lesson. In the beginning of June 1816, Mr. C. consulted me concerning a small foul ulcer inclined to phage- dena, which had appeared about a week before on the prepuce. I prescribed antimonial pills and the mercurial yellow wash, but did not see him again until the 12th of July, when I was called upon to visit him at his own house. I found him in bed, complaining of the most severe pain in his head, which was increased by the slightest noise. His pulse was 110. The ulcer of the penis had nearly healed. I directed some smart opening medicine, and took sixteen ounces of blood from his arm ; and two days afterwards leeches were applied to his temples. On the 22d, the pain not remitting, the physician who attended his family was consulted, who advised a continuance of the cathartic raedi- PHAGEDENIC VENEREAL DISEASE. 227 cines, and diaphoretics at night. On the 28th aijd 29th he complained of pain in a part of his forehead, which was tender upon pressure, and the same ten- derness and pain also attacked one of the clavicles. The ulcer of the penis, which had healed, began again to ulcerate, and a few large piniples or pus- tules, of a suspicious aspect, had appeared on his forehead, arm, and back. In four or five days after- wards, the spots had extended into ulcers covered with crusts. As it was now apparent that the high fever with which he was attacked was a venereal eruptive fe- ver, which preceded the appearance of the pus- tular spots, I hoped to stop the progress of the dis- ease by the exhibition of mercury, which I combin- ed with antimony, on account of the high degree of excitement which still continued. With these views I therefore ordered for him, on the 30th, pills con- taining a grain of calomel, with two of antimonial powder, to be taken thrice a day. I, however, was perfectly aware from the symptoms, that I had a difficult disease to manage, and gave the patient an «arly intimation of the obstinate nature of his disor- der. Aug. 8th. — His mouth was affected by the mer- cury ; the ulcer of the penis had increased, and ex- hibited a burrowing disposition. The constitution- al ulcers, four or five in number, had also extend- ed ; he complained of pain in the back of his neck, and in his left knee. Decoction of sarsaparilla was now added to his former prescription. On the 14th, the pain of the knee had considerably increased, 228 PHAGEDENIC VENEREAL DISEASE. and was attended with puffiness on each side of the ligament of the patella. This symptom was reliev- ed in a few days by hot fomentations and warm poul- tices of bread and water, and he had also ceased to complain of his head and clavicle. 18th. — The gums were much swelled, and the ptyalism was considerable ; but the ulcers continu- ed to extend, and the crust covering that on his forehead, the base of which was nearly as large as a shilling, exhibited the conical form and appear- ence of a limpet shell, as delineated in the plate. The right testis had also become swelled and pain- ful. As the disease, instead of being checked by the mercurial affection of the system, was decided- ly making advances, as was evinced by the exten- sion of the constitutional ulcer and the appearance of new symptoms, the mercury was discontinued ; but on the 28th, his complaints being stationary, he was directed one-eighth of a grain of muriate of mer- cury, thrice a day, with the compound decoction of sarsaparilla. Sept. 12th. — The swelling of the testis had in- creased, and no amendment had taken place in his other complaints. The solution of the muriate of mercury was changed for pills thrice a day, contain- ing one-half grain of calomel, and two grains of an- timonial powder. Decoction as before. Oct. 4th. — The crusts had fallen from all the spots, leaving the parts underneath healed. The testicle, however, remained as it was. His mouth was slightly affected. It was now thought advise- able to increase the mercurial affection of the sys- PHAGEDENIC VENEREAL DISEASE. 229 tem, with the view of dispersing the swelling of the testis. He was, therefore, ordered four grains blue pill, with one-half grain calomel, thrice a day, and on the Bth he was directed to discontinue the pills, and to rub in 5i. of ointment every night, which, on the 14th of October, affected his mouth severely. The mercurial affection of his system w-as ob- viously, however, a second time attended with the most injurious effects ; for the spot on his forehead had again ulcerated, and a new pustule, which ex- tended into an ulcer, had appeared on one of his cheeks. The testicle had increased in size, and he began to complain of severe deep-seated pain in one of his thighs, and felt, according to his account, as if it proceeded from the bone. The mercurial plan of treatment was, therefore, again laid aside, and he was ordered the compound decoc- tion of sarsaparilla, with ten grains of Dover's pow^ ders, thrice a day. An endeavour was made to re- lieve the pain of the thigh by the use of the tartariz- ed antimonial ointment ; this treatment was follow- ed by a crop of pustules on the part, and afforded him considerable relief. At this period, as the pa- tient lived in an unhealthy and crowded part of Dub- lin, he was advised to change his residence for one in the environs of the city, but this measure was not adopted, although its necessity was urged to him and his friends in the strongest manner. The ulcer on his forehead had increased to such a degree as to extend from his hair to the root of the nose, and was about three-fourths of an inch in breadth. The upper part presented large, loose, 230 PHAGEDENIC VENEREAL DISEASE. spongy granulations, but the lower was spreading and phagedenic, and I greatly feared it would ex- tend to the loose cellular structure of the eye-lids. I therefore thought it adviseable to destroy, if pos- sible, the surface of the ulcer, and induce a new ac- tion in the part, by touching it daily with a strong solution of nitrate of silver. It was also applied to the smaller ulcer which was on his cheek, and ex- hibited much the same appearances. This application was attended with advantage, for on the 9th November, it was noted that the ul- cer had a healthy healing appearance at its lower part. It, however, exhibited loose, spongy granula- tions above, but the smaller ulcer was nearly healed. November 1 9th.— The ulcer continued to contract in size, but it was not healing to my satisfaction, as the granulations were soft and spongy. The testi- cle remained undiminished in size, and on its upper part had formed a small abscess, which broke and discharged some pus. As upwards of a month had elapsed since the mercury was discontinued, the patient became dis- contented that something more efficient was not do- ing for him, particularly as his complaints remain- ed so nearly stationary ; and I myself, hoping that an alterative plan of mercury, combined Avith the woods, might produce a beneficial change, directed 4 grs. of the mercurial pill twice a day, which on the 27th was increased to thrice a da}^ ; but on the 5th December, it became necessary to abandon mercury for the third time, because it was appa- rent, although his ^ums were now severe! v affected, PHAGEDENIC VENEREAL DISEASE. 231 that the ulcer on his forehead was making advan- ces, and he was again complaining of the deep-seat- ed pain in the femur. All mercury being therefore discontinued, he was put upon the use of nitrous acid. Upon this plan he continued until the 15th December, during which time the ulcers gradually amended, but the testicle became more swelled, and extremely painful. As venereal swellings of the testicle are, above all other symptoms, most apt to yield to mercury, a cautious trial was again made of that medicine. The patient was directed to rub in half a drachm of ointment at night, and to take l-8th of a grain of the muriate of mercury twice a day. On the 22d December, the symptoms all getting worse, a consultation was held with a surgeon of eminence, who was made acquainted with the per- plexing circumstances of this obstinate case, the re- peated trials of mercury, and the reiterated disap- pointments which followed its use. He, however, recommended a steady and gradual exhibition of that medicine in the form of friction, and a more powerful application of lunar caustic to the ulcer, and that the patient should at the same time enjoy the benefit of country air. This plan was strictly followed, and in order to prevent too sudden an affection of his mouth, he was directed to rub in but half a drachm every night : however, before the end of January his mouth was strongly affected by the mercury. But at this pe- riod, and while the medicine had full possession of the constitution, the testicle began to grow intoler- 232 PHAGEDENIC VENEREAL DISEASE. ably painful, and the ulcer of the forehead, which had been checked at its lower part, was again ex- tending towards the scalp, b}^ undermining the skin. He also repeated his complaints of severe pain in the head and shoulders. Under these cir- cumstances, it was determined, in consultation with the same gentleman, to discontinue the mercury, and apply three leeches daily to the testis, until the pain subsided. But unfortunately, the leeches, instead of diminishing the pain and swelling of the testis, excited so much irritation as to produce consider- able inflammation, and an extensive slough of the scrotum; and the symptomatic fever ran so high, that it became necessar}^ to take blood more than once from the arm. After the separation of the slough, the greater part of the right testis became exposed, and the ulcer produced was of a most irritable nature ; with this, different lenient applications were tried, but the great irritability of the part could only be re- lieved by anodynes. In the mean time the ulcer on his forehead continued, in its superior part, to gain ground by undermining the integuments of that portion of the scalp adjoining the forehead, and he was again put on the use of nitrous acid. February 9th, 1817. — The gentleman who saw him before, and another surgeon, met me in consul- tation this day, when it was determined to add to the nitrous acid one-third of muriatic acid, so as that the mixture should correspond with that re- commended by Dr. Scott. It was also agreed to touch the edges of the ulcer of his forehead daily. PHAGEDENIC VENEREAL DISEASE. 233 with the oxymel ^eruginis, and to procure rest by means of anodynes. At this period the patient was obliged to remain in bed, not only on account of his great debility, and emaciation, but from the very painful state of the exposed testis, which was in- creased by the slightest motion. His pulse was in general about 110. His friends were anxious that he should try a patent medicine, De Velno's vege- table Balsam, with which I willingly complied, as I had seen in other instances, where mercury had been given extensively, and without benefit, appa- rent advantage from the use of this medicine. On the 20th February, he commenced with a wine-glass full thrice a day, which was afterwards gradually increased to such quantity as his stomach and bowels could bear. He continued to take it for several months, during which time it did not excite the slightest tenderness of the gums, or foetor of the breath. These circumstances I mention, as they evince that this medicine does not contain, as is ge- nerally supposed, any portion of mercury.* It is but candid to acknowledge, that immediate and decisive amendment ensued on the exhibition * Such evidence is certainly far from being conclusive, inasmuch as the Oxymurias Hydrargyri may be exhibited in moderate doses for months without aifecting" the gums or breath. This observa- tion will apply with equal force to certain panacea's^ which have lately been palmed upon the American public, as entirely of vege- table composition. The effects which these nostrums often exert upon the gums and breath, their ordinary influence upon the system, and operation in certain chronic diseases, with many other cir- cumstances which might be adduced, evince to those who are familiar with the effects of the Oxymurias Hydrargyri, that it is to this valuable mercurial salt, all the good and barm they do i^ attributable. E. 2g 234 PHAGEDENIC VENEREAL DISEASE. of this patent medicine. His appetite and strength improved, the ulcers became clean, and began to lose their irritable phagedenic edges, and by the end of March were more than two-thirds healed. About this time, however, new symptoms arose to damp our expectations ; pain and tenderness oc- curred in both tibiae, which prevented him from walking, and deprived him of his rest at night, un- less he took a dose of Dover's powders. With De Velno, he was ordered to take daily a pint of strong decoction of sarsaparilla, and he went into the tepid bath every alternate day. About the middle of May, the ulcer of the scro- tum had cicatrized, but a small portion of that on his forehead still remained, without showing any disposition to heal. He continued to take De Velno and the decoction of sarsaparilla, until the middle of June, during which time numerous spots of a pustular character appeared on his face, and a few on his body ; but instead of degenerating into ulcers, they desquamated into broad scaly patches of a copper colour, very different, however, in cha- racter, and appearance, from the syphilitic lepra. Great pains and tenderness of the tibiae continued to disturb him, attended with puffiness of some parts, as if the periosteum was diseased. The knees, also, became so tender and painful that he could not stand. The ulcer on his forehead had contracted to the size of a sixpenny piece, and ex- hibited a smooth red fungous surface. June 21st. — He wns attacked with severe pain in the ri2;ht testicle, and the right iliac region, which PHAGEDENIC VENEREAL DISEASE. 235 yielded to a dose of castor oil, warm fomentations, and six leeches applied to the testicle. The aspect now assumed by the eruption, accurately corre- sponded with those appearances, which I had fre- quently known to give way before the influence of mercury. I therefore determined upon a cautious trial of blue pill ; but unfortunately it disagreed with his bowels, and was therefore laid aside for the pre- sent, as was also De Velno, which seemed not to produce any good effects during the last month. On the 5th of July, I saw him in consultation with two professional gentlemen, who had not be- fore been consulted. After considering the many embarrassing circumstances of this intricate case, the result of the consultation was, that he should again have recourse to De Velno, and to continue the Iceland moss, and ass's milk, which he had been previously ordered, but that as soon as his strength had improved, that a cautious trial of mercury should again be made.^ He continued on this plan, neither getting better nor worse, till early in the following August, when I conceived that the mer- curial process determined upon by the last consul- tation, might with propriety be commenced. At this juncture I received a letter from my patient, informing me that he had placed himself under the care of another professional man, the second who was consulted on his case. From this gentleman * One of these gentlemen, a surgeon of long experience and extensive practice, observed on this occasion, that in his day, practitioners had but little perplexity with such cases, for that they persevered in the use of mercury whatever were its effects, till it solved every difficulty by curing or killing the patient. 236 PHAGEDENIC VENEREAL DISEASE. I afterwards learned that the symptoms yielded gradually, and without any farther embarrassment, to a course of mercurial friction. The premature use of mercury was the cause of all the distressing and embarrassing circumstances which attended this case. If antimony and sarsa- parilla had been persevered in with steadiness, un- der confinement, the patient would probably have recovered in the course of eight or ten weeks, and with but little suffering, compared to that which he underwent after the fever had been superseded, and the eruption checked by the use of mercury. The only period that this medicine ought to have been employed, was when the eruption had become scaly. But although mercury was unwisely exhi- bited too soon in the present instance, yet whenever it was found to disagree, it was discontinued for a time. This moderation, w^e shall find, was not ob- served in the following case of a similar description, and the result was of a much more lamentable cha- racter. Case 30.— On the 5th of April, 18 17, 1 was called upon to meet tuo practitioners in consultation, one of whom, the attendant in the present instance, was the surgeon who brought the case I have just de- tailed to so favourable a termination. The subject of our consultation was Mr. S., a gentleman about 3v0 years of age, who was affected •at the time with both primary and secondary symp- toms. The former Were decidedly phagedenic. The latter exhibited spots covered with thick conical crusts, like the limpet shell in figure, scattered over PHAGEDENIC VKNEREAL DISEASE. 237 his face, back, and sides, and these larger crusts were intermingled with pustules and smaller scab- by spots. I learned that about five months previous to my visit, the disease commenced on the prepuce. — Mer- cury had been resorted to, and the ulcer extended under its use until the entire prepuce was destroyed. It being found that the disease was not to be sub- dued by that medicine, I understood it had been laid aside for decoction of sarsaparilla, and the ulcer was induced to heal under the application of butter of antimony and lunar caustic. — Some short time afterwards, the ulcer had again broken out, and was followed by the constitutional symptoms I have described. The patient was again put upon a course of mercury; and at first under its use, the sj^mptoms seemed to amend ; but as soon as the system be- came fully impregnated with that medicine, new symptoms appeared, and the old ones became worse. A third mercurial process was tried with precisely the same result At the period of the consultation, that medicine had been just discontinued, and the patient was taking decoction of sarsaparilla with Fowler's solution of arsenic, which I was informed had in a very short time produced a favourable change. Under these circumstances, I advised a continuance of the plan he was upon, and in the strongest manner stated my objections to the far- ther use of mercury, from my experience of its in- jurious effects upon every case I had met, which exhibited the same character of primary or consti- tutional symptoms. 238 PHAGEDENIC VENEREAL DISEASE. I never afterwards saw the patient, but I learned that mercury had again been essayed, and course after course persevered in, till the patient was re- duced to the lowest ebb, without deriving any far- ther benefit from these repeated attempts than a removal of the disease from the skin to the bones. He was then sent to Lisbon, as a last resource, where he soon ended his days ; and thus unhappily perished a most promising young member of the Irish bar, eliually remarkable for the extent of his attainments, the quickness of his intellect, and the brilliancy of his wit These cases sufficiently evince the virulence and obstinacy of that species of venereal disease which is attended by a pustular eruption, terminating in ulcers covered by conical crusts; and decidedly prove the impropriety of the present practice of interrupting the natural progress of the complaint? by the exhibition of mercury, before the cessation of the eruptive fever, or the manifest decline of the disease. This declension may be clearly inferred, when any of the constitutional ulcers have healed, or when any new spots or pustules which occur, have terminated in desquamation, or extended into scabby blotches, instead of assuming or preserving the form of ulcers covered with thick conical crusts. Cases exemplifying the ejicacy of the plan of treat- ment recommended for the constitutional symptoms of the phagedenic disease^ many of which exhibited at the same time the primary symptoms. Case 31. — Michael Malone, admitted August 5th, PHAGEDENIC VENEREAL DISEASE. 239 1812, on account of an extensive phagedenic ulcer, irregular and irritable, engaging the whole upper surface of the glans penis, one half of which was at least destroyed by its ravages. The surrounding prepuce was of a bluish colour, as if ready to fall into a sloughing state. He complained of severe pain in the part, particularly at night, which pre- vented him from resting. On examining his throat, I found superficial ulceration on the back part of the pharynx. There was no other appearance of secondary symptoms. He stated, that he had been admitted into the Lock Hospital the preceding Jamiary, where he had remained eleven weeks, during which period, he rubbed in seven ounces of ointment, which sali- vated him severely ; that under its use the original sore healed, but immediately another broke out, and a succession occurred, till at length he was dis- charged, labouring under the present ulcer, for the benefit of country air; that during his absence he also used mercury, which at first had been of ser- vice, but that the ulcer again became worse, as soon as salivation commenced. I desired him to keep a poultice of bread and water to the penis, and to take pills containing five grains of extract of cicuta three times a day, which on the 10th were increased to ten grains. He was also directed to take decoction of sarsaparilla. 17th. — The pain was considerably lessened, and the entire ulcer was improved ; and on the 27th, it was completely healed, and he was discharged the hospital. He returned to it, however, on the 29th 240 PHAGEDENIC VENEREAL DISEASE. of November following, with a painful and oede- matoiis swellins; on the lower part of the leg, ex- tending over the tibia, which either seemed to be slightly enlarged, or the periosteum affected. This complaint came on six weeks before his present admission. He also complained of pain in his right hip and elbow; his tongue was foul, and appetite bad. I therefore ordered him a smart opening medicine, and after its operation, to take antimonial solution, and decoction of sarsaparilla. He was also directed to keep cloths moistened in saturnine lotion to the tumour on his leg. Dec. 10th. — He was ordered fifteen grains of the compound powder of ipecacuanha, night and morn- ing, and to continue the decoction. Under this plan, in the course of a week, the tumour of his leg was considerably reduced; his throat became well, his appetite improved, and on the 28th, he was dis- charged the hospital, perfectly well. Case 32. — Peter Murphy was admitted July 13th, 1313, on account of a deep foul ulcer, covered with white viscid matter, which engaged the back of the pharynx, as far as it could be seen. He stated, that he had been in the hospital two years before, for pains in his breast, head, and shoulders, and an ul- cer on his right arm, the cicatrix of which, on ex- amination, I found to be as large as the palm of the hand — that he was severely salivated during three months which he had remained in the hospital, and was discharged apparently well — that the disease some time afterwards appeared in his throat, for which, he was again taken into the hospital, a year PHAGEDENIC VENEREAL DISEASE. 