TANDARD MEDICAL FEBRUARY LON THE -Cf-LEC-E OF OrSTEOFATf-ffC ^fCf/:fi PATHOLOGY AND TREATMENT OP GONORRHCEA! BY Jd^L. MILTON, SENIOR SURGEON TO ST. JOHN'S HOSPITAL, FOR DISEASES OF THE SKIN, LONDON FIFTH EDITION NEW YORK WILLIAM WOOD & COMPANY 56 & 58 LAFAYETTE PIACE 1884 nO MJ OltriWWC - ,n^ ' ^ TROWS miNTIHG AND BOOKBINOmO COUPANT, HEW YOflK. PREFACE. THE following work contains, in an abridged form, the substance of the earlier editions ; the papers on scalding, chordee, and gonor- rhoea printed in the Medical Times / those on the treatment of gon- orrhoea published in the Medical Circular, and several papers read before the Medical Society of London and the Korth London and Western Medical Societies.' The sections on the treatment of gleet, on gonorrhoea in the female, on orchitis, and on gonorrhoeal rheumatism, have been revised and amplified. Those on gonorrhceal affections of the heart and peri- cardium, the peritoneum and pleura, dura mater and sheath of the spinal cord ; on gonorrhceal pyaemia, pyelitis, etc., are now added for the first time. With the view of reducing the bulk of the work, many of the cases given in the first edition have been omitted, and those which are retained have been selected chiefly as examples absolutely necessary to show the power of certain remedies, or because they illustrate peculiar forms of the disorder which have been rather overlooked. It was in- dispensable to retain these in a work intended, not for a class book, but as one of reference for the busy practitioner. The same reasons which induced me to leave out superfluous cases, make it incumbent to dispense with all description of symptoms. It is not to be expected that the adverse judgment passed upon many remedies, which have been at one time or other so strongly ad- vocated, will prove acceptable to those who recommended them to public favor. But for this there is no help. Experience compels me IV PREFACE. to say that they have not fulfilled the expectations which the first accounts of them were calculated to raise. Whether the attempt now made to prove that gonorrhoea may, when admitting of removal, be cured without the use of the so-called specifics, is hased on sufficient grounds or not, it would ill become me to say. This much, however, I can vouch for ; the doctrines I have ventured to lay down have been pretty severely tested. Nothing ha& been recommended by myself in this work but what has stood the brunt, not merely of experience, for that I rate rather low, but of special observation. My aim was, as far as possible, to separate clearly what might be looked on as established from what was doubtful, and not merely to prove every assertion, but to place it on such a basis that it could not be disproved. How far I have succeeded I leave to the decision of my readers. For the remedies advised, or the views up- held, by other authors, I do not hold myself answerable. I considered my task was to select what seemed most likely to improve treatment, and only hope I have executed it in a satisfactory way. That such a work was needed is proved by its steadily increasing sale among the profession ; that the mode of examining the thera- peutic action of remedies, adopted in it from the very first, was sound, is shown by so many authors having testified to the accuracy of the results obtained, as also by the British Medical Association having appointed a committee to carry out the same method, but, with all deference be it said, in a much less exact and complete shape. 18 SUFFOLK STREET, PALL MALL, LONDON, S. W., and SIGN HOUSE, KING'S ROAD, S.W., Nmember, 1883. CONTENTS. CHAPTER L HISTORY OF GONORRHOEA, p. 1. CHAPTER H. PATHOLOGY or GONORRHCSA. GENESIS OF GONORRHCEA A, IN- THE MALE, 12 ; B, IN THE FEMALE, 26 ; Point at which Infection takes place in the Male, Seat of Gonorrhoea in the Male, 32 ; Period of Incubation, 37 ; Seat of Gonorrhoea in the Female, 38 ; Period of Incubation, Milder Nature of Gonorrhoea in subsequent Attacks, 39 ; Does Gonorrhoea infect the System ? 40 ; Prognosis of Gonorrhoea, Results of Gonorrhoea, 40 ; Origin of Gonor- rhoea from a Fungus, 45 ; Micrococcus peculiar to Gonorrhoea, 46 ; Varying Duration of Gonorrhoea Connection between Inveteracy and Diathesis, 49. CHAPTER HL TREATMENT OF GONORRHCEA. VARIETY OF REMEDIES RECOMMENDED, 54 ; Continuance of the same funda- mental Principles of Treatment, 55 ; Sydenham's Treatment, 58 ; Moyle's, 59 ; Marten's, 60 ; Turner's, 61 ; Cockburn's and Astruc's, 62 ; Hunter's, Howard's and Foot's, 64 ; Sir Astley Cooper's and Judd's, 65 ; Expectant Treatment, 68 ; Gonorrhoea as. a Cause of Stricture, 70 ; Table I. Cases of Gonorrhoea Treated in different Ways, 71. VI CONTENTS. CHAPTEK IV. TREATMENT OF GONORRHCEA (continued). CLASSIFICATION OF KEMEDIES. A. INTERNAL REMEDIES : 1. Copaiba, 73 ; Table IL Cases treated with Copaiba, 75 ; Dose and Mode of giving Copaiba, 77 ; 2. Cubebs, 80 ; 3. Kava-kava, 81 ; 4. Turpentine, 82 ; 5. Ngan-Plang, 83 ; 6. Matico, 83 ; 7. Oil of Sandal-wood, 84 ; 8. Gurgun or Gurghun, 87 ; 9. Erigeron Oil, 87 ; 10. Antiphlogistic Means, 88 ; 11. Purgatives, 89 ; Table IH. Cases Treated with Pur- gatives, 90 ; 12. Aperients, 91 ; Table IV. Cases Treated with Aperi- ents, 91 ; 13. Diuretics, 94 ; 14 Alteratives, 94 ; B. EXTERNAL APPLI- CATIONS : 1. Cold Applications, 95 ; 2. Hot Applications, 96 ; Form for calculating Action of Remedies, 96 ; 3. Sedative Applications, 98 ; C. DIRECT APPLICATIONS : 1. Injections, Variety of Substances used, 100 ; Can Injections bring on Stricture and Orchitis ? 105 ; Nitrate of Silver, 110 ; Table V. Cases Treated with strong Injections of Nitrate of Silver, 111 ; Chloride of Zinc, 113 ; Table VI. Cases Treated with Injections of Chloride of Zinc, 115 ; Table VIE. Cases Treated by Ricord, 117 ; Table VllL Cases Treated by Judd, Duration of Treat- ment under various Injections, Nitrate of Silver Pastilles (soluble Bougies), 118 ; Glycero-Tannin Rods, 120 ; Conclusions, 121 ; Pro- posed Plan of Treatment A. IN THE MALE, Abortive Treatment, 122 ; Ordinary Treatment, 124 ; Injections, 126 ; Syringes, 128 ; Mode of Injecting, 129 ; The long Urethral Syringe, 132 ; The Caustic Plug, 134 ; Cauterizing the Urethra, 136 ; Blistering the Penis, 137 ; Search for Complications, 140 ; B. IN THE FEMALE, 142 ; Injections, 143 ; Chronic Inflammation of Canal of Cervix, Uterine Discharges, 145 ; Ovaritis, 146 ; Affection of Duverney's Glands, 148 ; Abscess of Labia Majora, Inflammation of erectile Tissue of Vagina, Excessive Men- struation, Pain in Back, etc., 149 ; Diet, 150 ; Smoking, 151. CHAPTER V. TREATMENT OF GONORRHCEA (continued). COMPLICATIONS WHICH DO NOT INTERFERE WITH THE CUBE OF GONORRHCEA. 1. SCALDING : Pathology, 153 ; Treatment, Remedies usually recom- mended, 1. Anodynes, 156 ; 2. Demulcents, 157 ; 3. Diuretics, 157 ; 4. Alkalies, 158 ; Probable Explanation, Proposed Plan of Treatment, 161 ; 2. CHORDEE : Pathology. 162 ; Prognosis, Results, 165 ; Treat- ment usually adopted, 186 ; Proposed Plan of Treatment, 167 ; 3. SYMPATHETIC BUBO, 169 ; 4. IRRITABLE BLADDER, 169 ; 5. ORCHITIS : CONTENTS. Vll Pathology, 179 ; Causes, 173 ; Table IX. Statistics of Orckitis, 171 ; Prognosis, Results, 187 ; Treatment usually adopted, 189 ; Puncture of the Tunica Albuginea, 191 ; Puncture of the Tunica Vaginalis, 194 ; Strapping the Testicle, 1 95 ; Mr. Gay's Treatment, 196 ; M. Bonna- font's, M. Langlebert's, 197 ; Proposed Plan of Treatment, 198 ; Blistering the Scrotum, 200 ; Subsequent Treatment, 201 ; Deferenti- tis, 202 ; Inflammation of Spermatic Cord, 202 ; 6-7. PHIMOSIS AND PABAPHIMOSIS, 203 ; 8. BALANITIS, 204 ; 9. INFLAMMATORY SWELLING OF THE PENIS, 205 ; 10. INFLAMMATION OF THE SPONGY AND CAVERNOUS BODIES, 206. CHAPTER VI. TREATMENT OF GONORRHCEA (continued). COMPLICATIONS WHICH INTERFERE WITH THE CURE OF GONORRHCEA : 1. FAINT- ING FROM THE USE OF INJECTIONS, Cases, 207 ; 2. GREAT NATURAL OR INDUCED WEAKNESS, 209 ; Cases, 209 ; 3. TENDENCY TO INFLAMMATION OF THE LACUNA OF THE URETHRA, 212 J 4. MORBID SENSIBILITY OF THE URETHRA, 215 ; 5. STRONG TENDENCY TO STRICTURE, 216 ; Caustic- holders, 218 ; The Cage Bougie, 220 ; 6. RETENTION OF URINE, 221 ; Treatment, 221 ; 7. BALANITIS OCCURRING ALONG WITH PHIMOSIS AND STRICTURE, 222 ; 8. EXCESSIVE IRRITABILITY OF THE BLADDER, 222 ; 9. INFLAMMATION OF THE BLADDER, 224 ; 10. EXCESSIVE IRRITABILITY OF THE RECTUM, 224 ; 11. PERINEAL ABSCESS, 224 ; Cases, 225 ; 12. IN- FLAMMATION OF THE PROSTATE Pathology, Divisions : 1. Acute ; 2. Subacute or Chronic (Congestion of the Prostate), 226 ; Prognosis, Results, 227 ; Treatment, 227 ; 13. INFLAMMATION OF THE SEMINAL VESICLES, 228 ; 14. GONORRHCEAL PERITONITIS, 229 ; Prognosis, 230 ; 15. SUB-PERITONEAL INFLAMMATION, 230 ; Prognosis, Treatment, 230 ; 16. GONORRHCEAL PERINEPHRITIC ABSCESS, 232 ; 17. GONORRHCEAL (?) PYEUTIS AND NEPHRITIS, Cases, 233 ; 18. GONORRHCEAL (?) PLEURITIS, 234 ; 19. GONORRHCEAL RHEUMATISM, History, 234 ; Pathology, 235 ; Divisions, 240 ; Gonorrhoeal Synovitis, 242 ; Gonorrhoea! Sciatica, 244 ; Gonorrhceal Rheumatism in Women, 246 ; Complications, a-b, Gonorrhceal Endocarditis and Pericarditis, 247 ; c. Gonorrhceal Menin- gitis, 251 ; d. Gonorrhceal Myelitis, 252 ; e. Gonorrhceal (?) Hepatitis, 252 ; /. Gonorrhceal (?) Nephritis, 253 ; g. Gonorrhceal Pyaemia, 253 ; h. Gonorrhceal Adenitis, etc., 254 ; Mode in which Gonorrhoeal Rheu- matism is set up, Prognosis, 255 ; Treatment usually adopted, 259 ; Proposed Plan of Treatment, 258 ; 20. GONORRHCEAL AFFECTIONS OF THE EYE a. Ophthalmia, Pathology, 262 ; Prognosis, Treatment usually adopted, 263 ; Proposed Plan of Treatment, 265 ; b. Gonorrhceal Iritis, Vlll CONTENTS. Pathology, Prognosis ; c. Bheumatism of Eyeball, Pathology, 266 ; Prognosis, Treatment ; d. Aquo-capsulitis, 267 ; 21. STRONG TENDENCY TO BLEEDING, 268. CHAPTEK VIL PATHOLOGY AND TREATMENT OF GLEET. PATHOLOGY : 1. GONORRHCEA OF LONG STANDING, 269 ; 2. INVETERATE GON- ORRHCEA, 269 ; 3. Muco -PURULENT GLEET, 270 ; 4. PROSTATIC GLEET, 270 ; 5. PURE Mucous GLEET, 271 ; Dr. Otis's Views, 271 ; The Endo- scope, Auspitz's Researches, 273 ; Gleet of Cowper's Ducts, 276 ; Treatment A. IN THE MALE, 277 ; First Class Gonorrhoea of Long Standing, 280 ; The Bougie, 281 ; Nitrate of Silver, 284 ; Potassa fusa, 285 ; Blistering, 286 ; Diet in Gleet, 288 ; Complications of Gleet, 288 ; Second Class Inveterate Gonorrhoea, 289 ; Third Class Muco- purulent Gleet, 290 ; Fourth Class Prostatic Gleet, 290 ; Fifth Class Pure Mucous Gleet, Gleet of Cowper's Ducts, 292 ; B. IN THE FEMALE, 293. x INDEX . . . 295 ON GONORRHOEA CHAPTEE I. HISTORY. THAT gonorrhoea existed from a very early period is probable enough, but much of what has been written respecting the question is unreliable and conjectural in the highest degree. Mr. Berkeley Hill, quoting from Dabry, says ' that it was described 4,500 years ago in the collection of medical treatises made by the emperor Ho-Ang-Ti. I have not been able to obtain access to the work Mr. Hill quotes from, but I always heard that he was extremely painstaking, and I see nothing improbable in the statement. If, however, the Chinese writer's description of gonorrhoea be so full and ac- curate that we can unequivocally recognize the disease, it is not merely the earliest, but the only unimpeachable, account to be found for at least thirty-six centuries after. M. Chabalier traces the descent of gonorrhoea from the time of Moses downward, in a memoir 2 perhaps never yet surpassed for elegance and scholarship ; but while I cheerfully accord to it all praise on this head, I must contend that his desire to carry his point sometimes gets the upper hand of his judgment. The cause could scarcely have been taken up by a more able advocate, but even in his hands it is one of the weakest ever yet argued for. He begins with the often-cited passage from Leviticus, about a person with a running issue out of his flesh. He maintains that this must be gonorrhoea, although in the very next verse we are told that such a person is equally unclean, whether his flesh run with or be stopped from his issue ; as if any human being could identify a complaint described in such terms, which so far as we can understand them at all, might just as easily mean an ulcer of the leg with or without proud flesh in it. The fact is that men speak very confidently about diseases, e.g., syphilis, lepra, ele- phantiasis Gra?corum and furunculus, being portrayed in the writings of 1 Syphilis and Local Contagious Diseases, p. 6. 1868. 2 These pour le Doctorat en Medecine. 1860. 