241 after he had left it — that he remained in it five weeks, during which period, he was again salivated severely, and discharged the hospital a second time, apparently well ; and that two months after he left it, his throat became again ulcerated. The inadequacy of mercury to remove the dis- ease, as was apparent from the former trials he had made of that medicine, induced me to order him antimonial solution and decoction of sarsaparilla. 19th. — The appearance of the ulcer was unalter- ed ; he stated, however, that it was less painful. 26th.— The ulcer was very much improved, and was healing round the edges. August 3d.-^The ulcer was nearly healed, and on the 9th, he was discharged the hospital well, and has not since returned. Case 33. — James Carroll, admitted April 27th, 1815: — ^An extensive ulcer of the glans surrounded the orifice of the urethra. Ulcerated bubo in the right groin. He stated that he was four months disordered, during the entire of which period he had been using mercury, which kept his mouth con- tinually sore. Solut. Antim. — Catapl. — During the first week in May, several spots covered with crusts had appeared on his back, shoulders, and forehead. The ulcer on the penis had become more irritable, on which account the antimonial solution was dis- continued for five grains of extract of cicuta thrice a day. May 18th. — A small white excavated ulcer had appeared on his left tonsil. The primary as well as constitutional ulcers re- 2 H 242 PHAGEDEXIC VENEREAL DISEASE. mained obstinate for a considerable time — that on his forehead extended to the size of a shilling, and was particularly foul ; but under the exhibition of tlie sarsaparilla and antimonial solution, which lat- ter medicine was ordered again on the 5th of June, they were healed before the 26th of the same month, when he was discharged the hospital. He was, however, re-admitted on the 23d of July, on account of pains in different joints. For these he was ordered the pills of antimonial powder and calomel, under which he soon became well and was discharged again on the ^th of August. Case 34. — Michael Bannister, admitted June 20, 1815: An extensive ulcer of phagedenic character engaged the corona, superior surface of the glans, and what remained of the prepuce. The glans ap- peared to have passed through a large ulcerated opening i-n the prepuce ; the remnant formed a tu- mour which lay at the frenal side of the glans. The whole penis was inflamed; high symptomatic fever — pulse 120 — ^his mouth was affected with mercury. He stated that he was six months disordered, that he lay part of the time in the infirmary of Liver- pool, where he underwent a course of mercurial frictions during five or six weeks; but the ulcer not healing, he left the hospital and came to Dub- lin; that after his arrival in this city he again com- menced the use of mercury, which he had been ta- king three weeks immediately previous to his ad- mission. Mitt. Sanguis ad 3xvi. — Solut. Antim. — Fotus. — CatapL 22nd. — Repet vensesectio ut antea. PHAGEDENIC VENEREAL DISEASE. 243 26th. — Pain excessive; the ulcer had made so great progress that the glans appeared as if it was about to separate from the body of the penis. Pulse 120. His mouth was still affected by mercury. Mitt. Sanguis ad §xvi. July 3d. Pain and irritation severe, no rest. He was directed to take every sixth hour a pill con- taining four grains of the extract of cicuta, with one of opium, and sixteen ounces of blood were taken from his arm. After this, the pain was considerably reduced, and the ulcer assumed a less irritable appearance. The irritation, however, was still considerable, and appeared to me to be excited by that portion of the prepuce which I have already described as forming a useless mass behind the glans. This tumour I removed on the 28th of July with the knife, and all irritation afterwards ceased. The amendment was now decided and progressive, and the glans, which appeared in so dangerous a state, was preserved, but the ulcer had burrowed under the skin of the penis to a considerable extent. On the 1st of September he was affected with several tubercles on his legs and thighs, similar to those delineated in Plate I. fig. 4, 5, 6. These af- terwards spread into deep foul ulcers with over- hanging edges. When the tubercles appeared, he was put on the use of nitrous acid, in which he persevered until the latter end of October, when all the ulcers hav-- ing perfectly healed, he was discharged the hos- pital. 9||| PHAGEDENIC VENEREAL DISEASE. Case 35. — John Molloy, admitted December 7th, 1815, with phymosis. Ulcers of phagedenic ap- pearance on the prepuce and surrounding its orifice — pain and swelling of the left knee. He had been disordered three months, and stated that he had not used mercury. Solut. Antim. — Fotus. — CatapL Jan. 20th. — Ulcers' improved; but he complain- ed of pains in his different joints. Lot. Hydrarg. Nigra. February 18th. — The ulcers healed. Pains less- ened. March 3d. Discharged well. Case 36. — John Haydon admitted March 20th, 1816, with an extensive phagedenic ulcer on the external surface of the prepuce. There was also on the abdomen a constitutional ulcer somewhat larger than a dollar ; it exhibited an irregular pha- gedenic margin, but showed a disposition to heal at the centre. He stated that he was five months dis- ordered, and that he had been severely salivated by pills which he took for six weeks. Solut. Antim. — Decoct. Sarsap. — Fotus. — Catapl. April 15th. — The ulcer of the penis continued much in the same state, extremely painful and oc- casionally sloughy. He was ordered a pill every eighth hour containing three grains of extract of cicuta and half a grain of opium. 23d. — The ulcer of the penis considerably im- proved, that on the abdomen healing rapidly from the centre. May 13th. — The ulcer on the penis healing, that on the abdomen had healed. Decoct. Sarsap. PHAGEDENIC VENEREAL DISEASE. 245 June 7th. Discharged well. Case 37. — Hannah Clarke, admitted May 24th, 1815: — an eruption of ulcers covered with crusts, some flat and others conical, on every part of her body. The largest of these spots was situated on her upper lip, which was nearly covered by a crust similar to that in plate IV. There were also two small aphthous ulcers on the velum. The only circumstance which could be learned from the confused account which she gave of her complaints was, that she was affected with severe pains in her joints, which left her oh the appearance of the eruption. She was ordered a strong decoction of guaiacum wood with twenty drops of antimonial wine three times a day ; under this plan she continued with little variation as long as she remained in the hos- pital. For some time he^ debility was extreme^ a circumstance remarked in all the other cases. At length gradual slow amendment was observable by the falling off of the crusts, which left the parts un- derneath them perfectly cicatrized. She was free from all complaints on the 18th of July, but was allowed to remain in the hospital un- til the 21st of August, pajrtly on account of her ema- ciation and debility, and partly because I was desi- rous to ascertain whether any other symptoms of the disease would occur. Case 38. — Laurence Reynolds, admitted 24th Deceml^er, 1815, with large ulcers covered with thick crusts, situated on his trunk, legs and thighs. Three or four of those were without crusts, but "246 PHAGEDENIC VENEREAL DISEASE. with a phagedenic edge. An ulcer extended along the tarsus of the right eye-lid, which was consider- ably swollen. A large node was situated on the low- er end of the left tibia, and he complained of severe pain in his head. He stated that the primary ulcer on the penis, which occasioned these complaints, occurred so long back as four years before his admission, and was healed under the exhibition of corrosive subli- mate : — that an interval of two years took place be- fore any constitutional symptoms appeared, which were similar to those he then laboured under, and for which he was admitted into the Richmond Hos- pital, where he underwent a full course of mercury, of nine weeks' duration, which removed all his com- plaints, but that they began to appear again in less than a month after he was discharged; that he was again admitted in the preceding February into the same hospital, where he was kept under the influ- ence of mercury during fourteen weeks, which, a third time apparently cured his complaints, but that in a very short time they re-appeared in the extent and form already described, when he applied to me. I directed for him the compound decoction of sarsaparilla, and the following pills : R. Gum. Resin. Guaiaci ^i.ss. Pulv. Antim. jss. Ft. Pilul. xxiv. Capt. Un. 4a. qq hora. Repeated blisters were also applied to the node on the tibia, and the discharge from the part pro- moted bv savin ointment PHAGEDENIC VENEREAL DISEASE. 247 There was not the slightest variation made in this plan, as long as he remained in the hospital. His amendment proceeded in a gradual and unin- terrupted manner, except that a second node ap- peared on the ulna, to which blisters were also ap- plied. The crusts did not fall from some of the spots until the ulcers were healed, while those that were exposed to view healed in the manner I have so often mentioned, from the centre. On the 15th of February, 1816, he was discharged the hospital well. Case 39. — In January 1818, 1 was called upon to see an elderly gentleman on account of an extensive phagedenic ulcer which had committed sad ravages on his glans and prepuce. — They presented an irre^ gular surface either indented with existing ulcera- tion, or the cicatrices of that which had lately heal- ed. His urine passed through an ulcerated opening in the urethra, all the under part of the glans includ- ing the urethra being destroyed by the ulcer, which was still gaining ground. He had frequent desire to pass water, at least every half hour, probably in consequence of the irritation of the extremity of the urethra. There were two or three ulcers covered with crusts on his back and shoulders. He was greatly emaciated, although naturally robust, and was under the influ- ence of mercury:— -pulse 112, great thirst, and gene- ral symptomatic fever. He had been six months disordered. During the entire of this period he was using mercury both in the form of pill and ointment, under the direction 24$ PHAGEDENIC VENEREAL DISEASE. of an apothecary, so extensively as to keep up a con- stant mercurial irritation in the system. His medical guide at length finding himself completely bewil- dered under the evident failure of his specific, though administered neither sparingly nor remissly, told the patient to desist from its farther use, that the virus was totally eradicated, and that nothing more was requisite to his perfect recovery but wine and nour- ishing diet. This unfortunate and worn-out gentleman, accord- ingl}^ began to take a bottle of wine daily, and as much animal food as he could swallow, which it may readily be supposed was not much; but he found his fever and debility, and every complaint that he was assured was eradicated, increasing under this strengthening regimen, till at length he con- ceived it prudent, late as it was, to seek for advice. It was on this occasion that I was consulted. I directed him in the first instance to remove from about him every thing tainted with mercury; to get into a tepid bath, to take some opening medicine, a frequent saline draught, and an anodyne at night. The latter was necessary on account of the fre- quency of passing water, and the general irritabili- ty of his frame. — Under this plan, in a few days, one great source of his distress, the frequency of passing water, was removed. His thirst and general fever were, however, very considerable, and the ulcer, though slowly, continued to gain ground. I directed for him the decoction of sarsaparilla with fifteen drops of Antimonial wine three times a day. On the 28th of January, I removed with the knife PHAGEDENIC VENEREAL DISEASE. 249 several projecting portioDs of the edges of the ul- cer, which were jagged, and shewed by their livid colour a tendency to slough or ulcerate. The bleed- ing from the part was then encouraged with warm water. He found it of the greatest advantage, for the pain of the ulcer was that night considerably abated, and the ulcer afterwards gradually improv- ed in appearance. Early in February he was at- tacked with severe pain and swelling of the knee joint, which increased on the slightest motion. This symptom (one of the most formidable when encoun- tered with mercury) gave way to the application of leeches, twenty of which were applied on two suc- cessive days. The knee was also frequently fo- mented with hot water; and poultices of moistened bread, in the intervals of stuping, were kept to the part. On the 20th Feb. he was so much recoverd from this, as well as all his other symptoms, that he was able to walk about his room without pain or inconvenience. The antimonial wine was discon- tinued for a drachm of powdered sarsaparilla, thrice a-day. March 1st. — All the ulcers had healed, and his appearance, strength, and appetite greatly improv- ed. From this period he went abroad daily, and soon regained his former robust health and appear- ance. However he was not yet exempt from dis- ease, for on the 25th of April, he called to show me an ulcer, of foul appearance, about the size of a six- pence, which had appeared on his chin. I directed him again to recur to the powder and decoction of sarsaparilla. This, however, he neglected to do, 2i 25b PHAGEDENIC VENEREAL DISEASE. thinking that the ulcer would spontaneously heal ; but he again applied to me on the 9th of May, at which time it had extended to the size of a shilling, was deep and foul, and the entire jaw swelled and inflamed. I directed him to poultice it with bread and water, and renewed my injunctions as to the sar- saparilla. On the 1st of June the ulcer was perfect- ly healed, and he has since had no return of his complaints. Case 40. — John Murray, admitted June 1st, 1818, with a phagedenic ulcer of the glans and internal surface of the prepuce, the entire margin of which had been destroyed by the ulceration. The penis was greatly inflamed and swollen ; he complained of the most severe pain, which was sufficiently indi- cated by the extent of the symptomatic fever under which he laboured. Five weeks previous to his admission the ulcer commenced on the corona, for which he had taken about twenty mercurial pills, which had not afl*ected his mouth. He was order- ed the antimonial solution in nauseating doses ; the bread and water poultice was applied to the penis, and sixteen ounces of blood were immediately ta- ken from his arm. This depletion was repeated on the 2d, 5th, 7th, and 12th of the same month. The blood was buffy on these several occasions, and each venaesection was succeeded by an alleviation of pain, and diminution of symptomatic fever : but every recurrence of acute pain, according to my views, indicated the necessity of using the lancet. Under these active measures the pain and inflam- mation were at length reduced, and the ulcer be- PHAGEDENIC VENEREAL DISEASE. 251 gan to put on a more favourable appearance ; but he, at the same time, began to complain of difficulty of swallowing, and a deep excavated ulcer discov- ered itself upon each tonsil. On the 15th, I directed decoction of sarsaparilla, and the black mercurial wash to the ulcer. On the 22d, he took the powder of sarsaparilla with the decoction, in place of the antimonial solu- tion. Under this plan the ulcers of his throat were perfectly healed on the 7th of July, and the ulcer of the penis exhibited the appearance of a mild, healing, granulating sore, which healed before the 20th of July. Case 41. — J. Buckley, admitted January 13th, 1822, on account of phymosis and violent inflam- mation of the entire penis, profuse discharge from under the prepuce, pulse rapid, with thirst and rest- lessness. He had also four or five pustular spots on his left arm. Mitt, sanguis ad. ixx. — Solut. Antim. — Catapl. He was directed to inject warm water frequently between the prepuce and glans. 14th. — The vensesection was repeated. 15th. — The inflammation of the penis was less- ened, but an ulcer was discovered on the left ton- sil, and the spots on the arm were becoming crusted. Decoct. Sarsap. cum Acido Nitrico. 18th. — The inflammation was so far reduced as to admit of the retraction of the prepuce, when an ulcer of the phagedenic character was discovered on the glans. Pustular spots had appeared on his head, face, and thighs ; the crusts of those on his 252 PHAGEDENIC VENEREAL DISEASE. arm had assumed the conical limpet-shell appear- ance. Decoct. Sarsap. cum Acido Nitrico, ut antea. Pulv. Ipecac. Comp. gr. xv. o. n. Feb. 12th. — The ulcer of the penis had healed, leaving a deep indented cicatrix ; several of the co- nical crusts had fallen off, disclosing the surface un- derneath healed, but red. The ulcer of the throat had been healed for some days. April 1st. — Discharged well. We had ceased to take notes in the hospital in consecjuence of there being so little necessity to vary the treatment; that which I have detailed suc- ceeding in every instance. However, during the winter of 1823-4, while I was employed in giving clinical lectures to the hospital class, the two fol- lowing cases of phagedenic disease were admitted ; and as they excited considerable interest among the pupils, many of whom, educated by masters of the old school, insisted that the cases never could re- cover without the aid of mercur}, I had them noted by Mr. Belton, my resident pupil in the hospital, now a licentiate of the College of Surgeons, and the notes were read on lecture-days while the patients were under the scrutinizing eyes of the mercurial- ists as well as the non-mercurialists of the class. The following is the statement of these cases ta- ken from the case-book, but somewhat abbreviated. Case 42. — Edward Brennan, aged 25, admitted the 20th of November, 1823, on account of the fol- lowing symptoms. An extensive phagedenic ul- cer with irregular edges, and partly covered with PHAGEDENIC VENEREAL DISEASE. 253- sloughs, engaged the right side of the glans, and ex- tending underneath half round the penis, had made an opening into the urethra, through which all his urine passed. The orifice of the urethra was en- gaged in this extensive ulcer. There was also a pain- ful ulcerated bubo in his right groin. There were numerous spots covered with thick crusts, situated on his arms, thighs, and scalp, and also a foul and extensive ulcer covered with white slimy matter, engaging one-half of the lower lip, which, from the frequent motion of the part, excited much pain and uneasiness. He looked pale, worn out and ema- ciated, and stated that eight months previous to his admission, a small ulcer had appeared on the glans, which was followed by a bubo in each groin which suppurated, that he put himself under the care of some person (God knows whom !) that recommend- ed him to take mercurial pills, w^hich he continued to take off and on for six months, omitting them whenever he became salivated. The ulcer never healed during this long period, but at length feeling himself getting daily weaker, and affected at night by profuse perspirations and pains of his limbs, he was induced to apply for admission into the Rich- mond Hospital. I ordered for him decoction of sarsaparilla and a pill containing three grains of the powdered leaves of cicuta, thrice a day ; the ulcer of the penis was dressed morning and evening with lint dipped in equal parts of balsam copaivse and olive oil, with the view of promoting the separation of the sloughs, which covered the greater part of its surface. The 254 PHAGEDENIC VENEREAL DISEASE. ulcer of the lip, which was exceedingly irritable, was covered with a poultice of bread and water. % November 27th. — The ulcer of the penis was ex- tending, and had become more painful ; that of the lip stationary. The pills of cicuta were repeated with the addition of a grain and a half of the watery extract of opium to each pill. In other respects he was desired to go on as before. 30th. — The appearance of the ulcer more favour- able — pain abated. Dec. 6th. — The ulcers of the penis and lip much improved, the former only painful when irritated by the passage of urine. Pulv. Ipecac. Comp. gr. xii. o. n. — Decoct. Sar- sap. — Omitt Pilulse ex Cicuta et Opio. 18th. — The ulcer of the lip healed — that of the penis looking healthy was dressed with simple ointment — the crusts were gradually falling off from the spots on his skin, leaving red marks, and his general appearance had improved. He was however detained in the hospital until his general health was restored, and was discharged well on the 15th of January following. Case 43. — Thomas 3Iaher, aged 26, admitted 20th January, 1824, on account of a small irritable ulcer, covered with white adhesive matter, situated at the orifice of the urethra — an ulcerated bubo on the right groin — a deep excavated ulcer on each tonsil — another, half-covered with a thick crust, on the skin of the left eye-lid and superciliary arch, and a large foul ulcer nearly the size of the palm of the hand, with a phagedenic margin, was situated PHAGEDENIC VENEREAL DISEASE. 255 on the side of each of his legs. He exhibited a pale squalid countenance and an emaciated frame. Three months before his admission he had per- ceived the ulcer on the penis ; for this he took mer- cury extensively, and while under its influence the other symptoms detailed made their appearance. He was now ordered decoction of sarsaparilla, ten grains of Dover's powder at night, and the fre- quent use of fumigations of the sulphuret of mercu- ry to the ulcers of his throat. Those of his legs were poulticed. 