2 ON GONORRHOEA. Moses ; but in reality any description found there, of any one of these diseases, would at once break down if confronted with the simplest defini- tion of the complaint ever yet given, and all the more certainly when we recollect how doubtful we must ever feel about the nature of much of the translation from the Hebrew writ. M. Chabalier's next contention is that Hippocrates described five kinds of leucorrhoea, irrespective of those arising from inflammation of the womb. But a description of five and fifty would bring us no nearer the mark unless it showed that one of these was a purulent inflammation of the vagina and urethra derived from intercourse, and in its turn conveying infection to the male ; and I presume M. Chabalier will admit that this is one of the things which we do not find in Hippocrates. As to the quota- tion from Herodotus next brought forward by M. Chabalier, about the Scythians being afflicted with a running from the penis, I must, for rea- sons given elsewhere, 1 affirm that there is not the least justification for such a rendering of the passage, which clearly refers to a visible and here- ditary complaint. If M. Chabalier will bring forward the name of any commentator or lexicographer, who has thus translated in print the Greek adjective used by Herodotus, I will at once admit that he may be right ; till then I must contend that he is entirely wrong. The meaning of the term is hidden in impenetrable obscurity, and though it was used for ages after, only the vaguest of ideas was attached to it. But for one fatal ob- jection I should feel inclined to take part with Astruc, who, quoting from Hippocrates, says these Scythians were simply eunuchs who dressed like women and did woman's work. The objection is that the complaint was considered to be hereditary, and that in no . age or country did eunuchs ever do anything of the kind. After Herodotus comes Celsus, who is ushered forth as describing gonorrhoea and orchitis. No better authority than that of the famous old Roman surgeon need be asked for, if we only felt sure that we are dealing with attested facts. But the truth is that Celsus never does anything of the kind. He describes primary sores, balanitis and phimosis, but as to gonorrhoea, there is, in the whole of his work, not merely no definition, but not one unequivocal symptom of it, and the orchitis he mentions was most probably hydrocele. Certainly it was not gonorrhoea!, for he speaks of it as arising without inflammation, a very unlikely account for so great an observer as Celsus to give of an affection which bears all the visible marks of this state. Besides, if Celsus had been at all acquainted with gonorrhoea! orchitis, he would have referred it to its proper cause ; the connection between the inflammation of the urethra and that of the testicle is so direct and so palpable, that I question whether any one ever yet made a mistake as to what gonorrhoea! orchitis was due to. The same may be 1 A History of Syphilis, p. 2. 1879. HISTOEY. 3 said of at least two or three antecedent symptoms. Among many gonor- rhoea patients some will be sure to have the disease in a severe form, and I should say that the constant recurrence of thick discharge, turgescence of the penis, scalding and chordee, could not fail to rivet the attention of the most superficial observers. In every community yet discovered, where the inhabitants were found to be capable of distinguishing the right hand from the left and daylight from darkness, it has been observed, I believe without a single instance to the contrary, that if gonorrhoea had settled among them, it enjoyed not merely a local habitation but a name also. For this, among many other reasons, I believe that gonorrhoea was totally unknown to the Romans. Even supposing, what seems to me incredible, that it had by chance es- caped the observation of Celsus, the entire absence of all mention of it, in the works of Horace, Juvenal, and Persius is, in my opinion, sufficient to establish the position I have taken up. I consider it as certain that, had gonorrhoea existed at all in Rome at their time, they would have known of the fact ; and most improbable that, had they been acquainted with the disease, they would have failed to notice it. They were not likely to be restrained by any scruples of delicacy from touching upon such a ques- tion, for no set of men ever exercised less reticence in dealing with these topics than the Roman satirists ; Juvenal in particular was certainly out- spoken enough, and might be said to write professedly about such mat- ters. For much the same reasons too I must entirely reject the evidence of Cicero, whom M. Chabalier arrays in his cause on the strength of a passage to the effect, that those who are incontinent suffer from dysuria, a term which seems to have meant indifferently stricture and strangury. But the passage, if it can be considered to prove anything at all, shows that Cicero was totally unacquainted with gonorrhoea. Strangury is by no means a constant sequela of this affection, and not unfrequently attacks persons who have never been affected at all. Even in the incontinent, gonorrhoea is not in any way a necessary medium. I presume M. Chabalier is aware that the first Napoleon suffered rather severely from strangury during the Russian camgaign, and was at all times incontinent enough ; yet there is no evidence that he ever laid the foundation for the strangury by catching a gonorrhoea. Lastly, I must express my conviction that Cicero was not at all likely to have been so familiar with a disease, unknown to Juvenal and Celsus, as to make his opinion of any weight. Indeed I ought perhaps to say that the words quoted seem to me as destitute of anything like a definite meaning, or a basis of truthful observation, as a passage in Pliny or Rhazes generally is. M. Chabalier next quotes the very doubtful authority of John Mesue, a Syriac or Persian writer, whose era, to begin upon, is so uncertain that biographers differ as to the date of his death by six or seven and twenty 4 ON GONORRHOEA. years ; ' while there is good reason to believe that his works are a forgery, an utter, and in one respect a clumsy, imposture, Rhazes, who lived a century later, being quoted. 2 But though as a question of history such evidence is worthless, it yet goes to show that, at the time of the imposture or interpolation being perpetrated, gonorrhoea was in existence, as we are told that the patients suffered, among other symptoms, from itching or tickling at the orifice of the urethra and painful erections. If, therefore, we could fix the date of the writing, the passage quoted from would con- stitute a valuable landmark, but I cannot see in the least how this is to be done. M. Chabalier then proceeds to deal with the testimony of Haly Abbas, who lived in 980, and who speaks of obstruction of the meatus produced by a sufficiently large quantity of viscous humor which glues it together ; of the urine burning and of micturition being difficult, symptoms which al- most certainly point to gonorrhoea and to it only. But indeed the time when this disease was to appear indisputably on the scene in the shape of the Syknesse of Brennynge, and to be a source of shame and torment to man ; when the first absolutely reliable landmark in its history, the recog- nition of its contagious character and propagation by sexual intercourse, was established and acted upon, though far off, still drew near. After Haly Abbas comes Rhazes, the Persian, who however in strict order of time should have preceded him, having died in 932 at the age of eighty. From him M. Chabalier has contrived to extract the information, that he men- tions the case of one Machumet, a patient, of whom he predicted that he would have a gonorrhoea because he had seen a few drops of pus precede the urine. The result is creditable to M. Chabalier's industry ; but by what strange chance an author, who spent the first forty years of his life in the study of music, philology, and philosophy, and who during some part of the remainder, for he went blind, wrote at such a rate that he left two hundred and twenty-six works behind him ; who took to physic in comparatively old age, and could never have gained his knowledge at the source best worth notice, the strict and patient watching of disease ; who borrowed what was good in his writings from the Greek writers and heaped a perfect Pelion upon Ossa of verbiage on the top of it, ever got at an original idea at all, is more than I can make out. After this the disease is traced through a long succession of authors. Thus Avicenna describes internal ulcers of the penis with itching of this organ, due to the effusion of acute matter into it ; Alsaharavius says we may prognosticate ulcers of the penis and bladder when there exists a dis- charge of putrefied pus. But that Avicenna ascribes a contagious quality to this discharge, I should have to pass by his testimony, while that given 1 Dictionnaire Historique, tome iii., p. 284. Par H. F. J. Eloy. 1778. * The History of Physick, Part II., p. 38. By J. Friend, M.D. 1726. HISTOKY. 5 "by Alsaharavius is of the weakest nature. The strictures which Albucasem recommends should be treated with leaden sounds were not improbably of gonorrhoeal origin, and Constantiue the African, who flourished toward the end of the eleventh century, may mean the same thing when he recom- mends soothing measures for the contraction produced by a purulent run- ning. Gariopontus of Salemurn (eleventh century) describes blennorrha- gic cystitis, but the evidence is anything but conclusive ; the symptoms are more severe than those ever seen in neglected gonorrhoea, and they are not traced to such a source. Tortula, a century later, speaks of balanitis ; evidence which I think we may reject as weak. Kogerius describes a dis- ease marked by heat, pricking pains, and burning, with redness and in- flammation of the penis ; almost certainly gonorrhoea. This author seems also to have been acquainted with orchitis. M. Chabalier says, that John of Gaddesden (beginning of fourteenth century) describes blenorrhagia and recommends a suspensory bandage for orchitis, the latter piece of evidence being, I suppose, decisive. John of Concorreggio, he says, describes or- chitis, and John Arcalanus gonorrhoea! cystitis and running, recognized by issue of blood or sanies, or both, with pricking or biting pains. Guy de Chauliac prescribes injections when heat and foul discharge (foetiditas) show themselves on account of connection with an infected woman ; also fairly decisive evidence. John of Arden (toward close of fourteenth century) counsels injections against internal burning and excoriation of the male yard. Andrew Boord, 1546, and whose account is here accordingly rather a chronological mistake, speaks of the contagious nature of the complaint ; and lastly M. Chabalier cites the evidence of Bernard Gordon, which he had better have left out, the testimony being of anything but a convincing nature ; the utmost we can extract being that among the affections of the penis he ranks pain, swelling, and itching. Thus far M. Chabalier. There are, however, authors who go a long way beyond him, and if we were guided by what they say, we might safely con- clude that the genealogy of gonorrhoea can be as clearly traced through a long chain of written evidence as the house of Guelph or Este could. There is, however, really no warrant for any such conclusion. True, a host of writers can be selected from the works of Gruner, Hensler, Astruc, and Luisinius, who speak of gonorrhoea, and those who consider such evidence as decisive can easily make out a case for an almost unbroken history of the disease from a very early date down to quite a recent period. But this is far from the true state of the question. Undoubtedly these writers treat of gonorrhoea, but under that name they not only comprehend, but some of them exclusively describe, seminal emissions and their results. What we now term spermatorrhoea was the parent disease, of which gon- orrhoea was, by the few who really noticed it, considered to be a variety. From the time of Galen and Pliny downward we find occasionally depict- ed a form of seminal flux which was considered infectious, and so far as 6 ON GONORRHXEA. such evidence can be supposed to be worth anything at all, it helps to prove the antiquity of the disease. But every now and then every trace even of this, and indeed of every symptom of gonorrhoea, disappears, and we are face to face with a picture in which we find only some form of spermatorrhoea, not one symptom of the other, not a tittle of evidence that the author had ever seen a case of gonorrhoea, or had appreciated the nature of the complaint. This occasional mysterious silence is easy to trace when we turn to the mediaeval writers, and pursue the thread of history up to the epoch of syphilis ; and I think M. Chabalier himself would be rather puzzled to find in some of their descriptions anything like a picture of gonorrhoea. For instance Constantine of Carthage is often quoted as familiar with this affection, and the following is the account given by the African physician. " Owing," he says, " to deficient power of that retention which is natural to the vessels containing the semen, this passes away involuntarily, without desire for connection and without pleasure ; the act takes place without erection or orgasm of the seminal vessels." Comment upon such a de- scription is quite superfluous, for it cannot be held to apply in any way to urethritis. Arnold of Villanuova and Hugh Bencius seem to have stood in exactly the same position as Constantine, that is to say they were ac- quainted with spermatorrhoea ; beyond this their knowledge did not go. There is ample ground to think that this was the case with the great ma- jority of the writers mentioned by Hensler as speaking of gonorrhoea, and certainly those, whose words he does quote, describe in every instance an affection identical in nature with that described by Constantine. I should be