23d. — The ulcers were extending ; he was order- ed, in addition to his other medicines, five grains of the Ext. of Cicuta every sixth hour. Feb. 10th. The ulcers were granulating and look- ing healthy, and on the first of April he was dis- charged the hospital well. The following case is given for the purpose of ex- emplifying the usual fatal termination of venereal ulceration of the larynx. Case 44. — Terence Clarke was admitted July 31st, 1815, into the Richmond Hospital. The en- tire pharynx, as far as could be seen, was engaged in an extensive ulceration, which had destroyed the uvula and a great portion of the velum. If the fol- lowing account, which he gave of his complaints be credited, the warmest advocates for mercury must allow that the remedy had at least an ample trial. He stated that four years previous to his applica- tion to me, he had a large ulcer on the prepuce, •256 PHAGEDENIC VENEKEAL DISEASE. which healed with difficulty under a full course of mercury of two months duration ; that eight months afterwards, his throat became affected, and nodes, which ulcerated, appeared on his shins; that for these complaints he was admitted into the Lock Hospital in the winter of 1813, where he remained twent3'-one weeks, and underwent two protracted and sev ere courses of mercury, but without any de- cided results, as his throat was ulcerated at the time he was discharged. That after he left the hospital his throat at first improved, but a few months afterwards becoming as bad as before, he was re-admitted into the same hospital. On this occasion he fell under the care of different surgeons, who put him under a course of mercury again; but which rendering his com- plaints worse, was very properly discontinued, and sarsaparilla directed, under the use of which the ul- cer healed, and he was discharged a second time, after remaining in the hospital fourteen weeks ; that scarcely two months after his discharge his throat again became ulcerated, he was admitted a third time into the same hospital, under the care of a third surgeon, who probably not regarding the for- mer failures of the specific^ doomed him to undergo another severe course of fourteen weeks duration, which a naturally robust constitution enabled him to endure, and that he was discharged the hospital in July, 1814, the ulcer of his throat remaining nearly in the same state as at his admission ; finally, he stated that the ulcer afterwards spontaneously healed, and that it occasionally ulcerated and heal- PHAGEDENIC VENEREAL DISEASE. 257 ed of itself, but becoming more obstinate, he was induced again to seek admission into a hospital under my care. At this time his swallowing was extremely diffi- cult. I judge that the ulcer extended a consider- able way down the oesophagus, as he complained of severe pain extending from the lar3mx as far as the sternum. He could only swallow liquids, and the greater part of these regurgitated into the nares. Although in similar cases, I had immediately check- ed the progress of the ulcer by mercurial fumiga- tions, and the internal use of that medicine, yet its failure in the many trials to which this patient had been subjected, induced me to recur to other mea- sures. As I had sjeen similar ulcers which resisted mercury, give way to nitrous acid, I determined to tr}^ that medicine, diluted to such a degree as would enable him to swallow it. I also directed that the ulcer should .be touched thrice or four times daily with the oxymel seruginis, and that a seton should be inserted in his neck. Under this plan amend- ment immediately followed, and this extensive ul- cer as far as it could be seen, was healed before the 9th of September ; but his voice had assumed that whispering sound which denotes an affection of the larynx, and the bones of his nose had evidently be- come affected, for there was an offensive discharge through the nares, along with which several small pieces of bone had come away. Under these cir- cumstances I deemed it warrantable to make a trial of the internal exhibition of the muriate of mercury conjoined with sarsaparilla, but it was not produc- 2k 258 PHAGEDENIC VENEREAL DISEASE. tive of any beneficial change ; it was therefore, after a trial of three weeks, discontinued for a pill con- taining half a grain of calomel with five grains of extract of cicuta thrice a day. But this was as un- availing as the former, for the discharge from his nose became more offensive, and more bony exfo- liations came away. His breathing became quick and evidently impeded ; he complained of pain in the larynx, expectorated a great quantity of slimy matter — had a teasing incessant cough — his coun- tenance betrayed great anxiety, and his pulse was from 110 to 120 — at the same time also his throat again began to shew signs of ulceration, and two scabby spots appeared, one on the left ala nasi, and the other on the chin. Under these circumstances, about the middle of October I discontinued the mercury, and put him on the compound decoction of sarsaparilla. Counter-irritation by means of blis- ters was kept up for some time on the exterior la- rynx, which he always pointed out as the chief seat of his distress, and irritation was lessened by opiates. If the larynx had not been affected, in all proba- bility he would have recovered under the use of sarsaparilla ; for the foul discharge and exfoliation from the nostrils ceased, the ulcer of his throat heal- ed, as did also the scabby ulcer under his nose and chin, the process beginning from the centre of each, a circumstance which marked the phagedenic na- ture of his disease. But while these favourable circumstances were going forward, cough, dyspnoea, increased expectoration, hectic fever, emaciation, and (Edema of the legs gradually set in, and evi- phaged?:nic venereal disease. 259 dently evinced that he was affected with incurable phthisis. He lingered, however, till the 15th of Sep- tember, 1816. I had not an opportunity of examining the body afterwards, but I have been present at the exami- nation of several cases precisely similar, in which the cartilages and other parts were extensively de- stroyed by the effects of ulceration. Cases exemplifying the plan of treatment recom- mended where the nares are affected. Case 45. — Peter Murtough, admitted June 7th, 1816. A large ulcer with undermined edges, was situated on the right tibia — foul discharge from the nares, and ulceration appeared on the vomer. He also complained of severe pain in one of his knees. He stated that a year before, he had an ulcer on the penis, the cicatrix of which, on examination, was found to be extensive. For this he underwent three courses of mercury, by each of which he was severely salivated. The ulcer on the leg appeared from its undermined edges, and burrowing disposi- tion, to resemble those which I had observed to arise from, the large species of tubercle, and which in most instances, yielded to the use of nitrous acid. I therefore directed that medicine in the present instance; under the exhibition of which his com- plaints steadil}^ and progressively amended, and he was discharged well on the 22d of July, 1816. Case 46.— John Martin, admitted May 6th, 1818 : Extensive ulceration of the fauces — the velum and 260 PHAGEDENIC VENEREAL DISEASE. uvula were already destroyed — the ulcer was creep- ing forwards on the palate, and both tonsils, as well as the posterior pharynx as far as could be seen, were in an ulcerated state. The cartilage of his nose was sunk inwards — his voice was nasal — there was an offensive discharge from the nostrils, with occasional exfoliation of small pieces of bone, and he had profuse ptyalism, probably owing to the ir- ritation of the ulcer of his throat. The pupils of the hospital who accompanied me through the wards, on the day of this man's admission, will re- collect (as the case was of recent occurrence)* that on examining his throat, I stated my belief that the disease originated from a primary phagedenic ulcer, and that such an opinion would be strengthened, if we found an extensive cicatrix on the penis, or con- siderable loss of its substance. On examination, we found that the entire penis had been destroyed, and the history of the case strongly confirmed the opinion I had given of the nature of his disease. When we have any doubts on this subject, an atr tention to the cicatrix of the primary ulcer will as- sist our diagnosis ; for true chancre, and the other species of primary ulcers, except ivhere injiarmna' Hon and gangrene have bee?i excited, seldom cause any very extensive cicatrix, and the loss of sub- stance, if any, is inconsiderable. The history he gave of his complaints is briefly as follows. Nineteen months previous to this period, he had * This case is re-published verbatim from my work on the Symptoms and Specific Distinctions of Venereal Diseases, pub- lished in 1818= PHAGEDENIC VENEREAL DISEASE. 261 an ulcer on the prepuce, for which he was admitted into Stephens's hospital, where he was put on a course of mercurial friction, but as soon as he be- came salivated, the ulcer began to spread. That medicine was therefore discontinued for a time, but as soon as his mouth was well, it was again renew- ed, and he was put through a smart mercurial course, during which the ulcer gradually gained ground, until it destroyed the entire penis, and then its ravages ceased, and it began to heal. When the mercury was laid aside, he was successively order- ed sarsaparilla, cicuta, and nitrous acid. About the beginning of the present year (1818) the ulcer of his throat appeared. He was altogether eighteen months in the hospital alluded to, and left it with the view of going to the country, three weeks be- fore his admission into the Richmond hospital. 1 ordered for him the antimonial solution, con- joined with the decoction of sarsaparilla, thrice a day, and directed that the entire ulcer should be touched morning and evening with the oxymel seruginis. On the 11th, the ptyalism had ceased, and his swallowing was improved. The antimonial solu- tion was discontinued for a drachm of powdered sarsaparilla thrice a day. 19th. There was a per- ceptible amendment in the ulcer, and on the 29th, it was rapidly healing. June 8th. — The entire ulcer was healed, except two or three spots the size of a pea, which was co- vered with yellow adhesive matter ; these spots were touched frequently with a solution of nitrate 262 PHAGEDENIC VENEREAL DISEASE. of silver, in the proportion of three grains to an ounce. The oxymel jeruginis was discontinued. 22d. — Only one ulcerated spot the size of a pea remained : the offensive dischar2;e from the nose had totally ceased. 26th. — His throat was completely well, and hav- ing no complaints, he was anxious to leave the hos- pital, but by my desire he remained another week, and was discharged on the 2d of July. Case 47. — Thomas Farrell, admitted 31arch 10th, 1814, was affected with soreness and enlargement of the ossa nasi, a ])urulent discharge from the nos- trils, and a separation and sinking of the cartilage of the nose. An extensive granulating: sore with rais- ed edges, and surrounded by discoloured integu- ments, was situated on his right arm; and on the lower part of the left tibia there was a large node. He complained of pains in his head, knees, and shoulders, and difficulty of swallowing. On exami- nation, I found the phan;-nx raw and inflamed, but there was not any appearance of ulceration. He stated that he was near two years disorder- ed -. the first symptom was an ulcer on the prepuce, which healed under the internal use of the muriate of mercuf}'. The next symptoms that occurred were ulcers under his knee, and an eruption on his body, which disappeared also under the use of mer- curv, but asrain recurred. The node and affection of his nose appeared three months before his ad- mission, and from the commencement of the disease, he was constantlv usins; mercurv under the direc- tion of different surgeons ; almost every one of whom subjected him to mercurial frictions. PHAGEDENIC VENEREAL DISEASE. 263 I directed him to take fifteen grains of the com- pound powder of ipecacuanha, morning and even- ing, and the decoction of sarsaparilla ; but on the 34th, none of his symptoms being relieved, I order- ed him to discontinue the powders, and to take the solution of muriate of mercury with the decoction. 22d. — The pain of his head was alleviated ; that of his knees and shoulders completely removed; and he was in every respect better. He continued the same plan as long as he remained in the hospi- tal, from whence he was discharged well on the 1 1th of April. I have not among the preceding cases detailed any instance of the good effects of fumigating the nares with mercurial preparations, as recommend- ed for venereal ulcerations of this part, for it so happened, that there were not any cases noted in which this measure was employed. In almost every instance of the constitutional symptoms of the phagedenic disease detailed, mer- cury had been previously employed, and under every consideration of the circumstance, to an un- warrantable extent. The early use of this remedy as has been stated, not only rendered the disease more difficult of cure, but more liable to relapse after the patient had apparently recovered. So that a just estimate can scarcely be formed of the benefits of the plan of treatment recommended in the cases I have adduced. For so general is the employment of mercury in this, as well as in every other spe- cies of venereal complaint, that it is but seldom we 264 PHAGEDENIC TE>"EREL\L DISEASE. meet with an instance in which it has not been ex- hibited. If, however, we are fortunate enough to light upon a case in which the use of mercurv has not been adopted, we find the disease less compli- cated, less tedious, more uniform in its symptoms, and by far more easily cured. Affections of the bones of the nose I have found to o<:cur in several instances, while the primary symptoms, an ulcer of the phagedenic species, was still present, and I am inclined to believe that this common, but most dreaded effect of a venereal vi- rus, is the characteristic constitutional symptom of the ulcers under consideration. It was with no small decree of satisfaction that I perused 3Ir. Ferguson's •• Observations on the Ve- Bereal Disease in Portugal, as affecting the British soldiery and natives,"^ published in 1813; as I con- ceive his statement of the progress of the symp- toms, and the manner in which they were affected by mercury, together with the treatment found most applicable, strengthen the opinions I have of- fered on the nature of the phagedenic and slough- ing ulcers. "Tis true, he no where designates the primary venereal ulcers of Portugal by these terms ; Qor could it be expected that he should, as he evi- dently seems to be of the general opinion, that all venereal maladies spring from one common poison, the syphilitic. But I am inclined to believe, that the phagedenic and sloughing ulcers are far more general in Portugal than in these countries; and * See Medito-Chinirsical Transactions, Vol. IV. PHAGEDENIC VENERE.^L DISEASE. 265 that their constitutional symptoms were actually the subject of Mr. Ferguson's observations. I ground my opinion on the following reasons, chiefly deduced from his own paper. The frequent me- lancholy mutilations which occurred among our sol- diers, could only have arisen from the ravages of the phagedenic and sloughing ulcers ; and not from the slow progress of a true syphilitic chancre, which would not probably have been checked by the mer- cury, which at this period was, in every instance of venereal infection, recurred to by the surgeons of our army. Besides the name which the venereal disease in Portugal acquired among the British sol- diery, the Biack'Pox, reminds us of the most re- markable character of the sloughing ulcer. In the next place, the appearance of secondary symptoms, while the patient was strongly under the influence of mercury ; and lastly, the manner in which the disease was treated by the native practitioners; viz. by local applications, decoctions of the woods, and the exhibition of an insignificant quantity of mercury, when the disease attacked the bones. Mr. Ferguson, after stating a variety of interest- ing particulars of the venereal disease of Portugal, which one and all reminded me of the symptoms and progress of the phagedenic and sloughing ul- cers, comes to the following conclusion, which equally applies to those maladies as known in this country. - 1. " That the disease, in its primary state, is cu- rable in Portugal without mercury. 2. " That the antisyphilitic woods, combined with 2l 266 PHAGEDENIC VENEREAL DISEASE. sudorifics, are an adequate remedy for coDstitutioii' al symptoms; the quantity of mercury being al- wajs insignificant and often altogether omitted ; or^ 3. " That the virulence of the disease has become so much mitigated by reason of general and in- adequatel}' resisted diffusion, or other causes, that, after running a certain (commonly a mild) course, through the respective orders of parts, according to the known laws of its progress, it exhausts itself, and ceases spontaneouslj'." As to his last deduction, we have to regret, that the constant interruption to the progress of the dis- ease, by means of mercury, has, in these countries, prevented us from witnessing the gradual decline and exhaustion of the virus, as it seems is the case among the natives of Portugal : and there are strong grounds for believing, that the ravages which the venereal disease of that country committed on the British troops, arose not so much from the inflam- matory disposition manifested in the constitution of the inhabitants of colder climates, on their arrival in a warmer, as from the indiscreet exhibition of mer- cury : a medicine from which Mr. Ferguson informs us, the " native practitioners religiously abstain, considering it with horror, as one of the poisons which foreigners madly wield/' Among several instances which came under my observation of the mali2;nitv of the venereal disease of Portugal, and the inadequacy of mercury for its removal, the following was the most remarkable : Case 48.— On the 9th of April, 1814, 1 was consult- ed by a young oiSicer, who three years before had PHAGEDENIC VENEREAL DISEASE. 267 received a venereal complaint in Lisbon, which had produced the following catalogue of melancholy mutilations. The septum, alse, and cartilage of his nose had been destroyed by ulceration, leaving a wide extended opening into the nares. It had ceased to extend, and was nearly healed, but it still produced an offensive discharge. There was also an ulcer of the left leg, extending from the ham to the heel ; the upper part was granulating, the low- er foul and phagedenic : the calf of his leg had beeu entirely destroyed by the ulcer ; and his leg was contracted into a permanent semiflex position. He stated that the first symptom of his disorder was an ulcer, which, on examination, I found had destroyed the glans, and great part of the body of the penis. For this complaint, the surgeon of his regiment put him on a course of mercury, which he stated was of no service to his complaints; and that the ulcer extended rapidly, and by sloughs, under its influence ; — that in a few months afterwards an eruption of what he described as pustules, appear- ed on his back — the ulcer of his leg followed, hard bumps rose on his cranium, and the bones of his nose became affected — that the ulcer of the penis healed and the bumps on the cranium disappeared under the use of nitrous acid — that he afterwards came to England, where he remained near two years, and underwent several severe courses of mercury by inunction. In short, that from the com- mencement of his disease, to the period of his ap- plication to me, he was under the almost incessant action of that medicine. His 2;ums were all de- 268 PHAGEDENIC VENEREAL DISEASE. *stroyed by the rep' ated salivations he ha-d under- gone ; and he was at the time he applied to me un- der its influence. A stronger instance than this, of the inefficacy and injurious consequences of mercury cannot be adduced. I sent him to the countrv, where his fa- niily resided, with little else than directions respect- ing his diet ; to abstain from mercurv' ; and to take the compound decoction of sarsaparilla and antimo- iiials. Some time afterwards I heard that his health had considerably improved, but I never had the sa- tisfaction of ascertaining whether his recovery was completed. When my first edition appeared, so many daring and novel doctrines, contrary to the received opi- nions of the day, drew upon me, of course, the severest animadversions of my contemporaries. These I was prepared to meet in silence, until time should bring to the test the views I submitted to the public. A critic, however, appeared shortly af- ter the publication, in the Edinburgh Medical and Surgical Journal, for July, 1815, written with so much asperity and unfairness, that I felt myself called upon to relinquish my intended silence ; not so much with the view of replying to my Review- er's objections, which consisted chiefly of idle and dogmatical assertions, without proof or foundation, as to set the public right with respect to passages garbled or intentionally misunderstood and misre- presented. From the general tenor of the paper in question, I suspected the quarter from whence it came, and the object for which it was written. PI^AGEDENIC VENEREAL DISEASE. 269 These suspicions have been since fully confirmed ; and I am, probably, better acquainted than the Edi- tor of the Review himself, with the persons who were enojaged in the production of an article, which, to say the least of it, certainly did not add to the character of that most respectable Journal. From my own personal knowledge of the Editor, as well as the character he bears with the world, I am certain that he would never intentionally make his Journal the vehicle of a rancorous attack upon any individual, for the purpose of maintaining another in the elevated situation in which his opinions (at that time generally received with respect to vene- real complaints) had placed him, and which that other must have regarded as a despicable tissue of acrimony, delusion, and sycophancy. But I shall merely refer to my Reply, which appeared in the same Journal for October, 1815, and shall leave the critic without further notice, as an additional re- cord to the many which already exist, of the usual means to which interested and prejudiced indivi- duals resort to oppose the progress of truth. I shall occupy the time of my reader much better, by a consideration of the fair, manly, and scrutiniz- ing observations of Mr. Guthrie, who sees with the skilful eye of an experienced veteran, the weaker points of his opponent, and fairly grapples with the subject without changing its nature in order to in- sure an easy victory over an enemy of his own creation.'* In replying to Mr. Guthrie's objections, * Mr. Guthrie's " Observations, &c." have been republished in America; for which, see Eclectic Repertory, vol. viii. p. 321. 