inclined to limit the number of those we can suppose to have been acquainted with blennorrhagia, strictly to those who speak of the contagious nature of gonorrhoea, or who, like the writer of Mcsue's works, give us such symptoms as itching of the meatus, scalding, and painful erections ; all reference whatever to writers who simply use the word gonorrhoea, without such evidence being extracted from their works as will satisfy us that under that term they understood what we now under- stand, being rigorously excluded. This materially shortens the task in hand, for the others are easily dealt with. If to the evidence taken from the reliable authors quoted by M. Chabaher, we add that possibly Pliny and Galen were in some degree ac- quainted with gonorrhoea, as the idea that the semen, in certain states of deterioration, acquires a poisonous quality may be traced back to them ; ' that Avicenna describes a form of gonorrhoea of that day marked by mor- dication, painful erection, and scalding ; " and that Valescus of Tarentum, one of the first authors who for ages wrote only from experience, knew gonorrhoea, but evidently considered it a form of emissions, we have, con- 1 Hensler's Geschichte der Lustseuche, S. 190. s Ibid., p. 178. HISTORY. 7 centrated in the few foregoing lines, all the lore of gonorrhoea scattered through fourteen centuries. I see no reason to think that we can track its history through an uninterrupted descent down to the epoch of syphilis. On the contrary the account of it constantly breaks off as abruptly as any old fragment of a nursery tale ; the disease vanishes, if not from human at least from medical ken, and complete obscurity envelopes the scene for long periods together. Hensler at once admits this. Too honest to wrest evidence to his purpose, he confesses himself unable to understand how it happens that the outline of the disease is at one time expanded to its nor- mal dimensions, at another contracted to such narrow limits, and again at another lost in impenetrable darkness. Between the latter part of the twelfth century and the era of syphilis there flourished eight men who stand prominently forward as speaking with some degree of authority on these subjects. They are Michael Scott, William of Salicetus, Lanfranc of Milan, Peter d'Argelatta, Valescus of Tarentum, John Ardern, John of Gaddesden, and Bernard Gordon. The four first seem to have been totally ignorant of gonorrhoea ; I see no evidence in the quotations from their writings that they had ever suspected its existence. The fifth, as already mentioned, describes nothing more or less than spermatorrhoea, and the evidence of Gordon is too weak to be relied on. With the arrival of what is generally known as the first invasion of syphilis, gonorrhoea disappears from the scene with a suddenness and com- pleteness calculated to surprise us, when we consider how widely, compar- atively speaking, knowledge was now diffused by means of printing. Benedetti seems, according to Hensler, to have been acquainted with the disease, that is to say he was most probably acquainted with the seminal discharge, and had heard, like so many more, of the name. From the same author we learn that faint traces of a knowledge of gonorrhoea are to be found in Marcellus, Griinbeck, Steber ; but such dun and scanty mem- orials are valueless for the reason already urged, that unless an author's definition is given, we never know whether we are dealing with the gonor- rhoea of modern days or not. Indeed this was then so unknown or over- looked, that Hensler says that, during what he calls the first period of syphilis, the epoch of its imagined malignity, he can scarcely find a trace of the name and none of the disease itself ; and it is to be remembered that the name embraced every discharge from the urethra. With the arrival of the second period, that of the decline in syphilis from its first intolerable fury, gonorrhoea resumes its place in nosology, being now, 1504 or 5, described by James Cataneus in a work which Hen- sler and Astruc agree in praising as the best of its kind that had ever yet appeared on these subjects. Cataneus indeed was greatty in advance of all previous writers, especially as regards the contagious nature of the affection ; he had evidently studied Nature quite as much as he had Galen and Avicenna, and he studied her better than they did, for he penetrated 8 ON GONORRHOEA* farther into her secrets. He not only speaks of gonorrhoea being conta- gious, but says that it may arise without the infecting person having an ulcer. He even taught ' that a woman, who had cohabited with an affected man, might, while herself healthy, convey the disease ; the first clear, un- equivocal announcement, I believe, of its contagious qualities before the days of Paracelsus. Benedetti seems to have been familiar with the name, but I have not been able to make out whether he was acquainted with the disease itself. Another turn of the kaleidoscope of Time and the disease again van- ishes. Hensler finds mention of it in the Trias Romana, date unknown, but earlier than is usually supposed, 1542, as Ulrich von Hutten was ac- quainted with the book. From what little can be made out, it is not im- probable that blennorrhagia is really alluded to, but I do not see how any- thing like certainty can be arrived at, the passage quoted being simply to the effect that there were then " three citizens at Rome, Simon, Judas, and the gonorrhoea people." He also reports mention of it in the works of the elder Beroaldus, 1515, in whose account however I see nothing beyond some hazy idea about what was probably premature emission, of which he certainly takes a most lugubrious view. 2 With these exceptions all is silence till Bethencourt described it in 1527, and Paracelsus in 1527 or 28, after which it once more vanishes for nearly forty years, a solitary and most doubtful notice of it by Gattinara or Gatinaria, 1539, 3 possibly excepted. Hensler quotes 4 several authors between 1532 and 1563, including Massa, whose publications range over the whole of this period, and Fracastori, whose knowledge was supposed to embrace the literature of all times, countries, and subjects, not one of whom alludes to the disease. Some writers, however, consider that venereal gonorrhoea is plainly indicated in the works of Brassavolus, 1551, Fernelius, 1555, and Fallopius about 1560. Through all these ages of time, through all this long succession of authors, not the slightest progress had been made toward a real knowledge of the pathology of gonorrhoea. Men had been quite content to copy from one another, and the mediaeval writers could not, any more than their pre- decessors, get beyond the idea that all varieties of gonorrhoea were only so many forms of discharge of semen ; the disease was an affection of the seminal vessels, not of the urethra at all, an error I need scarcely say still perpetuated in the name we continue to give to the disease. In this re- spect the pathology of Valescus of Tarentum is not a step in advance of 1 " Quarta causa est coitus cum sana, cum qua de proximo coivit infectus, semine adhuc in matrice exsistente." Quoted in Hensler, op. citat. , p. 187. "Ibid., p. 171. His works were published in 1515, but Beroaldus died ten years before this. 3 He flourished toward the close of the fifteenth century. The date given is that of the first edition of his works which I have found. 4 Ibid., p. 197. HISTORY. 9 that laid down in the fifteenth chapter of Leviticus, although his account is one of the most complete that we have. "Gonorrhoea," he says, "is an involuntary emission of semen. The external cause of it is venereal passion for a concubine or her embraces." "But if the cause be internal its seat is in the vessels, the members, or the humors. If in the first it is because they are too hot or cold, or affected with paralysis or spasms. If in the second it is on account of a vice in the nerves or sinews. If in the third the humor is wrong, either in quantity or quality. The patient knows when he has derived it from an external source. The symptoms with reference to its internal origin are, that if it issue from the other members it takes place without erection of the penis and escapes insensi- bly ; if it be due to spasm of the nerves it is marked by pain in the privy parts and groins. If it arise from heat it is relieved by cold things ; when it comes from heat of the semen, heat and biting (mordicatio) are felt. Should it come from excess of semen then the body wastes as the semen passes sway. If due to the moistness and watery state of the semen, it soon passes away when it falls upon the clothes. Such is the account given, not by an obscure author or low charlatan, but by a professor at Pisa, so renowned then as a cradle of letters ; and I suppose the reader will agree with me, that it is difficult to imagine how ignorance, confusion, and assurance could go much farther. The author had evidently read some of the works on the subject, and had profited by them about as much as men of his generation were wont to do. It is true he was not likely to learn much from them, as most of them only repeat the same story, but if they had been capable of yielding him any solid in- formation, I should think it would have been put to little use by a person in such a state of bewilderment as t o assert that the same disease arose from the vessels being too hot and too cold, from being in a state of paral- ysis or spasm. Of course there was nothing either wonderful or criminal in the old writers being ignorant of the pathology of the disease. The fault lay in their not having the moral courage to say so ; in palming off upon their readers and hearers as scientific teaching what was in reality a rigmarole of meagre repetitions, empty words and baseless, or rather shameless, assumption of knowledge of which they well knew they were perfectly destitute. For it would be scarcely going too far to say, that the stock of solid information possessed by a few of them about the very sub- jects they undertook to enlighten the world upon, was not much larger than that of the old Roman philosophers, whom Juvenal ridiculed so mercilessly, was about philosophy itself ; and the statutes of Jean de Provence in 1347, and the edicts against harboring women with " the perilous Infirmitie of Brennynge," are of more value for our purpose than their opinions usually are. But a change in the pathology of gonorrhoea, a change destined not only to endure for ages but to reach our day, was at hand. This was the 10 ON GONOKRHffiA. discovery that gonorrhoea was really a form of venereal disease, or to adopt the ideas and language of by-gone days, a variety of syphilis. The dis- covery was reserved for the eagle glance of Paracelsus, who, braggart, buffoon, and charlatan as he was, possessed almost superhuman powers of penetration, and I quite agree with Simon of Hamburg when he says, that we must stand astounded at the keenness of his view. He at once arrayed gonorrhoea among the forms of syphilis, and when we consider that this doctrine survived the experiments of Bell and Balfour : that it was upheld by such men as Hunter and his followers ; and that the belief in a syphi- litic gonorrhoea is not extinct in our time, we must admit that the step taken by Paracelsus, pregnant as it was with error, was yet the first ever taken in the right direction, and the greatest till we come to the days of inoculation. James Bethencourt, too, got very near the truth when he spoke of a gonorrhoea, for which he was consulted, as a discharge of " a sanious and virulent Matter," " contracted by Venery." But their teach- ings do not seem to have been foUowed up, and indeed to have on one point rather fallen into desuetude, for we find Astruc some two centuries later telling his readers, that in venereal gonorrhoea there is always a large and lasting discharge of purulent semen. I have not been able to make out what author, after the long silence from 1532 to 1563 which Hensler speaks of, renewed the knowledge of gonorrhoea. I suppose Petronius, 1565, may claim to be the first, after which date the disease can be traced through a long succession of writers, whose number gradually increases as their date approaches our own. Prominent among these are Csesalpinus, 1602, Martiniere, 1644, Sydenham, about 1680, Musitanus, 1697, Devaux, 1711, Turner, 1717, and Cockburn, 1728. From this time all interest in its history ceases, as after that gon- orrhoea figures largely in general medicine and surgery. Judging from the total silence of later writers about any opposed views, it seems a legiti- mate inference that whoever again attracted notice to it, adopted on other points the pathology of Paracelsus, and that by unanimous suffrage gonor- rhoea remained incorporated with syphilis till the time of Cockburn, quite two centuries later. And even a century after that, the fatal teaching of Hunter, the prestige which his commanding genius imparted to every- thing he said, still made belief in the identity of the two diseases the rul- ing tenet of the day ; the arguments of Cockburn and the experiments of Bell, Balfour, and Hernandez counting for nothing against his dictates. Even now, notwithstanding the luminous teaching of Ricord, belief in their identity is not entirely given up by some writers and practitioners. Nor have I been more successful in my attempts to find out who is re- sponsible for the long prevalent error, that gonorrhoea is a critical flow, with which art ought not to meddle too much ; an error so widely spread that the profession of it, a few years ago, as an article of faith, by a physi- cian and a surgeon, each attached to a large general hospital in London, HISTORY. 