270 PHAGEDEMC VENEREAL DISEASE. I conceive that I answer all that has been urged of any weight against the opinions I espouse ; I can- not, however, enter into an examination of his re- marks, without first testifying my sense of the can- did, polite and creditable manner in which he has discussed the subject, the gratification I feel, that the particulars are so few in which we differ from each other, and my regret that there is a point, however unimportant, in which we are not agreed. But it is satisfactory to find that his objections do not lie against the practice I recommend, but almost exclusively against the doctrine of the plurality of venereal poisons, which I have been led by the strongest reasons to adopt. But convinced as I am, by a vast multiplicity of evidence, of the truth of this opinion, yet so little do I value it in comparison of the practical results to which it led me, that throughout my work, I advert- ed but little to this part of my subject, and confined myself altogether to points of practice, except so far as it was necessary to the explanation of my mode of discriminating the dangerous and malig- nant species of venereal diseases from the more mild and manageable. Indeed, my most strenuous endeavours, and I thought they could scarcely be mistaken, were directed to convince surgeons of the necessity of paying more attention than was cus- tomary, to the distinctive characters and appear- ances of both primary and constitutional symptoms in venereal complaints. I had satisfied myself that our diagnosis and mode of treatment ought to be regulated in a great mea- THAGEDENIC VENEREAL DISEASE. 271 sure by those very characters and appearances, no matter whether we consider them as arising from one poison, or from many, or whether they are ow- ing to peculiarities of constitution, or to those causes assigned by Mr. Guthrie, in his " Remarks," when he says, " I am, then, for the present, disposed to refrain from believing in a plurality of morbid poi- sons, each invariably producing a disease of one distinct character, or of one specific poison modified by the powers of the constitution, or of the part ; but rather to place reliance in the combined opinion of different morbid poisons {to use the common term) being generated^ in different people, and stages and states of the disease, wider circumstances which I no more understand than others do of the nature of the syphilitic poison itself'' Whether the views of this enlightened surgeon will serve to remove the obscurity with which this perplexing subject is enveloped, and better explain than any thing hitherto offered, the numerous symp- toms and appearances which venereal complaints display, I leave to the judgment of the reader, and shall altogether refrain from making any observa- tions upon them. But, in truth, the question will scarcely be allowed to be decided, until the institu- tion of an enlarged scale of experiments by inocu- lation ; which, as I have observed in my last Essay,* " it is not to be expected any man will be so public spirited as to submit to himself, or so unreasonable as to inflict upon others." The utility of experi- * " Observations on the Symptoms and Specific Distinctions of the Venereal Disease." 1818. •>7*> PHAGEDENIC VExXEREAL DISEASE, ments by inoculation has, since this observation was made, been sufficiently proved by those instituted by Mr. Evans, and referred to in my third chapter. My reasons for espousing the opinion of a pluralit}^ of venereal poisons are given at large in my first chapter, which it would be unpardonable here to repeat. In my publication I have detailed a number of cases of the primary phagedenic ulcer, which were all attended (two cases excepted) with a similar eruption ; viz. bj^ tubercles, or spots of a pustular tendency, which degenerated into obstinate ulcers. In the two exceptions alluded to, the eruption was papular; and I am inclined to conjecture that the primary ulcers from which it arose, were not origi- nally phagedenic, but became so through irritation or improper management. From various passages in Mr. Guthrie's remarks, 1 collect, that he is of opinion that there is no such ulcer as a primary venereal phagedena ; and that all ulcers of this description are originally mild, and become afterwards phagedenic, through causes with which we are at present unacquainted. But once they become phagedenic, he believes they affect the constitution in such a way as to produce the train of constitutional symptoms I have described as appertaining to the phagedenic venereal ulcer. I trust this is a faithful though concise account of his opinions, as it would render this paper too long to transcribe the passages from which I collect it. In support of his views and in opposition to mine, Mr. Guthrie, in the first place, assures us that he PHAGEDENIC VENEREAL DISEASJ;:. 2?3 has frequently seen those constitutional symptonii? which I had attributed to the phagedenic p^:"imary ulcer, succeeding primary ulcers which were prigi? nally of a mild nature, and which afterwards became phagedenic; and in the next he argues, that the slowness of the progress of the ulcer in many of the cases which I have detailed, sufficiently evinces that; they could not in their origin have been phagedenic. Against Mr. Guthrie's own experience I can havQ nothing to object, and the point niust remain at i$r sue between us, to be determil^ed by future ojjserr vations; but I cannot admit the accuracy of his views, when he describes the phag^d^nic ulcer as always necessarily rapid in its progress, for I can aver, (and I am confident that I am not singulfir in this respect,) that I have frequently witnessed the existence of this ulcer during four, six, or eight nionths, or even longer, creeping slowly from one part to another, alternately healing and ulcerating, and leaving deep furrows, yet without destroying^ as it mor^ usually does, the parts ij: attacks. Ano- malous, therefore, a§ it appears, we may readily conceive why the opera dancer at Lisbpn, ipentipiir ed by Dr. Ferguson, should infect many pf her par^? mours with a malignant disease, without being her^ self under the necessity of discontinuing the public practice of her professipn. " Ref)erring to my first edition," Mr. Guthrie obr serves, " we have a sketch of the progress of the phagedenic ulcer ; but we (Jo not find any descrip- tion of that ulcer from the commencement of ulcera- ted absorption, as we do of the slougjiing ulcer from 2 M 2v74 PHAGEDENIC VENEREAL DISEASE. the commencement of the sloughing process. Nei- ther is one given in the second book ; so that we are left in doubt whether his specific phagedena begins as such, or whether it assumes that charac- ter after a certain lapse of time. If the former be the fact, it adds strength to my objections to his cases ; if the latter, it is necessary we should be in- formed of the precise period required for the spe- cific character to show itself." In answer to this Qbservation, I must acknowledge that it has not been my good fortune to see a phagedenic ulcer at an earlier period than perhaps the second or third week after its commencement, and therefore I can- not aver, from my own experience, whether it pre- sents the precise phagedenic character ab initio'^ But I have happened to witness in one instance, the very commencement of the sloughing ulcer, the par- ticulars of which are reprinted in Case 21, of this edition, and are alluded to by Mr. Guthrie in his Remarks. The gentleman affected with it, who was an inti- mate friend, shewed it to me a few minutes after his own attention had been solicited to the part ; and at this time it exhibited the appearance of a black mortified speck, not larger than a grain of shot From this small beginning, it went on, alter- nately sloughing and ulcerating with a phagedenic edge, until it destroyed the greater part of the pre- puce and a portion of the glans. After it had existed a few days, it did not differ * See the commencement of the 5th chapter, where the char- acters of the phagedenic ulcer are considered. PHAGEDENIC VENEREAL DISEASE, 275 in appearance from the nunrerous advanced slough- iiag ulcers I had seen and treated in the wards of the Dublin Lock Hospital ; so that I think Mr. Gu- thrie must have been under some misapprehension, when he made the following observation: — "I ho- nestly declare, I cannot recollect more than two cases any way resembling it having occurred to me, out of several thousand instances ; I do not be- lieve that the proportion of such cases is greater than one in five thousand." — Mr. G., in making this observation, must mean to confine himself to the commencement of the ulcer ; and I do not marvel he has seen but two instances — I have seen but one ; and I scarcely expect to see another, as it excites so little sensation, not to say pain, at this stage, that it may even escape the observation of the pa- tient himself It seems Mr. Guthrie and I are agreed w^ith re- spect to the treatment of the phagedenic ulcer, and of the formidable train of secondary symptoms I have stated to arise from it ; and he even refers to cases (See p. 329 and 330 of his remarks) in which he witnessed the primary phagedenic ulcer and its secondary symptoms, as I have described them, both existing together in the same patients. But he con- ceives I am v/rong in attributing these secondar}'' symptoms exclusively to the phagedenic primary ulcer. His words are, " I can bring dozens of well substantiated cases, in which the ulcers were at first without any sloughing and phagedenic charac- ters for a considerable time, yet subsequently assum- ed them, a7id tvere foUoived by the secondcu^y symp- 27^ PHAGEDENIC VENEREAL DISEASE. toms which Mr. C, considers as the true constitutioh' al ones of specific venereal phagedena^ It would be presumption in tne td maintain, that Ihe constitutional symptoms I have detailed as ap- pieirtaining to thie phagedenic ulcer, can never ari^e from any dther form Of primary ulcer ; all that I have stated is the fruit of niy experience, and that enables me to affirm, that in every instance in which I had an opportunity of tracing the constitutional Symptbnls in question to their primary ulcer, that tllcet always exhibited the phagedenic character — Mr. Guthrie brings forward his own experience in isupport of the contrary opinion ; but acknowledges that thfe ulcers he refers to aftei'wards became pha- gedenic. I give him full credit for his assertions, arid am certain the investigation of this intricate subject cannot be in better hands. But it is proba- ble th^fe is less difference of opihion ori this head belwieen us theri hie is inclined to imagine. He will, at lieast, do nle the justice to allow that my cases are detailed with candour, since he has found in them Wherewithal to assail the very opinions I grounded upon them ; for so far from arranging them i'n support of a preconceived theory, I made no at- tempts at generalization until the cases were com- pleted, and the circumstances they contained were carefully examined and compared with each other. But so solicitous was I in noting those cases, that if I entertained any doubts with respect to the na- ture of an ulcer, I endeavoured to convey my own uncertainty in the language in which I described it. Thus, in niy last Essay, in Cases 28, 29, and 32, the PHAGEDENIC VENEREAL DISEASE. 277 primary ulcers, which were followed by the phage- denic constitutional symptoms, are cautiously de- scribed in the following words : — Tlue first is " a small ulcer of foul appearance and phagedenic character^ on one of the labia." The second, " a small foul ulcer inclining to phagedena. — The third, an ulcer about the size of a sixpence, exhibiting a white sloughy appearance, was situated on the body of the penis ; the integuments of which were under- mined to sotiie little extent." Id all the other cases, where iio doubt could exist with respect to the nature 6f th^ ulcer, it was, witht)ut circumlocution, termed a phagedenic ulcer. The doubtful ulcers were, I well i^collectj covered with a white tenacious adherent matter ; and after a time, evinced a disposition to burroiv, with a phage- denic border, which, together with the constitutional symptoms that attend them, induced me to class them with the phagedenic. Perhaps, indeed, I was guilty of some remissness in not pointing my read- er's attention to the language I employed in those different descriptions. Under these circumstances, it is not improbable but that the cases which came under Mr. Guthrie's observation were of this nature ; and it would be highly advantageous if he, as well as all future en- quirers, would attend particularly to the characters of such primary ulcers as are followed by the con- stitutional symptoms, which I have, without circum- locution, termed phagedenic. It has been denied, that these constitutional symptoms exclusively ori- ginate from a phagedenic ulcer, but whatever may 278 PHAGEDENIC VENEREAL DISEASE. be the primary ulcer from which they arise, they indicate to the practitioner the most obstinate and dangerous of venereal diseases — one in which full courses of mercury are most decidedly injurious j but which is often benefited by the alterative plan : but even this I would postpone (except the safety of some important part was threatened) until the disease was evidently on the icane. A few other objections still remain to be answ er- ed. Mr. G. observes, " In the first work we find, that the tubercular eruption is considered as a dis- tinct constitutional symptom, and arranged as the fourth in order, and he was then disposed to attri- bute it to the burrowing ulcer. In the second work we find he distinctly classes the pustular and tuber- cular eruptions under one head, and refers them to the phagedenic and sloughing ulcer." My answer to this is very simple, and may be very brief. My experience was not stationary and opportunities oc- curred of seeing pustules and tubercles in the very same patients, who were a,frected with primary phagedenic ulcers ; add to this, that I had sufficient reason to consider the burrowing and phagedenic ulcers as the same species of complaint, because these ulcerations are very similar, and they produce the same constitutional s3^mptoms. From another passage in the same page I collect, that Mr. G, con^ ceives I am guilty of the inconsistency of overturn- ing my own doctrine by the detail of cases of the spontaneous origin of tubercles in deranged consti- tutions, where there was no reason to suspect the communication of any morbid poison. PHAGEDENIC VENEREAL DISEASE. 279 That tubercles which terminate in ulcers, are produced by morbid poisons, and that they also oc- cur simpiy in deranged constitutions, where no morbid poison has been imbibed, cannot, at pre- sent, be denied; though to account for the anomaly will not be so easy a task. But I do not see how I have overturned my own opinions ill detailing these facts — as well might it be argued, that buboes do not arise from a venereal poison, because they some- times originate in other causes. To his arguments in support of the same objec- tion, derived from an eruption both papular and pustular, existing at the same time, (p. 337 of Mr. G.'s Remarks) I answer that the eruption adverted to by Mr. G. consisted of ulcers covered with thick crusts and pustules intermingled with papulse. The character of the eruption was, however, obviously pustular, though papulae were present ; precisely in the same manner as the eruption in small-pox is pustular, though papulse may be intermingled with the full formed pustules. The case of sloughing ulcer, with constitutional ulcers, Avhich I stated in my first publication as healing from their margins, is also urged against me in the same page, in corroboration of the same objection. It is true, I have pointed out as one of the distinctive marks of the constitutional ulcers of the phagedenic disease, their healing from their centre, and not from their margins. A peculiar character, which I had so often observed in the se- condary ulcers that arise from a primary phage- dena, that I could not but resjard it as a mark of 880 PHAGEDETNIC VENEREAL DISEASE. great practical importance, which designated an ob- stinate and dangerous disease ; but I did not, and do not affirm, that this mode of healing is exclusive- ly attendant upon the constitutional ulcers of a pri- mary phagedena. In that part of my work >vhich treats of the constitutional phagedenic ulcer, I have explained the cause of this mode of healing. From which we may infer, that although it occurs so often in this form of disease, as deservedly to be consi- dered a diagnostic character, yet it may not always be present, for the reasons there stated. My mean- ing is sufficiently evinced by the following passage in my Synopsis :— " Eruption of tubercles, or spots of a pustular tendency, or both intermixed, preced- ed by fever, and terminating in ulcers covered with thick crusts, which often assume a conical form, healing from their centre, and extending with a phagedenic margin." — But the primary ulcer, in the above instance, might have been originally of my second class — that with high edges, which ap- proaches to the phagedenic character, and have be- come sloughing through irritation; and if so, the constitutional ulcers would naturally heal from their margins. An enquiry of this kind should meet with that candid indulgence which its delicacy requires, while the strictest scrutiny need not be neglected. " The difference of opinion, (Mr. Guthrie, in con- cluding his remarks, observes,) which exists be- tween us, does not, I am happy to say, e:^tend to the mode of curing these complaints, except in one instance. In the antiphlogistic treatment of the pjiagedeni.c and common sloughing ulcer, I fully PHAGEDENIC VENEREAL DISEASE. 28 1 coincide; it is the practice which Dr. Ferguson recommended before Mr. Carmichael wrote, and which I have for some years pursued. I concur with him in the necessity of abstaining from the use of mercury in the earlier stage of the constitutional symptoms, whilst I bear the strongest testimony to its great utility in the latter, when administered with caution. It is as gratifying to me as to Mr. Guthrie, that in the more material points — those of practice — we are agreed ; although he is disposed to give Dr. Ferguson all the credit of this coneurrence ; still, however, unwillingly, I must, in duty to myself, make some references to dates, which will be found below,* in order to prove that I have not endea- voured to appropriate to myself the discoveries of any man. The object of Dr. Ferguson's candid and excel- * The 4th vol. of the Medico-Chirurgical Transactions, in which Dr. Ferguson's mostinteresting paper is inserted, is dated Novem- ber 24, 1813, and it came to my hands early in 1814. The first part of my work was published in the beginning of January, 1814 j but cases are detailed of the successful employment of blood-let- ting, and the antiphJogistic means in painful ulcers attended with inflammation, which occurred so far back as 1811, 1812, and 1813. (See Cases 2, 3, 4, and 6, all of which were Hospital Cases, under the eye of many of the profession.) The Second Part of the same work begins with my 4th Chap- ter, and was published in the latter -end of 1814. In which it ap- pears that the same treatment, that I had found so useful in in- flammatory ulcers, I had also adopted in phagedenic ulcers, which are so generally painful and irritable ; and many of these cases so treated occurred in the Lock Hospital so far back as 1811, 1812, and 1813. See particularly Cases 48, 51, and 53. Many other cases to the same eifect, I detailed in ray public lectures on the ■subject delivered at the Lock Hospital in the winters of 1812 and 1313. «-^ 2n 282 PHAGEDENIC VENEREAL DISEASE. fent paper is to inform us of the practice among the Portuguese surgeons, aiid of the successful is- sue of their mods of treatment^ in which mercury is so little employed^ and not to detail any improve- ments emanating froin himself; and it was with no little satisfaction that, in thiB second part of my workj I was enabled to resort to his important testimony in support of my own views, at that time standing ffo much in nieed of such corroboration. Mr. Guthrie, I find, differs from me in one point bf practice — the use of the lancet in the slough- ing ulcer. This diffei^ence of opinion is, however, grounded, not on his experience, but, as appears from the passage, p. 339, (where he compares the sloughing ulcer to the gangrenous toes of old peo- ple) on theoretical views* The practice I have re- commended is supported by a sufficient experience ^f its utility ; for these ulcers spread rapidly under the influence of wine and bark, yet cease their rava- ges ori the occurrence of a spontaneous hsembrrhage from the part, or from tlie use of the lancet, and the antiphlogistic plan combined with the exhibition of t)pium or cicuta. But, with respect to the existence of a pliirality t)f poisons, each of which produces primary and se- condary symptoms peculiar to itself, there are deci- sive facts to vindicate my adoption of this munh canvassed opinion, and they are these^^that ih each of the four classes, into Avhich I have divided vene- real diseases, I have witnessed the eruption, or other secondary symptoms, immediately succeed- ing the corresponding ulcer, or other primary s^p- PHAQEDENIC VENEREAL DISEASE. 