1 1 elicited no remark in the medical journals. I suppose, however, that those who have studied the subject, and whose opinions alone are worth consid- eration, are now agreed that gonorrhoea is an unmixed evil, that the dis- charge carries off nothing but itself, and that the more there is of it the more suffering and risk for the patient. I have long suspected that till about the beginning of thfe eighteenth century gonorrhoea was rare, and only an occasional visitor in western Europe. Among other reasons I may mention the long periods of silence about it observed by writers on venereal disease in the first three quarters of the sixteenth century ; the absence of all allusion to it by the lay writers like Shakespeai'e who followed close upon them, and who are yet so liberal in their notice of syphilis ; the utter ignorance of the complaint displayed by the leading medical authority of the latter part of the seventeenth cen- tury, in England, Sydenham, who I should think could never have seen a case of the disease, or surely he could not have written an account of it so confused, that had it emanated from an obscure author like Martin or Profily, it would have been censured as the product of barefaced empiri- cism. And that the lay writers of those times were not deterred from mentioning gonorrhoea by the nature of the topic, is, I think, clearly shown by the fact that we find the pious and moral Johnson speaking of it in the plainest terms. The last reason I would urge is, that having had the opportunity of tracing this disease for many years back, in what was then a very small town in the north of England, where gonorrhoea is now rather firmly established owing to the growth of the place, I was able, by means of the books of a successive line of surgeons, kept for a long time, to make out pretty certainly that in their practice it had, till about forty years ago, only been very rarely seen and sometimes not heard of for years together. All the inquiry I could make tended to fortify this opinion ; the general experience seemed to be that gonorrhoea always died out soon after it was acquired, and did not spread, the horror of communicating it having perhaps greater weight then than now. This feeling, only too often deadened amidst the dissipation of larger places, possibly long oper- ated as a check upon the spreading of a disease infecting only by sexual intercourse ; while syphilis, conveyed by unsuspected routes, and often by modes impossible of prevention, long gained ground with greater speed. CHAPTER II. PATHOLOGY. UNDER the term gonorrhoea I propose to include all purulent discharges due to connection, or to the contact of infecting matter originally secreted by the mucous surfaces of the genital and urinary passages, and reprodu- cing the same disease in another person, who can again give it to a third. As I have seen reason to doubt some of the conclusions arrived at by certain eminent specialists in respect to the pathology of this disorder, I take the liberty of stating the grounds for dissent. To do so effectually, however, it will be necessary to go somewhat into detail. This is unavoid- able where accuracy is aimed at. General statements may serve very well as the staple mode by which opinions are communicated, but they are easily met by denials of the same nature. Minuteness will not allow of this. By narrowing the subject under examination, it reduces it more to a form which admits of demonstration, and thus really shortens a discus- sion which, under a looser system, might become endless. Genesis of Gonorrhoea. A, In the Male. As regards gonorrhoea in the male sex, the most practical division of the affections lumped together under this name, or that of blennorrhagia, seems to be the separation of them into : 1. Cases resulting from connection with a female suffering under gonorrhoea, or gleet. 2. Those which ensue from intercourse with a woman laboring under any form of discharge not due to connection, such as leucorrhcea, ' menstruation, 3 an unhealthy, irritable state of the vagina, malignant disease of the os or cervix uteri, simple excoriation or ulceration of these parts, uterine catarrh, or even a person in whom these organs are in a perfectly healthy state. 3 3. Those arising from errors of diet, from drinking beer, the use of asparagus, and certain other articles of food, blows, 4 violent exercise, sue has galloping on a bare-backed horse excessive work, hard travelling, 6 erotic excitement, over-indulgence in 1 The Practice of Medicine, vol. i., p. 306. By Thomas Hawkes Tanner. 1869. * On Urethritis and Syphilis, p. 25. By William Henry Judd. 1836. a Swediaur : Practical Observations on Venereal Complaint, p. 41. 1788. Ricord: Lettres sur la Syphilis, pp. 50 and 51. 1863. 4 Diseases of the Genito-Urinary Organs, p. 36. By Henry James Johnson. 1851. 6 Judd: Op. citat., p. 33. PATHOLOGY. 13 sexual pleasures, protracted attempts at connection under the influence of wine, 1 late hours, 2 direct application of irritants, 3 the presence of calculus, and finally the suppression of cutaneous eruptions ; the remainder of the thirty-seven causes to which gonorrhoea is ascribed 4 being left over for the present. Strictly speaking, the cases in the third class hardly belong to the sub- ject in hand, as, with one or two exceptions, they are not due to connection at all, and these exceptions are not counted as instances in which conta- gion is communicated. But as they are often called by the same name, and as every such disorder seems to be considered by some authors a very probable cause of discharge in the other sex, they cannot well be omitted. 1. The question as to the power of the first class of agents to bring on gonorrhoea in the male sex may, I suppose, be regarded as so completely settled, that it would be wasting the reader's time to dwell on the topic. Those in the second class deserve more attention. 