283 toms, or both existing in the same patient at ope and the same time ; and in no instance do I attempt to establish a class in which it is not supported on those solid foundations. It is true, in one of those classes (the Pustular Venereal Disease) I have not had the good fortune to witness this conjunction more than half a dozen times. But in all the other classes, the evidence which in this way confirms them, is amply sufficient, and I will add, in two of them superabundant. I trust therefore, that I have perfectly satisfied Mr. Guthrie, that his objections to my theory, if theory it can be called, which does not depend on speculation, but on indisputable facts, are 7iot sufficient to subvert it ; but even if these facts were annihilated it would be to me as it must be to others, a matter of comparative indifference, as long as the practice I have recommended shall be considered as of value. Yet, as a step to that practice, I must acknowledge my obligations to the views I connected with them, and which led me at once to the beneficial measure of rejecting the pre- vailing prejudice of the medical world, and with- holding the use of mercury in the generality of ve- nereal disorders. This mode of treatment, chiefly in consequence of its successful adoption in the ar- my, already prevails^© an extent that could scarce- ly, in so short a period, have been hoped for; and (to give it no other name) the theory which was of such advantage to my labours, may possibly be no longer of any considerable importance, unless, in- deed, it shall hereafter be discovered, that each pe- Guliar species of venereal complaint will admit of a 284 PHAGEDENIC VENEREAL DISEASE. speedier cure by means of a remedy that is less effi- cacious in those of a different character. But this is now of little moment, since every species of ve- nereal disease can be combated by specified means, and with the fairest hopes of decisiv^e success. Let me not, however, be understood as admitting, that the classification I have introduced (if that classifi- cation is miscalled my theory, for theory I have none) having accomplished its purposes, may now be abandoned. Its utility must hereafter be as great as heretofore, in developing and explaining the circumstances of anomalous cases ; and may one day be a means of distinguishing those venereal dis- eases with which we are at present acquainted, from those that may be imported among us from abroad, or which may possibly originate from very different causes, not necessary here to investigate or conjecture. Without pluming myself, however, upon these considerations, I rest all my credit upon more sub- stantial grounds, the practice to which they gave birth ; and particularly the distinctive characters I have established for the more ready discrimination of malignant and destructive disorders from the milder and safer ; the appropriate remedies I have experienced as useful, and some of which I was the Ifirst to adopt, particularly those extensive depletions which are now found of so much benefit under cir- cumstances of inflammation ; the use of antimonial preparations in every form of venereal disease, the free exhibition of medicines of the narcotic tribe in painful phagedenic ulcers ; and, lastly, the simple PHAGEDENIC VENEREAL DISEASE,, 285 and satisfactory criterion I have introduced into no- tice, by which it is ascertained when mercury may be employed with effect, and when it ought to be discarded as useless or pernicious. CHAPTER VI. SCALY VENEREAL DISEASE- The primary syphilitic ulcer, or that which gives origin to the scaly eruption, has been well described by Mr. Hunter in the following words : '^ The sore i^ somewhat of a circular form, excavated, without granulations, with matter adhering to the surface, and with a thickened edge and base. This hard- ness, or thickening, is very circumscribed ; not dif- fusing itself gradually and imperceptibly into the surrounding parts, but terminating rather abruptly.'* Every word of this description should be strictly attended to, as conveying an exact definition of chancre ; so far, at least as it occurs on the glans and prepuce, though not on the body of the penis, where a slight difference is observable. Ulcers which are not sj^philitic may, but seldom have a full- ness and slight induration round the circumfer^ ence ; but then, this induration does not convey that sensation of solidity and firmness to the touch which that of a real chancre possesses, neither does it terminate abruptly, but diffuses itself gradually and imperceptibly into the surrounding p^rts ; in which circumstance, it differs from chancre so evi- dently, as to be at once distinguished by an expe- rienced practitioner. The induration of a chancre is not confinet} to SCALY VENEREAL DISEASE. 287 the edges only, but extends under the entire sur- face of the ulcer. We often meet with chancres in which the ulceration is inconsiderable, when com- pared to the extent of the induration ; and even in- stances of an indurated knob^ or tubercle, on the penis, without any visible ulcer, which have been followfed by the constitutional symptoms of syphi- lis, are not uncommon ; but on enqitiry, we shall probably learn, that in every such instance, a small ulcer existed at first on the callous part, which healed under the use of some locd applications. Chancre is, in fact, an indolent ulcer, and makes but slow progress, compared to those ulcers of the parts of generation, which are destitute of any surround- ing induration, and particularly the phagedenic and sloughing ulcers. It is to be recollected in forming our diagnosis respecting chancre, that frequent irritation is capa- ble of producing around the most simple sore con- siderable induration; and experiments have been made which are stated to have produced so great a degree of callosity, as to deceive the most experi- enced practitioners. Whether irritation is capable of causing a hardness which might be mistaken by an experienced person for the remarkable callosity that characterises chancre, I cannot determine, and very much doubt the circumstance. But in form^ ing our diagnosis we should always take into consi- deration the previous management of the ulcer. Chancre, when situated on the body of the penis, IS of a dark livid colour ; the ulcer is not excavated, but is on a level with the surrounding parts. It is 288 scalV venereal disease* attended with less induration than the excavated chancre ; and in the cases which came under my observation was generally from the size of a six- pence to that of a half-crown, and sometimes even extended round the body of the penis. Its edges are a little raised, and the surrounding induration very perceptible to the touch, though not in so great a degree as the chancre described by Hunter. If mercury is employed, the ulcer soon assumes a healthy appearance ; but if that medicine be not resorted to, its livid surface is alternated, every third or fourth day, with that of a light brown or tawny co- lour. The ulcer, at the same time, extending its dimensions slowly, and, as it advances, the surround- ing induration obviously increases. As few have witnessed this alteration of colour in a chancre, on account of the immediate exhibition of mercury, it ma}^ be of service to relate an instance. Case 49. — William Murray, setat 25, was admit- ted, February 1 1th, 1813, into the hospital. He was affected with phymosis, accompanied by discharge under the prepuce. An ulcer, about the size of a bean, of a livid colour, with callous edges slightly elevated, was situated on the body of the penis ; he had not used mercury previously to his admission, and I directed him merely to poultice the penis mth bread and water. On the fourth day from his admission, the ulcer had assumed a light brown, or tawny colour, and its edges had become more callous and elevated. On the sixth, it again exhibited the dark livid ap- pearance ; the penis was considerably swollen, and SCALY VENEREAL DISEASE. ' 289 the patient complained of pain which deprived him of rest. On the ninth day, the livid surface of the ulcer was changing to the same tawny appearance as be- fore, a rash, or efflorescence (roseola annulata) over- spread different parts of his body, agreeing with the appearance described by Mr. Hunter in the follow- ing words : " The disease in the skin first shows itself in discolouration, making the skin appear mottled, many of them disappearing, while others continue and increase with the disease."* On the eleventh, the entire ulcer assumed the tawny colour. The efflorescence of the skin had disappeared in some places, while it appeared in others, and there was a swelling of the glands in the right groin. On the seventeenth day the ulcer was again livid, and had extended to the size of a shilling ; the sur- rounding induration had also increased. As the character of the ulcer w^as sufficiently es- tablished by the increase of the callosity, mercurial frictions where now prescribed, and these, in a few days, caused a favourable change in the ulcer. He was discharged the hospital well in a month after- wards, having undergone a smart mercurial course. The dark livid appearance of this chancre, when extensive, bears some resemblance to that of the sloughing ulcer, and may possibly be mistaken for it. They may, however, be distinguished from each other, by the indurated edge and base of the chan- * Hunter, p. 476. 2o 290 SCALY VENEREAL DISEASE. ere, which are not attendants upon the sloughing ulcer; and, on a close inspection, the surface of the chancre, though dark, will not exhibit a state of slough or mortification. Its progress is slow, and, in both of these circumstances, there is an obvious and remarkable difference between these ulcers. If any doubt, however, should still remain, a little de- lay will disclose the true nature of the ulcer. If chancrous, it will, in three or four days, assume the tawny appearance already mentioned; and, if slough-r ing, the process from which it derives its name, will continue to extend, or the sloughs to separate and expose to view a corroding ulcer, to all appearance phagedenic, but which is soon covered by a slough that is again thrown off? again to be renewed, till the part is destroyed, or perhaps the patient. Phymosis and inflammation are less frequently attendants upon chancre than upon those ulcers which are destitute of its characteristic marks ; but when they accompany the former, they ought pro- bably to be ascribed to a very irritable habit, or to some irregularity in the patient, rather than to any stimulating quality of the poison which disposes it to excite inflammation. It is not very likely, that the distinction existing between syphilitic buboes, and those from other causes, before ulceration takes place, will ever be discovered ; and even in the ulcerated state, it is almost impossible, with any certainty, to point out such discriminating marks as will clearly distinguish them. The following circumstances, in conjunction with the history of the disease, may assist in form- SCALY VENEREAL DISEASE^ 291 ing a diagnosis. Syphilitic buboes have frequently aching pains ; in vi^hich respect they differ from in- dolent ulcers of the groin, which seem to maintain themselves by habit. The bottom of the syphilitic bubo, which has not been affected by mercury, has frequently a callous feel, and is either of a dark foul appearance, or of a light brown tawny colour. If an ulcer of this description spreads, we may, with confidence, have recourse to mercury ; and we shall, in most instances, find, that quick amendment fol-^ lows its exhibition. If the tumour in the groin has not been preceded by an ulcer on the genitals, mercury is unnecessa- ry, and may be highly injurious. I am not in the habit of ordering that medicine for buboes which have not been preceded by chancre ; yet the sub- sequent appearance of syphilitic constitutional sy mp-^ toms has never, in any instance, occurred; or any other circumstance, to induce me to repent of this line of practice. When the syphilitic matter is absorbed into the general mass, the first constitutional symptoms ap- pear upon the skin, throat, or mouth, and afterwards upon the periosteum, bones, and other deep seated parts. The eruption on the skin is usually considered the first constitutional symptom, but ulceration of the throat is as frequently the earliest intimation we have that the disease is become general. Before the occurrence of these local symptoms of a gene- ral disorder, there is often observed, considerable de- rangement of the patient's constitution. His coun- 292 SCALY VENEREAL DISEASE. tenance is dull and palid; and he complains of rest- lessness, want of sleep, and often head-ach. This derangement is analogous to the fever which pre- cedes the eruption in the different species of the venereal diseases as described, and in the exanthe- mata; but in the latter class of disorders, as the eruption appears, the fever diminishes : and the con- stitution completely gets the better of the disease, by its own unassisted powers. Not so in syphilis ; the slow fever which precedes the constitutional symptoms, may subside on their first appearance, but the irritation from the unsubdued poison still remaining, the same effort for relief is renewed ; in other words, the fever returns, but at uncertain in- tervals, till the constitution is worn out, or the in- tervention of medicine excites an action sufficient to supersede the syphilitic irritation. Hence, Mr. Hunter very properly observes, that this habitual fever of syphilis partakes very much of the nature of hectic fever, which he esteems to be an effort of the constitution to rid itself of a disease, but which it is inadequate to accomplish. The eruption in syphilis is frequently preceded by an efflorescence of the entire skin, which has been noticed by Hunter. Doctor Willan remarks that it is similar to the roseola annulata, and gives the skin a mottled red appearance ; an instance of which I have already adduced, in a case of livid chancre. The true syphilitic eruption is scaly ; a circum- stance by which it may be distinguished from the eniptions of the other forms of venereal disease, SCALY VENEREAL DISEASE. 293 which we have seen are either papular, pustular, or tubercular. No author describes this eruption so clearly as Doctor Wiilan, in his admirable work upon Cutaneous Diseases. It is true, he also de- scribes as syphilitic, the papular eruption, under the term of lichen syphiliticus; and I am perfectly aware that the first writers on syphilis introduce this epithet, pustular, in their description of its eruption ; as, also, that the disease, in many coun- tries of Europe, received its name from the appear- ance of the eruption. But whether that appear- ance was papular, pustular, scaly, or tubercular, is not very evident from those denominations ; which, singly, might afford a clue, but taken in conjunction, seem to confound together all those different spe- cies of eruption.* But we are under the necessity of recollecting, that at the period in question, there was but little regard paid to the distinctive charac- ters of cutaneous diseases; and that every appear- ance on the skin, which happened to terminate in- ulceration, or produce a discharge of matter, was termed a pustule. This is apparent in the writings of all the older authors, who treated on the subject; and even As- true himself, who published his work in 1735, seems to confound every species of eruption together, as is evinced by the following passage: "Pustules or ulcerous tubercles of the skin, both such as are pu- * According to Astruc, the Spaniards called it Las Bubas, Bu- vas, Buas or Boas. The Genoese, Le Male de le Tavelle, The Tuscans, II malo delle Bolle. The people of Lombardy, Lo ma- lo, de le Brosule ; and the French, La Vairole or Verole. See book L page 4, , 294 SCALY VENEREAL DISEASE. rulent, and such as are dry and crusty, not only ap- pear in the venereal disease, but likewise in many others ; as, in the scurvy, tetters, scab, and in all other cutaneous distempers.*** In fact, there was not any accurate distinctions of the various erup- tions that occur on the skin till our own time ; w hen Doctor Willan classed, according to their external characters, diseases, which previously were not un- der any regular arrangement. I have to add, that I have not, in any one instance, observed the eruption to be papular, pustular, or tu- bercular, when it arose from the true syphilitic pri- mary ulcer ; or to be scaly, w hen it followed those ulcers which do not possess the characters of chan- cre, the indurated edge and base. A few pimples occurring on the face of a man, affected with the scaly syphilitic eruption, ought not to be consider- ed as an exception to this statement, for, in order to form a fair judgment on the nature of a general eruption, the appearance of the entire surface of the body should be taken into consideration. The following is Doctor Willan's description of the syphilitic eruption, which he places among the scaly eruptions, and in the order lepra. " In the venereal disease, circular patches sometimes ap- pear, w^hich resemble those of the lepra nigricans in size and colour, but which are not incrusted. The dryness and harshness of the skin, so remarka- ble in the lepra vulgaris and alphoides, do not oc- cur in the venereal lepra ; its patches, when some- what advanced, being as soft and pliable as other "^ Astnic. p. 50. SCALY VENEREAL DISEASE. 295 j3arts of the skin. It is, however, proper to observe, that every patch originates from a small, hard^ red- dish protuberance. As this gradually dilates, the increase of its circumference is not attended with an increasing ulceration of the centre ; on the con- trary, the sides of the patch are somewhat raised, and the central part of it appears a flat surface co- vered with thin white scales. The patches are ge- nerally distinct, and at a distance from each other. There is seldom seen any of them exceeding the size of a shilling; yet, it is probable, they might ac- quire a greater magnitude, if the progress of the disease were not arrested by the use of mercury. When the constitution is under the full influence of mercury, the sides of the patch shrink and become paler ; the centre is also depressed, but the desqua- mation proceeds slowly ; and the disease cannot be removed, without a perseverance in the course for six or eight weeks. A circular red spot usually ap- pears, for some time in the place of every declining patch ; and a minute shallow depression, like a ci- catrix, is left at the centre ; but no permanent dis- colouration of the skin remains, as in some cases. The leprous form of the syphilitic eruption takes place, like other venereal eruptions, at very differ- ent periods after infection, in different cases. If no medicines were employed, it would at length ter- minate in ulcerated blotches."* Dr. Willan also describes another scaly appear- ance of the syphilitic eruption, under the species psoriasis, of the same order. The only difference * Willan, p. 129. 296 SCALY VEx\EREAL DISEASE. between this and the other is, that the spots in the former are circular and larger, and in the latter, they are irregular, smaller and less elevated. (See plate V.fig.4.) The scaly syphilitic eruption is almost in every instance, to be found on the forehead, breast, back of the neck, on the groins, and adjoining surface of the pubes. On the back of the neck and groins, those spots situated near the parts covered with hair, spread into each other, so as to form extensive copper-coloured blotches, as are represented in plate V. %. 1,2, and 3. On the palms of the hands, or soles of the feet, its appearance is different from that on other parts. The cuticle separates, and is quickly succeeded by another ; and this process may be several times re- peated, for the thick skin of those parts has not the same disposition to form scurf, as the common skin ; for which reason, if a case would arise, in which the appearances were confined to the hands and feet, it would be impossible to determine, whether or not it were syphilitic ; for all diseases affecting the cutis of those parts, produce a separation of the cuticle, attended in all with the same appearances. When the eruption affects a skin which is oppos- ed by another skin, as, between the nates, or be- tween the scrotum and thigh ; or under the arms, or between the thighs, it is not scaly ; but the skin be- comes elevated into a moist, soft, flat, or somewhat convex surface, which discharges a whitish matter. These are the appearances which, L believe, in au- thors, are termed condylomata, fici, crista?, mariscae. SCALY VENEREAL DISEASE. 297 &c. denominations applied, according to their figure, or perhaps the fancy of the practitioner. In this stage of the disease, that part of the fin- gers and toes upon which the nail is placed, is often attacked. A separation of the nail follows, similar to that of the cuticle in the eruption of the skin ; but Mr. Hunter well observes, there cannot be here that regular succession of nails, as of cuticle. If mercury is not employed, the eruption pro- ceeds to ulceration in the following manner. Each spot is covered by scales, or by scurf, which is thrown off, and succeeded by another ; every suc- ceeding scurf which is formed, becomes thicker than the preceding, till, at length, it forms a crust under which matter collects, and it becomes a true ulcer ; in which state it spreads but very slowly. The next constitutional symptom of syphilis, is the ULCERATION OF THE THROAT; where the tonsils, in most instances, are the seat of the disorder. The ulcer forms without much previous pain or swelling, although it soon produces a considerable excavation in the tonsil. It is, as Mr. Hunter observes, " a fair loss of substance ; part being dug out, as it were, from the body of the tonsil, with a determined edge, and is commonly foul, with thick white matter ad- hering to it, like a slough, which cannot be washed away."* This is the description of a well-marked syphilitic ulcer of the throat ; but as the tonsils are sometimes deeply ulcerated in the phagedenic dis- ease, we can only ascertain the nature of the ulcer m question by a most careful examination of tha * Hunter, p. 482. 2p ' ^ 298 SCALY VENEREAL DISEASE. patient, in order to discover the character of any other ulcer or eruption he may have; which, to-^ gether with an accurate knowledge of the history of the case, will seldom leave us in doubt with re^ spect to the nature of the disease. It is scarcely necessary to mention here, a very common affection of the tonsils, noticed by Mr, Hunter, which is not unfrequently mistaken for a syphilitic ulcer, viz. chronic inflammation of those glands, attended with irregularity of their surface, which is covered with coagulable lymph, that gives it the appearance of ulceration. Any mercurial affection of the throat is easily recognized, by the mercurial foetor of the breath, which accompanies it. The use of this medicine may caijse considerable inflammation and ulcera- tion of any part of the fauces, particularly if the patient should expose himself to cold and wet, when under its influence. I have witnessed, in a very considerable number of instances, profuse ptyalism, in patients who had not used mercury; but all thus affected, had, at the same time venereal ulcers of the fauces. It is pro- bable, that this spontaneous salivation is a constitu- tional symptom of syphilis, and analogous to a sim- ilar occurrence in small-pox. I am not inclined to attribute it to the irritation of the ulcers of the throat upon the mouth and salivary glands; for the syphilitic ulcers in question were attended with scarcely any pain. It is a curious circumstance in these cases (but one which I would naturally ex- pect from this view of their nature,) that as the pa^ SCALY VENEREAL DISEASE. 299 tient becomes affected with mercury, the salivation begins to diminish, and, at length, entirely ceases ; but is renewed again, as the mercurial process is farther advanced; first arising from the disease, and afterwards from the remedy. The BONES, PERIOSTEUM, FASCIjE, AND LIGAMENTS) arC the deep seated parts most liable to the attacks of the syphilitic poison, and it is generally thought, are affected after the disease has appeared constitution- ally on the superficial parts of the body, if the dis- ease has not been arrested in its progress by mer- cury, which disturbs the regular succession of the symptoms. Of the bones, it is observable, that those nearest the surface are most liable to the disease, as the ti- bia, sternum, clavicle, and cranium. When the deeper seated parts are affected, the progress of the disease is more gradual than in the superficial. Swellings of the testes, tendons, and fasciae are in general, very indolent, do not excite any pain, and have very pmch the character of scrofulous swel- lings. The true syphilitic node is a solid enlargement of the bone, and is not at its commencement, nor for a considerable period afterwards, accompanied by any discolouration of the integuments. It is, in most cases, a very indolent swelling, increasing by slow degrees, and exciting but little pain and inflamma- tion until in an advanced state. The true syphilitic pains are generally supposed to affect the centre of the long bones, but this is not universally the case ; while those of the resembling 300 SCALY VENEREAL DISEASE. diseases, as we have observed in its proper place, affect the joints, and all in common with other aches or pains, have their exacerbation at night. It is most satisfactory to observe the certainty and rapidity mth. which the constitutional symp- toms of syphilis affecting the soft parts, yield to mercury. The scaly eruption begins to decline, even before it is observed to affect the system, and ulcers of the skin and throat, as soon as that event takes place, assume a healthy and granulating as- pect, and soon afterwards cicatrize. The same good effects are also observable in the soft eleva- tions of the skin which are found between the nates, under the scrotum, and in the axillae. The ulcers of the tonsils also immediately ajnend. All these secondary symptoms yield much more rapidly than chancre to mercury; in illustration of which, it is but necessary to mention, that if the same person is at the same time, affected with chancre and the constitutional symptoms above enumerated, the lat- ter will yield much sooner than the former to this remedy. A circumstance, which I have elsewhere stated, would induce us to suppose, that the syphi- litic virus undergoes some chan2:e in its transmis- sion through the system, and is thereby rendered less virulent; and this supposition, as observed by Dr. Adams, is farther confirmed by the incapabilit}' of the matter of constitutional ulcers to communi- cate the disease, contrary to the effects of the other poisons, as, for instance, that of small-pox. It must be allowed, that syphilitic nodes by no means yield to mercury with the same regularity SCALY VENEREAL DISEASE. 301 and quickness as the constitutional affections of the surface of the body ; a circumstance most probably owing to the organization of tiie bones, which is so low, that the strongest mercurial action in the skin and throat, may be accompanied by a very weak one in the vessels of the former. Yet, in the most obstinate instances, I doubt the propriety of con- tinuing a full mercurial action longer than two months. This period is more than suflicient to su- persede the syphilitic action, if managed w ith judg- ment. I have always found it unnecessary to per- severe in the use of mercury, until the tumour of the bone is entirely removed. And there can be no doubt, that if the node remains after a judicious course, we should regard it merely as a simple en- largement of the bone, deriving no character what- ever from its syphilitic origin. Syphilis, like other contagious diseases, is obedient to certain laws, from which there is little deviation; but from the details of most authors, it would ap- pear that it possesses but little uniformity in its symptoms, or regularity in its progress. This opi- nion of the multiform appearance, and irregular course of the disease, is occasioned by several cir- cumstances : — 1.-^ — Ulcers on the genitals, which are not syplii- litic, are frequently mistaken for syphilitic, and treated accordingly; and this is a source of error, not only in respect of the original disorder, but in the entire train of complaints which may arise from the distemper thus mistaken. 2.--If the primary complaint is syphilitic, the 302 SCALY VENEREAL DISEASE. progress of the disorder is interrupted by the use of mercury, and if it is not totally subdued by that remedy, its return occurs at uncertain intervals. 3. — There are a number of complaints which arise from the use and abuse of mercury, which are fre- quently mistaken for the symptoms of syphilis; for instance, erratic pains, diseases of the viscera, ner- vous affections, mania, fatuity, and a variety of other complaints, which can evidently be traced to the imprudent use of this medicine. In the treatment of true syphilis, there is nothing perplexing or dubious, if we except the mercurial phagedena, and other effects of that mineral, which may be mistaken by the inexperienced, for the symptoms of syphilis. But the remedy in the hands of the experienced practitioner, will remove, I may say with certainty, every symptom of that disease, both local and constitutional. I am decidedly of opinion, that mercury acts by exciting an irritation capable of superseding that of the syphilitic, and in this point of view, it can be of little consequence, by what quantity of mercury, whether little or great, that irritation has been ex- cited. By referring to the hospital books, I find that numbers have been cured both of primary and secondary symptoms, by a very small quantity of mercury. Frequently from an ounce to two ounces has been found sufficient to cure the disease, and of preserving a strong mercurial irritation in the sys- tem, from one to two months; and this I suspect is all that is required; even if one drachm w^as found capable of producing this effect, I should not think bCALY VENEREAL DISEASE. 303 bf administering an additional grain. But whatever be the quantity, it is necessary for the cure of sy- philis, to excite a strong mercurial action, and to make the constitution feel and suffer under the de- bilitating effects of the mineral. Alterative courses, as they are termed, may suspend, but will seldom supersede the poison altogether.* In stating the very small quantity of mercury I have found capable of exciting strong mercurial ac- tion in the system, and of thus curing the disease, we must take into consideration the warmth and mercurial atmosphere of a hospital ; and therefore in private practice we are not to expect a result per- fectly similar. It is not a little perplexing, that a primary vene- real ulcer may be affected by the mercurial phage- dena, without having the action of its poison en- tirely superseded, for after the phagedena is remov- ed, we too frequently find, that the ulcer, instead of healing, assumes again the venereal character, so that it appears as if the venereal action had only been suspended, and not extinguished in the part. We ma}^, perhaps, better account for these succes- * The author, in the last words of this paragraph, recommends more mercury than will be found requisite, in the treatment of this or any other form of Syphilis, which appears in the practice of Philadelphia. In fact, since it is now proved beyond a doubt, that every variety of the disease may be readily cured without the use of mercurials of any kind, it would certainly appear at least injudicious '^ to make the system feel, and suffer under the debilitating effects of the mineral." Such a course mig-ht be ex- pected to defeat one of the most important intentions of the author's excellent work; that is to say, to lessen the evils arising from the improper admiaistration of mercury.. E. 304 SCALY VENEREAL DISEASE. sive morbid changes, by supposing that the mercu- rial phagedena had not extended to every part of the ulcer, but that some minute portion of it still continued under the syphilitic action, and conse- quently secreted a contagious poison ; but as soon as the mercurial phagedena has subsided, there is reason to believe, that the remainder of the ulcer be* comes affected by the poison, and the entire sore consequently assumes the syphilitic action. These circumstances are elucidated by the progress of ul- cerated buboes, in which the mercurial phagedena more frequently occurs than in any other venereal ulcer, on account of the practice of opening them while the system is mercurially affected. The crude wound inflicted by the lancet in opening them, if the system is affected by mercury, Avill immediate- ly assume the mercurial phagedena, which will ra- pidly extend, although a sufficient quantity of mer- cury has not been exhibited to supersede the vene- real irritation in the part. The same circumstance will occur in the suppurating sore made b}^ caustic, and in either case we have an instance of mercurial action in one portion, and of venereal action in an- other portion of the same ulcer. I have never seen the mercurial phagedena as it appears in chancre and bubo, (in which it exhibits a peculiar fiery red colour,) affect ulcers of the throat in the same manner; but I have frequently seen a dark foul phagedenic ulcer make its appear- ance, and extend along the edges of the velum and uvula in patients strongly affected by mercury, which I suspected was caused by that medicine. SCALY VENEREAL DISEASH:. 305 Bat to decide that this was actually the case, re^ quires much farther observation than I had an op* portunity of bestowing. It is, however, certain, that we every day meet with cases in which merpury produces high inflammation of the fauces ; and, oi) inspection, the velum and uvula appear of a deep red colour, and their edges exhibit a peculiar white excoriated appearance. The ulceration of these parts is the same as that which occurs on the tongue and inside of the cheeks, during a severe salivation; and which is occasioned by the pressure of the dentes molares. The mer- curial foetor in the mouth is sufficient to point out the true nature qf these affections, whenever they occur. It is supposed by many that mercury is capable of producing nodes upon a sound bone, as they very frequently occur while the constitution is under its influence ; but I should be unwilling to admit thi^ as a fact, until I shall have an opportunity of wit- nessing the appearance of nodes, in persons under the influence of mercury, for any disease not vencr real; because I have frequently found, that the mer- curial irritation of the system will not prevent the accession of nodes, ii) thq pustular or phagedenic venereal diseases ; and, therefore, their occurrence may have been erroneously attributed to the mer- cury employed; while, in fact, they were pro4uced by the agency of a morbid poison. But although I would not, without farther proofs, ascribe the production of nodes to the operation of mercury, I will, without hesitation,' admit, that it is 3q 306 SCALY VENEREAL DISEASE.. often the cause of pains which are frequently mis- taken for the effects of the venereal poisons. Such as are produced by mercury, are found to affect the muscles, tendons, and joints, and have a strong re- semblance to those of rheumatism. These pains are usually produced by exposure to cold, while the patient is under the influence of mercury. I have not, however, any doubt, but that pains in the joints, very generally ascribed to mercury, are, in fact, at- tributable only to one or other of those poisons which resemble syphilis in their symptoms; for we have found that one of their most prevailing cha- racteristics is to excite pains in the larger joints, which mercury is incapable, in the greater propor- tion of cases, of removing : and even if the}- are di- minished by its influence, they return with increas- ed severity, as soon as the mercurial irritation of the system has subsided. Besides the usual and characteristic local and constitutional effects of mercury, there are two singu- lar affections, which not unfrequently attend its use. The one is the erethismus mercurialis described by Mr. Pearson,* and the other is a peculiar eruption, which has received different appellations from the authors who describe it.t These diseases are not dependant upon the quantity of mercury absorbed into the body, or upon the preparation, or mode of * Pearson's Observations, S^c, p. 196. 2d edit. t Doctor Alley calls it HN'drarg-yria ; Dr. Moriarty, Lepra Mer- curialis; Doctor Speas, Erythema Mercuriale : and Doctor Bate- man places it as a variety of Eczema Rubrum, in the order vesi- culae. ^CALY VENEREAL DISEASE. 307 administering that remedy,* but seem rather to arise from a peculiarity of constitution in the patient; the cause of which, in our present state of knowledge, is not likely to be discovered. I have observed, that females are in general more easily affected by mercury than males ; and, there- fore, always direct them to begin with half a drachm of ointment every night ; and, in almost every in- stance find, that this quantity is sufficient to induce a proper degree of irritation in the mouth, in the usual time, which may be estimated at six or eight days after the commencement of the course ; and if a considerable soreness is produced in twelve, it may be esteemed an adequate commencement. On my first appointment to the Lock Hospital, I pre- scribed, as was the general practice, a drachm of ointment every night for the females, not making any /distinction between them and the other sex. But, having continued this plan for some time, I found that no precaution could prevent the most exces- sive salivations, attended with dysenteric affections, extreme debility, and sometimes dropsy ; but when I adopted a more considerate practice, I found the most beneficial advantages. These severe effects, from the usual mode of exhibiting mercury, may ap- pear surprising, but we should recollect the debili- ty arising from frequent courses, to which those wo- men who frequent Lock Hospitals are accustomed, * I know a gentleman who has always been attacked by this eruption, when he took but a single grain of calomel. I also knew an instance of" the disease being produced by the application ©f the black mercurial wash to a venereal ulcer. 308 hCALY VENEREAL DISEASE. and the influence of a mercurial atmospliere, such as was formerly present in hospitals restricted to venereal patients. When a patient^ whether male or female, has been salivated several tiiiies, and the system there- by habituated to mercur}^ it is incredible the small quantit}^ of that mineral that is sometimes capable of exciting the severest effects. The following case, one of the most remarkable I have inet with, will elucidate the fact. Case 50. — Daniel Nowlan, setat. 30, was admitted into the hospital on the 26th of December, 1811, af- fected with sj^philitic ulcers of the tonsils, and an enlargement of both testicles. He recently was in the hospital for six months, and had been discharg- ed the preceding April, after suffering repeated heavy saliviatibns for an ulcer on the glans penis, which entirely destroyed the part. i directed him to rub in half a drachm of oint- inent every night. In four days his mouth was so se- verely aflected, that he spat two quarts in twenty- four hours; and although he had used but two drachms of ointment, the mercurial affection of his system increased afterwards to so alarming a height, that his face and entire head became swollen in an extraordinary degree. His tongue projected from his mouth, its edges were ulcerated, and of a white sloughing appearance. He lay in a state of insensi- bility, or coma, and his breathing was laborious, like a man affected with apoplexy. He was removed to the convalescent ward, and was directed a smart opening medicine daily ; under SCALY VENEREAL DISEASE. 309 tliis, and other appropriate means, the dangerous lethargy in which he lay was removed, but he was not able to resume the use of mercury until the be- ginning of February following; and it is remark"* able, that he afterwards bore the exhibition of mer^ cury like other patients, being able to rub in three ounces and a half of ointment before the 20th of March following. If a similar case were again to occur, I should conceive it necessary, during the comatose state, to take blood as freely as I w^ould in a case of apoplexy. If the system has been debilitated by reiterated courses of mercury, oedematous sw ellings of the legs is a very frequent occurrence. It is an event which should w^arn the surgeon not to give another grain of mercury, but to make use of such means as are calculated to recruit the broken constitution of his patient. And I believe, for this purpose, country- air, generous diet, and exercise proportioned to his strength, will be found more effectual than medi- cine. If mercury be persevered in after oedema makes its appearance, general dropsy will follow; and it is surprising the rapid progress it makes in such cases. In a few days I have seen the entire cellular membrane of the body (Edematous, with as- cites, and every symptom of hydrathorax. Nitrous acid, given in as large quantities as the stomach and bowels can bear, conjoined with digi- talis, is of the greatest service in these cases. The following instance will evince the rapid progress of dropsy, under those circumstances, and the utility of the practice recommended. 310 SCALY VENEREAL DISEASE. Case 51. — John Delany was admitted into the hospital the 26th of Januan^, 1813, on account of a foul ulcer, situated on a remnant of the glans and prepuce ; the greater portion of those parts having been destroyed by former ulceration. There were also numerous ulcers on his arms and shoulders, covered by large crusts. During the preceding year his constitution had suffered under reiterated courses of mercury, administered on account of an obstinate ulceration of the glans and prepuce ; and at the time of his admission, his countenance Vvas bloated, and his legs and thighs anasarcous. Under these circumstances, I did not deem it ex- pedient to employ mercury, but merely ordered him nourishing diet, and decoction of sarsaparilla. Feb. 1st. — His dropsical symptoms having in- creased with considerable dyspncea, and (Edematous swelling of the scrotum, I put him on the use of nitrous acid, conjoined with digitalis; from fifteen* to thirty drops of the tincture were taken in half a pint of nitrous acid mixture thrice a day. 8th. — He passed urine in large quantities; the swelling of his limbs and scrotum had considerably diminished; and I had the satisfaction of observing at the same time, that the ulcer of the penis had as- sumed a disposition to heal. 16th. — The dropsical symptoms had nearly dis- appeared, but the ulcers on his arms were extend- ing, and he complained of severe pains in his wrists. The nitrous acid and digitalis were discontinued, and he was ordered the decoction of sarsaparilla, and 30 drops of antimonial wine three times a day. SCALY VENEREAL DISEASE. 311 March 1st. — The ulcer of the penis had healed, and many of the crusts had fallen off, and left the parts underneath perfectly cicatrized ; at the same time several papulag appeared on different parts of his body, and he complained of severe pains in his wrists and shins, particularly at night. The decoc- tion and antimonial wine were continued. 14th. — He was discharged the hospital, all the constitutional ulcers having healed; the pains being dissipated, and the oedematous swelling entirely re- moved. The greatest circumspection is necessary in the exhibition of mercury in persons labouring under the slightest pulmonary affection, whether it be he- moptoe, asthma, or dyspnoea, from whatever cause it may originate. I have seen in the Lock Hospi- tal repeated instances of the fatal effects of mercury in such cases ; but it is certain, that the mercurial atmosphere of the house contributed in no small degree, to the danger of the patient ; and it is abso- lutely necessary that there should be annexed to every foundation of this description, convalescent wards detached from the hospital, and enjoying the advantage of a pure atmosphere.^ The justice of these remarks will be confirmed by the following case : — Case 52.— Owen O'Neale, fetat. 30, was admitted with chancres attended by considerable inflamraa- * 1 leave the above passage as it stood in my fii*%t edition in 1814; but the small quantity of mercury at present employed even by those of the old school, compared to what was given at that period, would, 1 am now inclined to think, render such an establishment sunerfluous. 312 SCALY VENEREAL DISEASE. tion of the prepuce, on the 6th of December, 1811. He had a large curvature of the spine, and a corre- sponding distortion of the chest, and his counte- nance was of that livid hue which marks impeded or imperfect respiration ; he had also a severe cough. I directed twelve ounces of blood to be drawn im- mediately from his arm, not only with a view to the af- fection of his chest, but to the inflammation of the penis. The antimonial solution was also ordered. Three days afterwards, his breathing was so much re- lieved, that I did not think it necessary to postpone any longer the exhibition of mercury, and I direct- ed him to rub in but half a drachm of ointment every night, and to persevere at the same time, with the antimonial solution. On the 29th, the chancres had improved, and his mouth w^as slightly aff'ected by the mercury, but his breathing, on the preceding night, had again be- come laborious, and his pulse was upwards of 100. He was removed immediately to the convales- cent ward, sixteen ounces of blood were taken from his arm, the ointment was discontinued, and the an^ timonial solution persevered in. On the 21st, 22d, and 23d, the venesection was repeated each day. Blisters were applied to his breast and back, but the different means employed were ineffectual in checking the progress of the af- fection of his chest. On the 25th, his respiration was rapid, pulse 130, and countenance livid; in short, there was every symptom that effusion had taken place into the che^t or lungs ; and on the 27th SCALY VENEREAL DISEASE. 313 died, not having rubbed in more than four drachms of ointment from the time of his admission. This is a striking example of the ill effects of mercury, and a mercurial atmosphere, in persons la- bouring under pulmonary complaints. No neces- sary precaution was omitted before the adoption of the medicine, and the caution that was obsen^ed dur- ing its exhibition, would under other circumstances have been altogether superfluous. But in such cases, no caution can be excessive. The frequency and rapidity of effusion into the lungs or chest of patients labouring under pulmonary complaints, while exposed to the mercurial atmosphere of an extensive Lock Hospital, is too common a subject of observation, and can only be remedied in the mode I have already recommended. Before I conclude this part of the subject, it may be of service to recapitulate the usual and charac- teristic effects of mercury on the frame, and like- wise those effects which now and then occur from its use, and which seem to originate in peculiarity of constitution : — 1 . Mercury induces a specific fever different from all others, and attended with an increase of the va- rious secretions. 2. When the constitution has been incessantly harassed by mercury, it induces dropsy, various nervous affections, epilepsy, mania, and fatuity. 3. It produces peculiar local effects. A crude wound or suppurating sore, under its influence, will immediately become spreading phagedenic ulcers, of a fiery red appearance. The ulcers of morbid 2 R 314 SCALY VENEREAL DISEASE. poisons, after the peculiar action of their respective poisons has ceased to act, may become in the same manner, mercurial ulcers. But if the poison retains its influence in any portion of the ulcer, as soon as the mercurial phagedena has subsided, it may in- fect the remainder of the ulcer, which will conse- quently re-assume its original character. 4. It occasionally produces pains resembling rheu- matism, and swellings of the joints, particularly when the patient exposes himself to cold. 5. It is asserted to be capable of producing nodes, which resemble the syphilitic ; but this I doubt, be- cause there is no authenticated instance of nodes of the bones occurring under courses of mercury for any diseases except venereal. 6. It produces two affections of the constitution; the mercurial eruption, and mercurial erethismus, which, unlike its usual and characteristic effects, are evidently owing to some peculiarity of constitution. In the same manner, most medicines, and many of our common aliments, produce phenomena in some constitutions, attended with great disorder of the system, totally different from their accustomed and well known effects. 7. Mercury, and more particularly a mercurial atmosphere, are iu the highest degree prejudicial and dangerous to patients labouring under any pul- monary affection, by producing a rapid state of ex- citement, and consequent effusion into the lungs or chest* *The ill effects of mercury upon the system, may be prevented, or greatly lessened, if a free vent or discharge is maintained SCALY VENEREAL DISEASE. ' 315 When I commenced my inquiries, with respect to the treatment of venereal diseases, so universal was the use of mercury, that the utmost stretch I could allow my imagination, was merely to entertain a suspicion that these numerous symptoms, which did not correspond to Hunter's well known descrip- tion of syphilis, might possibly recover without the use of mercury : and this, both the friends and ad- versaries of my practice will acknowledge was a tolerably bold step, at a time that every venereal symptom, except gonorrhoea, was doomed to under- go a full course of mercury. In some recent publications, however, we are taught that every form of venereal complaint, in- cluding syphilis itself, has been successfully treated without the use of mercury. Mr. Rose is particu- larly explicit on this point; and in support of his opinion, details several cases of primary ulcers, pos- sessing the surrounding callosity, and other charac- teristics of chancre which were cured without mer- cury.* Mr. Guthrie is also equally decisive, but does not detail the instances ; his words are, "Every kind of ulcer of the genitals, of whatever form or appearance, is curable without mercury. This I through some of the emunctories, which in this case, as in many disorders, act the part of safety valves. It is no great matter which of these is selected ; but the skin and kidneys are in gene- ral the most convenient. Salivation ought, we think, at all times to be carefully avoided, as it is-most frequently attended with great inconvenience, and unpleasant consequences, \vithout having any thing specific in its operation. The salivary secretion should, if possible, always be preserved from vitiation, as it mixes with the food and drink, with which it goes into the stomach, and when the product of morbid action, doubtless ter^ds to increase the depravity of the sj^stem. E. * See particularly his 2d, 4th., Gth, 7th, and 8th cas.es. 3|i SCALY VENEREAL DISEASE. consider to be established as a fact, from the obser- vation of more than five hundred cases which I am acquainted with, exclusive of those treated in the different regiments of guards, and which occurred in consequence of promiscuous intercourse/'t Since those pubHcations fell into my hands, I have been anxious to ascertain, by personal obser- vation, whether true syphilitic chancres did really admit of being cured without mercury ; but this dis- ease, as described by Hunter, has diminished in so extraordinary a degree in this country, that strange to say, I have not from that period met with more than half a dozen cases of true chancre, thousjh. without adverting to my private practice, my op- portunities, as surgeon to an extensive hospital, are by no means inconsiderable. I am certain that others are more easily satisfied than I am with re- spect to the characters of chancre ; but adhering strictly to the definition of Hunter, I do not consi- der any primary ulcer to be syphilitic which does not possess the callous edge and base, terminating abruptly under the skin, and feeling nearlv as hard as a piece of cartilage. There are ver^' few ulcers of an irritable nature which have not some degree of fullness around them, which induces many to pro- nounce them chancres ; but this fullness is very dis- tinct from that callosity which Hunter, and tliC ear- ly writers on syphilis, describe. However, in consequence of the respectable au- thorities mentioned, as well as that of Dr. Thomp- t Mr. Guthrie's paper on the treatment of the Tenereal disease without mercurv. Med. Chirur2". TransaciioD?. r Tiij n. ir.p. SCALY VENEREAL DISEASE. 317 son, Mr. Ilennen, and others, I determined to seize upon the first opportunity of affording ocular de- monstration, whether true syphilis, like the other forms of venereal diseases, were capable of being cured without the aid of mercury ; and I have had sufficient proofs, though few, to convince me that syphilis, as well as the others, is capable of being cured without mercury. But it does not by any means follow that there- fore the non-mercurial is the most judicious mode of treatment; for in the cases thus treated which have come to my knowledge, the recovery has been remarkably slow, both from the primary as well as constitutional affections. And on the contrary, as far as my experience extends, the recovery is cer- tain and rapid, where mercury is exhibited for the symptoms which I have detailed as belonging to true syphilis. I have only met with the two follow- ing cases of syphilis exhibiting the constitutional symptoms, which afforded me an opportunity of trying the non-mercurial treatment. Case 53. — James Murray, admitted May 20th, 1818, with an undurated chancre situated at the junction of the prepuce with the corona glandis. The surface was covered with a small crust, but the callosity was of that remarkable kind that termi- nates abruptly, and feels like a piece of hard carti- lage under the skin. He had also the psoriasis sy- philitica in distinct patches, each about the size of a sixpence, scattered over his back, breast, forehead, arms, &c. According to his statement, the ulcer appeared 318 SCALY VENEREAL DISEASE. three months previous to his admission, but had in a great measure healed in a month after its appear- ance without the use of medicine, leaving, however, behind it the callosity, which was constantly cover- ed with a small crust already mentioned. He add- ed, that six weeks afterwards the eruption began to appear, and that he had taken onl}'^ nine mercu- rial pills, which did not affect his mouth. From the time of his admission until the 15th of June, a period of 26 days, no medicine whatsoever was given to him, during which the callous substance increased in size, and the eruption became more ex- tended by the addition of new spots, and the en- largement of those that had first formed. Finding that the disease was not yielding to the powers of the constitution, I determined to make a trial of sarsaparilla, the decoction of which was ordered for him, with a drachm of the powder thrice a day. Shortly after the exhibition of this medicine the callosity began to decline, and so early as the 5th of July, it was noted that the callosity had consi- derably lessened, and the eruption was of a paler colour. July 20th. — The ^ruption had nearly declined, but there still remained some induration in the seat of the chancre. At this period he thought proper to quit the hospital without leave. However, on the 4th of August he applied again for admission ; the eruption had increased, and the callosity of the penis still remained. He was or- dered the decoction and the powder of sarsaparilla as before, which he continued to take until the 28th SCALY VENEREAL DISEASE. 319 of September following, at which time the eruption had disappeared, and the callosity dispersed. He was discharged apparently well : on the 10th of No- vember following he again came to the hospital on account of some faint spots of the psoriasis syphili- tica on his back and arms ; and several small super- ficial ulcerations on the scrotum. It was not thought necessary to receive him into the hospital on ac- count of these trifling symptoms ; but he was desir- ed to return if any aggravation of his complaints should take place. He, however, did not afterwards apply at the hospital. Case 54. — The other case of syphilis treated without mercury, was that of Edward O^Brien, who was admitted into the hospital on the 24th of May 1818. At this time there was a large ulcer extend- ing along the dorsum of the penis, from the prepuce almost to the pubis. It was of a livid colour and in every respect corresponded with the description of chancre on the body of the penis. June 1st. — The ulcer had extended, and its sur- face had changed from a livid to a tawny colour ; but in a few days afterwards, the same livid appear- ance returned. 8th. — He began to complain of pains in his shoul- ders, arms, knees, and tibiae. The pain in the lat^ ter afterwards became extremely acute, and he could not bear the slightest pressure on those bones. He lost his rest and became emaciated. On the 16th of June, the pain and tenderness of the tibia? were so ver}' acute, as were also those in his joints, and particularly in his hands and wrists, and the enip- 32() SCALY VENEREAL DISEASE. tion had so far extended, that I conceived that mer- cury was absolutely necessary for this individual ; and I was disposed to order it on the instant : and in this opinion a most attentive and intelligent class of pupils who watched this, as well as all the other venereal cases, with the greatest assiduity, seemed anxiously to concur; I am now, however, well pleas- ed that I postponed this intention, and determined upon giving a trial, in the first instance, to sarsa- parilla ; although I confess, at the time I had little or no hopes of succeeding by its means. I direct- ed it in the form of powder and decoction in fulL doses. On the 28th, however, to my surprise, a very re- markable amendment was apparent in all his com- plaints. The ulcer looked healthy in the middle, and had ceased to extend. The pains and tenderness of the tibiae were diminished, and the eruption was obviously on the wane. From this period his amendment was regular and decided ; the eruption and pains had entirely declined before the 14th of July, and the ulcer had healed to one-half its former size. His countenance and general appearance were at the same time improved. But at this very juncture, when the ulcer was healing rapidl}'^, by some imprudence, he excited inflammation, and a partial paraphymosis. He was again directed to confine himself to bed and to poultice the penis with bread and water. In a few days the inflam.mation was dispersed, and the ulcer progressively amended, but was not healed until the 8th of August. He was discharged per- fectly ^Vell on the 13th of the same month. SCALY VENEREAL DISEASE. 321 Although these two cases cannot fail to make a due impression, yet if they stood alone, their evi- dence could not be deemed sufficient to establish a belief that true syphilis, like the papular disease, is capable of yielding to the powers of the constitution, or to remedies in which mercury does not form an ingredient. But this deficiency is amply supplied by the testimony of Messrs. Guthrie, Rose, Hennen, Dr. Thompson, and other equally intelligent sur- geons. It must be admitted, however, from these cases, that although mercury may not be absolutely ne- cessary for the cure of true syphilis, yet that recov- ery may be greatly expedited by the exhibition of that medicine. In thus relinquishing my opinion, that true syphi- lis differs from other venereal complaints, by always requiring mercury for its cure, it is necessary to reduce the doctrine I hold to this proposition ; that with respect to the use of that medicine, it differs from them only in not being injured, but decidedly benefitted, by it in all its symptoms and stages. I may not soon have an opportunity of advancing this investigation much farther on account of the extra- ordinary fact already adverted to, that syphilis is now comparativel}' seldom to be found in this coun- try, although the verj^ form of venereal disease, which, there is reason to believe, was most predom- inant in the time of Hunter. A few years back, and particularly in 1812 and 1813, that malignant attendant of the phagedenic disease, the sloughing ulcer, was extremely prevalent in Dublin; but I 2s 32^ SCALif VENEREAL DISEASE. have only seen it in one or two cases either in private or public practice, during the last six years. It may therefore be considered as far from improbable, that there are prevailing forms of venereal affections, like prevailing epidemics, at different times and in different countries — a circumstance that may possi- bly depend on the importation of fresh infections; although these arrivals are seldoQi recorded with the same notoriety as that of syphilis from St. Do- mingo.^ This hitherto unnoticed phenomenon may serve to explain the universal adoption of mercury for every form of venereal disorder ; for when syphilis became the prevalent malady, the reputation of mer- cury must have greatly increased, and its utility at once been acknowledged and exaggerated. But we have seen that although this medicine is injurious in the commencement of the papular, pustular, and phagedenic diseases, yet Avhen they are on the de- cline, and their eruptions have become scaly, and bear some resemblance to the syphilitic eruption, its exhibition in this stage of the disorder often ope- rates like magic, in bringing a lingering disease to a quick and favourable termination ; and when all * That the forms of the venereal disease are often influenced by epidemic causes, the editor was induced to believe from his own observation, long before he was furnished with a hint of the cir- cumstance from any other source. He has frequently noticed that, during certain periods, nearly all the cases under his treat- ment, were of the same nature ; whilst, at other times, different forms have prevailed. These variations may have depended upon accidental circumstances; but their frequent occurrence has cer- tainly led to a different conclusion. In another part of this work, the author has adverted to this subject still more pointedly. E. SCALY VENEREAL DISEASE. 323 tliese diseases were treated alike, it is no wonder it should soon be forgotten that there was any distinc- tion between them, or in fact that there was any other venereal disease besides syphilis. These cir- cumstances were of a nature to hood-wink and mis- lead the majority of the profession, and establish the practice which has so widely and absurdly pre- vailed. Yet early and at all times there existed a few clear-sighted and discerning individuals who perceived the mischiefs attendant upon the indis- criminate employment of this powerful drug; and who were not contented with the expedient of in- venting names to delude themselves and their pa- tients, and ingeniously satisfy their consciences while committing, through the medium of this medi- cine, the most unwarrantable depredations upon the constitutions and lives of those who confided them without reserve to the disposal of their judgment. CHAPTER VII. DISEASES 3I0ST LIKELY TO BE CONFOUNDED WITH THOSE OF VENEREAL ORIGIN.^SYNOFSIS OF THE WORK. The genital organs are of course liable, in com- mon with all tlie other parts of the body, to phleg- monous inflammation and its consequences : to erysi- pelas, anthrax, &c. In addition to these the pre- puce is subject to a peculiar vesicular eruption, which from irritation often extends into sores that are frequently confounded with venereal ulcers- This eruption is termed herpes preputialis. Phlegmonous inflammation of the penis, which does not arise from external injury, almost always terminates in suppuration, notwithstanding every effort made to procure resolution ; therefore, gene- rally speaking, it is the better practice to encourage suppuration at once by means of warm poultices, and to discharge the matter by a free opening at soon as its presence is indicated. When phlegmon forms on the prepuce, it is at- tended with considerable thickening and induration, which remain even after the matter is evacuated; a chronic burrowing ulcer often succeeds, which is extremely difficult to heal ; and all our eflTorts to bring about this ev^ent are in general useless, until the sinous ulcer which usualh^ forms, is laid freely open. And even this is often unavailing, without DISEASES RESiyMBLING VENEREAL. 325 a removal of a portion of the indurated integument, which may be either done with the knife or com- mon caustic ; but the former, as least painful, is to be preferred. When this is once accomplished, the part usually heals without farther difficulty. Wo- men are also liable to be affected with painful abscesses, which form within the labia, perineum or sides of the vagina. They are generall}^, as well during their formation as afterwards, attended with considerable pain; and often in married women great mental uneasiness is occasioned, under an appre- hension that they are of venereal origin. As soon as matter is perceived, a free opening gives immediate relief, and the part usually heals afterwards without difficulty. Sometimes, however, sinuses take place which are tedious, and must be treated according to the general principles of sur- gery, before they can be induced to heal. From the protracted and tedious nature of those sinous ulcers in both sexes, we may readily conceive what mischief must ensue, if they should be mistaken for venereal ulcers, and that course after course of mer- cury be exhibited, until the constitution of the pa- tient is irretrievabl}^ ruined; such instances I regret to observe, have often fallen under my observ ation. Erj'sipelatous inflammation of the penis I have only seen as an attendant upon a foul irritable ulcer ; therefore it is unnecessary to treat of it as a distinct affection : neitlier have I ever w^itnessed the pre- sence of anthrax on this part ; but as there is no reason why the penis should not be as liable to this affection as any other part of the body, we ought 326 DISEASES LIKELY TO BE to be prepared to encounter it. Mr. Evans states, that he has frequently witnessed the circumstance, and giv^s two cases in illustration. The repeated returns of sloughing in his first case, however, ap- pears to be unlike what is observable in anthrax in other parts of the body. The reader will do well to consult his work upon the subject.* Herpes preputialis is a very common affection. On the external prepuce it usually occurs in the form of a cluster of four or five vesicles, which soon scab and heal in a few days, if not irritated by the friction of the patient's clothes, or the improper ap- plication of stimulating or caustic washes. On the inner surface of the prepuce, owing perhaps to the moisture of the part, we seldom have an opportu- nity of seeing the vesicles, which pass into minute circular ulcers that often run into each other. All that is required to cure this trifling complaint is the prevention of irritation. When it occurs on the in- ternal surface of the prepuce, it may be well to in- terpose a bit of dry lint, as the secretions of the part are in such instances usually acrimonious, and may possibly have occasioned the complaint. The di- agnosis between this affection and venereal ulcers, when the former occurs on the external prepuce, is obvious, — the cluster of vesicles sufficiently point out its nature. But if it has been irritated, so as to produce ulceration, or when this takes place on the internal surface of the prepuce, we must wait until * See Evans's Remarks on Ulceration of the Genital Oi^ns. p. 12 to 22, CONFOUNDED WITH VENEREAL. 327 time develops its true nature, before we can ven- ture to give a decided opinion* I have met with eight or ten cases of ulcers situ- ated either on the groins, pubes, or scrotum and fossa of the nates, or on all these parts at once in the same individual, which resemble, in their raised edges and obstinate nature, the primary ulcers of the pustular venereal disease. These ulcers exist in distinct patches, and have a zig-zag appearance. They creep on slowly, with margins both raised and undermined. I know not whether we ought to consider them as venereal ; but place them in this section of my work until their origin is deter- mined. In all the cases of this description, a large quan- tity of mercury had been used ; so that we might be inclined to consider them as mercurial, if such ulcers were ever observed to arise from the exhibi- tion of mercury for any diseases that were not ve- nereal. Under every mode of treatment they are * For want of proper discrimination and experience, this affection has often received the treatment applicable only to the most virulent syphilitic affections. The editor has seen many instances of its occurring to married men, with an aspect well calculated to alarm such as are unacquainted with its character. It is most common to those in whom the prepuce covers a considerable por- tion of the glans, and where the secretions from those parts are greater than ordinary. A lotion of lime water, or solution of white vitriol, will often cure it very speedily : but sometimes it disappears and soon re- turns, so as to prove, by repeated recurrence, very troublesome to the patient and his physician. When the curative means already recommended are not found sulGficient, advantage may result from dusting the parts affected, with a powder consisling of equal por- tions of calomel and arrow root, confined in a gauze or cambric bag. Frequent ablution should never be neglected by those sub- ject to or labouring under this affection. E. 328 DISEASES LIKEJLY TO BE obstinate. Caustic and irritating applications are always injurious. The patient often recovers under sarsaparilla, country air. and sea-bathing; but it is not easy to decide whether these means are instru- mental to his recovery. One of my private patients was affected two years with ulcers of this description, which had spread over the groin, fold of the thigh, pubes, and lower part of the abdomen. He had been in the hands of several professional men, but at length the obstina- c}^ of these ulcers yielded to the exhibition of Fowl- ers solution of arsenic, and pressure upon the dis- eased part by means of adhesive straps and ban- dages, according to Baynton's method, with the ex- ception, that in place of diachylon, the straps were spread with equal parts of soap and strengthening plaister, which excites less irritation of the skin than the former. For this hint I am indebted to Mr. Young, who, it is well known, employs this com- position in cancerous cases. Different complaints are also frequently met with besides those mentioned in my first chapter, which bear a close resemblance to the constitutional symp- toms of venereal diseases, particularly to those of the phagedenic disease, and yet cannot be traced to a venereal origin. This subject has been already so ablv considered bv JMr. x\bernethv, that Jittle re- mains for me. except to add my suffrage to the doc- trines he has enforced. In ^\es\ instance in which constitutional affections occur that are liable to be mistaken for those of venereal diseases, but cannot be traced to anv infection, it universally happens. CONFOUNDED WITH VENEREAL. 329 that the patient has been previously, for a consider- able time, disordered in his health; his digestion is bad, and he feels himself dispirited and unwell, without being able to point out any particular ail- ment as the cause of his indisposition. On another occasion,^ I have adduced incontro- vertible facts, which demonstrate, that disorder of the chylipoetic viscera precedes and accompanies the symptoms of scrofula, and that there are the strongest grounds for believing that such disorder is, in a very great majority of cases, the immediate cause of the disease. A defective digestion, con- tinued for any length of time, must as certainly pro- duce chyle or blood of a vitiated quality, and unfit to replenish the waste of the body, as the constant use of unwholesome food, which is undergoing the putrefactive or acetous fermentation. A disorder- ed state of the system at first ensues, followed by various local complaints. Among these are swel- lings of the lymphatic glands, which frequently ul- cerate, different species of cutaneous affections, particularly the tubercular eruption, which likewise ulcerates. Ulcers are often . seen in the throat, which it is not easy to distinguish from those of ve- nereal orgin ; and, lastly, ulceration of the pituitary membrane is very frequent, attended with caries of the bones, of the nose and palate, and often with fistula lachrymalis. Even the deep-seated parts do not escape ; for the patient complains of pains in the joints, which are often mistaken for those of * See my Essay on Scrofula. 2 T 330 DISEASES LIKELY TO BE chronic rheumatism ; and affections of the bones or their coverings, producing a kind of node, are not unfrequent. In fact this train of symptoms occurs ever}^ day under our eyes, in children, whose youth fortunately protects them from the suspicion which lights on their elders ; for it is by no means unusual to find in scrofulous children ulcers which arise from tubercles, and also ulcers of the tonsils, nodes on the shins, and pains in the joints, which, if they oc- curred ^at a more advanced period of life, would in- evitably condemn them in the hands of a great ma- jority of practitioners to a severe course of mer- cury. In these countries, almost every chronic complaint which cannot otherways be accounted for, is sus- pected to be a symptom of latent venereal disease ; and it is in vain for the unfortunate patient to pro- test his innocence, if one or two of the train of symp- toms I have stated, concur to satisfy his medical at- tendant of the incredibility of his assertions ; whose doubts, if he had any, are completely dissipated by the favourable change which almost always ensues on the first exhibition of mercur}\ The patient cannot withstand this accumulation of evidence, and begins to think that the remnant of some old venereal taint has been lurking in his system for a long series of years ; or that the poison may have been imbibed by drinking out of the same cup with an infected person, or caught in some accidental w^ay, that he can neither describe nor account for. But the opinions of friends are seldom so lenient, and many a happy family has been plunged into CONFOUNDED WITH VENEREAL. 331 the deepest distress by the unqualified and unjust^ fiable sentence of a practitioner, who can not rise above his prejudices, or conceive that symptoms in any degree resembling the venereal, can originate from any other than a venereal poison. It is chiefly by an attentive consideration of the history of those cases, the state of general health of the patient previous to the occurrence of local dis* ease, and the non-appearance of primary symptoms, that we are enabled to form a just judgment on the nature of the disease. They often bear so clos^ a resemblance to complaints of venereal origin, that it may be well to impress the circumstance the more strongly on the minds of my junior readers by the illustration of two or three instances. Case 55.— In the winter of 1810, a gentleman consulted me on account of a complaint which he supposed to be a commencing fistula lachrymali$. One of his eyes continually watered, and on exami- nation, the bones of his nose felt enlarged, and were tender when pressed. He snuffled also very much, and breathed with difficulty through his nose* He mentioned, accidentally, that he felt a soreness for a few days in his palate; on examination, I perceiv^ ed a round hole, about the size of a pea, in the pa- late, through w^hich the probe passed readily into the nose. There w^as an ulcer of the same appear- ance, but somewhat larger, covered with white vis- cid matter, on the soft palate, just above the velum. I immediatel}' suspected syphilis, but he posi- tively denied having had any venereal complaint §ince he w^as married, a period of nine years, during 33^2 DISEASES LIKELY TO BE which time he had seven children, who were all healthy from their birth. His wife was also per- fectly healthy. This gentleman had not enjoyed good health for the two years previous to his ap- plication to me. He felt himself unwell without being able to ascertain the cause, and was affected with an unaccountable lowness of spirits. He was afterwards attacked with pains in his joints, which were treated by a physician of the first eminence as rheumatic. His tongue was furred, his sleep disturbed at night, and by day he felt himself inca- pable of attending to any thing which required in- tellectual exertion. I gave him my opinion that a course of mercury would be necessary to remove the disorder, whe- ther or not it proceeded from a venereal infection. This advice was thought so extraordinary, that my patient would not submit to so severe a remedy, without the opinion of another surgeon. Mr. Richards was consulted, and he agreed with me in the propriety of a mercurial course, although we had no facts to lead us to suppose that the patient had been affected with syphilis during the preceding ten years : except the appearances I have described. In a week after the commencement of mercury, the ulcers were completely healed, but the opening in the palate bone did not close. The tenderness of the bones of the nose, and the disposition to fistula lachryiiialis, were also removed. The course of mercury was, however, persevered in for two months, during which period he rubbed in eight ounces of ointment, which sustained for almost all CONFOUNDED WITH VE^SEREAL. 333 that time a full mercurial action. He has since re- mained perfectly well. If a similar case was to occur to me at present, my reader is by this time satisfied that I should deem it sufficient to give mercury in alterative doses, conjoined with the simple or compound de- coction of sarsaparilla.* The following case was so treated. Case 56. — On the 12th of June, 1815, 1 was call- ed upon to see a young unmarried lady, whose con- dition and morals placed her altogether beyond the reach of suspicion ; yet the symptoms with which she was affected precisely resembled those which are undoubtedly of venereal origin. There was a considerable number of large tubercles similar to those described in the last chapter, scattered over her legs, arms, and thighs, attended with discolour- ation of the integuments. She complained of sorer ness of her throat ; and on examination, I found the back of the pharynx ulcerated and covered with white tenacious matter, evincing a similar corre- spondence between the affection of the skin and throat to that which I had often witnessed in ve- nereal cases. Her tongue was white and furred, with bad appetite and general derangement of the system. I merely regulated her diet, ordered five grains of blue pill every night, and three drachms of sul- * Mr. Abernethy gives a case perfectly analogous to this, in sup- port of similar opinion, of which he has the merit of being the first promulgator. See Abernethy on Diseases resembiing Syphi- lis, page 80, 334 DISEASES LIKELY TO BE phat of magnesia every morning, under ^vhich plan she had perfectly recovered before the 12th of July following, when I ceased to visit her. I might adduce many instances of similar tuber- cles terminating in ulceration in children, in whom they are generally esteemed to be the signs of a strongly marked scrofulous constitution, and cannot be suspected to be venereal complaints, because they occur too late after birth to be ascribed to a venereal taint derived from the parents ; and too early in life to be visited as an imputation on the young patients themselves. But by whatever name the disease may be called, it is in children, as well as in adults, accompanied by general derangement of the constitution ; and vields in both to the same inode of treatment, viz. small alterative doses of mercury, conjoined with decoction of sarsaparilla. I shall only add two other cases in illustration of the constitutional diseases which are liable to be mistaken for those of venereal origin. Case .57. — John Larkin, a very young man, ad- mitted July 3d, 1816, with an extensive phagedenic ulcer of the throat, engaging the velum, tonsils, and back of the pharynx. The entire uvula and a con- siderable portion of the velum and tonsils had been destroyed by the disease, and he complained of se- vere head-ach and deafness. According to his statement, the ulcer commenced about six months previous to his admission, with- out his having had any primary affection, and he persisted in affirming that he never had sexual con- nexion in his life. He also stated that the practi- CONFOONDED WITH VENEREAt. 335 tioner whom he had consulted, did not appear to believe his assertions, as he put him through two severe mercurial courses, which, however, did not produce any beneficial effects upon his throat. I directed for him the decoction of sarsaparilla, antimonial solution, and the following lotion, with which the ulcer of his throat was touched every third hour. R. Muriatis Hydrarg. cor. (sp. vini. solut.) gr. sex. Aquae, distillatse unciam cum semisse. Mellis despumati semiunciam. Under this plan immediate amendment ensued ; the ulcer was healed before the 28th, and he was discharged the hospital on the 3d of August. Case 58.— On the 8th of July, 1816, 1 saw Cap- tain S. in consultation with Doctor Little, of Tuam, on account of a disease of the bones of the nose, at- tended with a most offensive discharge. The car- tilage of the nose was much depressed in conse- quence of the want of its usual support, owing to the destruction of the vomer and perpendicular car- tilage attached to it. The greater part of the spongy bones were also destroyed; and on examination with a probe, all the bones forming the walls of the cavity of the nose felt rough and carious. — The commencement of this complaint occurred, as he stated, near two years previous to his application to me, and took place at a period when his bodily health and strength were greatly reduced by most fatiguing military duties, and an intermittent fever, caught in the marshy parts of Canada. He stated in the most positive manner that he had not been 336 DISEASES LIKELY TO Bft affected for as long a period as fifteen or sixteen years before with any venereal complaint, an asse- veration which the surgeon of his regiment seemed not to regard with much attention, as he put him through several severe courses of mercury, which reduced him to the lowest extremity, without pro- ducing any amendment of his complaints ; on the contrary, he always felt himself worse when mer- curially affected, and during the use of that medi- cine, extensive exfoliations occurred. When leaving Canada, he was so much enfeebled that he was carried into the vessel; but during the voyage and after his return to Europe, he rapidly regained his strength. Large exfoliations, engaging portions of the bones of the nose, palate, and upper jaw, continued to come away, from time to time, for the next ten months, during which period several medical men were consulted and a variety of remedies were em- ployed. Attention to cleanliness and country air seemed, however, to be the only means from which he derived any advantage. At length intense head- achs, and a tendency to delirium at night, made me suspicious that the disease had extended to the bones which supported the brain, and affected that organ. On the 14th of June, 1817, 1 was called upon to see him. — His manner was quick and irritable, pulse 1 12, tongue furred. He complained of a distract- ing head-ach and intolerance of light. General and local blood-letting was resorted to, and the exhibi- tion of active purgatives. — On the 16th his pulse CONCLUDLXG OBSERVATIONS. 337 was 120, and he lay comatose. In the evening con- vulsions set in, and he died a few hours afterwards. . On examination of the head, the vessels appear- ed remarkably turgid; and coagulable lymph was found in a greater degree than is usual even in in- flammatory infections of the head, effused over the pia matter. On cutting through the right anterior lobe of the brain, it presented a yellow tallow-like appearance, and was of a very soft consistence; and on penetrating deeper, near to its lower surface where it lay on the orbitar plate, an abscess was found about the size of a walnut, containing a tena- cious, turbid, flaky fluid of the colour of pus. The cribriform lamella of the sethmoid bone was com- pletely carious, and adjoining this the right orbitar plate of the frontal bone upon which the abscess lay, presented a yellow unsound appearance. The ventricles were filled with a fluid similar to that contained in the abscess, and there was a large quan- tity of the same matter accumulated about the me- dulla oblongata. It appeared to make its way by the fourth ventricle, and to have also passed into the sheath of the spinal marrow. Persons of judgment and discrimination will know how to estimate the value of the cases detailed in this work, because the great majority of them rela- ted to persons in a humble sphere of life. Those who seek an asylum in hospitals aflbrd better ex- amples of the progress of diseases, and the effects of remedies upon them, than the cases of private practice. This is more particularly observable in 2 u •^38 CONCLUDING OBSERVATIONS. the maladies under consideration. In the mode of practice for so many years prevalent, as soon as a private patient had undergone a severe course of mercury, without amendment, and that his medical attendant, seeing the inutility of a farther perseve- rance in that medicine, laid it aside, he usually sought the advice of a second professional man, who perceiving that a sufficient quantity of mercury had not been exhibited, put his patient through another course. The disease still gaining ground, a third, or a fourth was consulted, till at length he ran the gauntlet through the greater part of the profession, each practitioner inflicting on him his own favourite mode of administering his specific. At last the un- fortunate patient, with broken constitution, spirit, and resources, possibly returned to the advice of his first attendant, with regret that he ever sought any other. But it is not from him, or those of our fra- ternity who were most familiar with his symptoms, that it is now possible to obtain a satisfactory his- tory of his complaint, except in a single point— the inefficacy of repeated courses of mercury for its re- moval. Therefore, I say, it is only from the regis- try of a hospital that we can gain a faithful account of the symptoms and progress of these obstinate diseases, where the patient is restricted to the regi- men and medicine prescribed by the surgeon of his ward, and not allowed to indulge his own fancy and caprice in wandering from one practitioner to ano- ther, or in employing in a clandestine manner, means not known to his medical attendants. But as al- most all our registered experience of venereal dis- CONCLUDING OBSERVATIONS. 339 eases seems to be taken from private practice, we should not be surprised at finding that the promi- nent facts stated in this work are not to be found in other publications on the subject: orif they are hint- ed at, that they should, either from preconceived opinions, be distorted, overlooked, or laid at the door of the remedy so long and so pertinaciously exhibited without benefit. — Thus both the acute and the lingering pains in the joints, are very gene- rally ascribed to mercury, and not to a venereal virus ; and even a modern author, who has written expressly on the subject, has attributed to the ex- cessive use of this medicine, eruptions, ulcers on the skin and throat, and nodes on the bones. A mis- take we cannot be surprised at, when we recollect how lavishly it is used in those venereal diseases which do not yield to its influence ; and the frequent appearance of these symptoms, while the patient is suffering the most severe salivation. The variety of venereal appearances, and the modification and change which they are perpetual- ly undergoing, together with the fact, that these maladies are not exactly alike in any two countries ; and the consequent frequent introduction of new symptoms, by m.eans of foreign infection, require that we should be always on the watch, with a view to ascertain the nature of the most prevailing vene- real complaints ; for I have constantly observed that there is a predominant infection for a season, which in general, on the succeeding, gives way to an- other. It may be considered a strong corroboration of 340 CONCLUDING OBSERVATIONS. the opinions supported in this treatise, that relapses were far more frequent in all venereal diseases (the scaly or vSyphilitic excepted,) when mercury had been used, than when they were treated exclusive^ ly, by the other means recommended. And in clos- ing these pages I have the gratification of stating, that after several years of observation and scrutiny, during which, the symptoms and progress of these diseases were constantly and carefully watched and followed, I have not met with any circumstance to induce me to doubt the principles I have endeav- oured to enforce in the course of this work. Having now brought this complicated subject to a close, and endeavoured to put in order a numer- ous class of symptoms, which it has been often said bid defiance to any system of arrangement, it may be well, in concluding the work, to present them to the understanding of my reader according to 'their classification, detailed in a tabular form ; and I shall only remark, that a classification of venereal com- plaints, grounded on the character of the eruption, is not only the most natural, and most in accordance to the pathological arrangement of other eruptive dis- eases attended with fever, but it is also, in a practi- cal point of view, the most useful that can be de- vised ; — for the general tendency of the disease, either with respect to mildness, severity or duration, may be anticipated by the character of the erup- tion. SYNOPSIS. I. PAPULAR VENEREAL DISEASE. Primary Symptoms, l.The simple primary ulcer, 2. Patchy excoriation, attend- ed with a discharge, 3. GonorrhcEa virulenta, 4. Buboes, R'emedies. Astringent washes. Antimonials. Purgatives. Astringent washes. Antimonials. Terebinthinates. Leeches. Cold applications. Blisters. Poultices. Secondary Symptoms, 1. Papular eruption, preceded by fever, and ending in desquamation, 2. ^rithematous inflamma- tions of the fauces, 3. Swelling of the tonsils and glands of the neck, 4. Pains in the larger joints resembling rheumatism. 5. Iritis, General blood-letting to be adopted when indicated by the fever, and proportioned to its degree. Antimonials. Sarsaparilla. I Mercury unnecessary in any ^ stage ; and highly injurious un- til the eruption desquamates,, the fever is subdued^ and the disor- der is evidently on the wane; and then an alterative course of antimony and calomel may oc- casionally accelerate the cure, [Full mercurial affection of the j system until the inflammation is -^ subdued. i Local bleeding, l^ Blistering. 342 STNOPSIS. II. PUSTULAR VENEREAL DISEASE. Primary Symptoms. I. The ulcer with elevated edges, without induration. 2. Buboes. Secondary Symptoms, , Eruption of pustules in ge- neral phlyzacious, preced- ed by fever, and terminat- ing in ulcers covered with thin crusts that heal from their margins, and when the disease is on the wane, the eruption desquamates into scaly red blotches. Remedies. Astringent washes. Antimonials. Purgatives, The same treatment as for the buboes in No. I. Excision of the undermined edses of the bubo. ^General blood-letting, as in No. I. Antimonials. Sarsaparilla. Guaiacum. Tar Ointment. Baths of sulphurated kali. Sulphureous fumigations. Nitro-muriatic acid baths. 2. Ulcers on different parts of Mercury is decidedly pernicious until the pustules terminate in scaly blotches instead of forming Vilcers ; and then mercurials^ in alterative doses^ conjoined -with sarsaparilla or guaiacum, may occasionally he employed v)ith benefit. The same general treatment, conjoined with the following local applications : Common detergent gargles. iv^.o v,w ^ r-"- Lyommon ueiergei the fauces, m general o\ . ^^^^^^,[^1 gargles a white apthous appear- ^ Qxymel ^ruginis ance. Fumigations of Hydrarg. Sulphuret. rub. or of Hy drarg. cum Creta. SYNOPSIS. 343 o. Pains in the joints. 4. Nodes. ^The same general treatment, conjoined with the following local applications : Leeches. Fomentations. Bread and water poultices. Blisters. Ointment of tartarized anti- mony. Mercury is to be particularly avoided while inflammation of ^the knee exists, f The same general treatment, conjoined with the following local applications : Leeches. Bread and water poultices. Blisters. •