2. The first step is to clear them from an overlying stratum of some- what loose assertion. It is constantly assumed as incontrovertible, that a female, having any one of the affections in this category, may communicate gonorrhoea to a man who has connection with her, a doctrine more than once of late years proclaimed as a discovery, particularly by the late Mr. Skey. With all deference to those who hold this view, I am inclined to say that the fact has in some cases been admitted on insufficient grounds ; that it has been accepted without such a foregoing knowledge of the pa- tient's history, and searching examination of the persons concerned, as could alone justify our looking upon it as irrefragably established, and that many histories of gonorrhoea thus set up are open to grave suspicion. One strong argument in support of such doubts is, that only too often an old gleet, or a disposition to it, is oveiiooked ; irrespective of this, we fre- quently find that a patient who comes with, very plausible reasons for hav- ing acquired a discharge in this way, afterwards changes his mind of his own accord. Still, after allowing for this source of error, cases remain which merit inquiry, and these I propose to examine. Simple inflammation of the vulva, accompanied by purulent discharge (acute or subacute vulvitis), not of course due to connection, seems at first sight one of the most likely causes, but I have not met with a single in- stance of gonorrhoea thus communicated. What is more, I have seen vul- vitis set up by connection take on a pretty severe form, and yet a patient, quite liable to gonorrhoea, cohabiting with a girl thus situated, has es- caped. Among other cases I may give the following : 1 Lancet, vol. i., p. 211. 1851. 2 Nouveau Traite des Maladies Veneriennes, p. 61. Par le Docteur Melchior Robert. 1861. 3 Swediaur : Op. citat. , p. 38. 4 Nouveau Dictionuaire de Medecine, tome v., p. 131. 1866. 14 ON GONORRHOEA. I was consulted in the summer of 1874, by Mr. F , for what he called gleet. He was thin, nervous, delicate, and afflicted with a strong tendency to dyspepsia. He had suffered from gonorrhoea, followed by gleet ; there was, however, now no discharge from the urethra, neither had there been any for some time. A few small shreds passed occasionally in the urine, and the canal was tender. I recommended passing a bougie once a week, and if that did not set matters right, a weak nitrate of silver injection. Some time after this he contracted an illicit connection with a girl who, for all I could make out, seemed never to have had any disease. The entrance to the vagina was narrow, and connection was difficult. It was followed by soreness of the vulva, accompanied by muco-purulent dis- charge ; yet, though connection went on till she could bear it no longer, on account of the pain it occasioned, this gentleman had, according to his own repeated statement, no symptoms of infection ; certainly when he called upon me he was free from anything of the kind. Now if these discharges really possess an infecting power equal to that of gonorrhoea, which is the only construction we can put upon the opinions expressed by many authors, how comes it that men escape under such circumstances ? About the probability of leucorrhcea, by which name I understand ca- tarrhal inflammation of the vagina, being a frequent cause of gonorrhoea in the male, I confess myself somewhat incredulous. In a man who has married, as many do marry, without being thoroughly cured of a gleet, or even tenderness in parts of the urethra, leucorrhcea, especially if it take on the more serious form of inflammatory vaginitis, may light up the slumber- ing embers of disease. But I am disposed to think it is the connection and excitement that do this, and to rate the infecting power of leucorrhcea low even here, and still more so in the case of a healthy man, and I have seen reason to believe that men liable enough to gonorrhoea expose them- selves with impunity to the contagion of leucorrhcea. I had under my care a patient who was particularly susceptible of the former complaint, yet he had connection over and over again with a girl who was scarcely ever quite free from leucorrhcea, without ever displaying a sign of con- tamination. I have, too, seen pretty good evidence that a man may have intercourse with a woman in the early stage of the more inflammatory form of vaginitis, a period when gonorrhoea is sometimes, if not always, highly infectious, and yet contract no disease. Mrs. E , a healthy-looking woman, about thirty-six years old, con- sulted me, June 4, 1872, about a discharge which she said she had caught from her husband. She was suffering from rather plentiful greenish-yellow secretion, and some vulvo-vaginitis, accompanied by great heat and sore- ness of the parts, pain on walking or long standing, etc. She had only been married a fortnight, and was greatly distressed. On learning, however, from her, by cross-questioning, that she had no ground for suspecting her husband beyond the symptoms just mentioned, and that his conduct did PATHOLOGY. 15 not seem to be in any way incorrect, or to have been so prior to marriage, I thought it might be wiser to defer giving any positive opinion, as pos- sibly the affection was due merely to intercourse, which had called a mor- bid disposition of the parts into play, for, though healthy in appearance, she was not strong. Meanwhile, I prescribed a lead lotion and saline mix- ture, which soon stopped the discharge. On March 30, 1873, she again consulted me. She had remained free from discharge till quite recently, but her health, which had improved du- ring the summer, had begun to fail as far back as October, since which time she had suffered from dyspepsia and some degree of bronchitis, ac- companied by severe cough. Latterly, the discharge had re-appeared. I inquired very carefully into the husband's case, and found that on this, as on the previous occasion, cohabitation had been kept up till her symptoms had set in. Notwithstanding this, she had observed no sign of infection in him, though she had been inquisitive enough on the point, neither had she found any farther reason to believe that he was infected at the time of marriage. In this case, then, which is only a specimen of what I suppose most practitioners have repeatedly seen, there is good ground for thinking that the husband remained free from disease, whereas, had his wife been suffer- ing from an affection equally as contagious as gonorrhoea, he could hardly, when taking no precautions, have exposed himself so many times to danger and have got off safe. We hear, indeed, of men who visit women of the town constantly without using any means of prevention, and still manage to steer clear of disease. Perhaps we hear a little more than the truth, or at any rate what is calculated to mislead us, seeing that, if I am to judge from what I have heard of later experiences of such a nature, scarcely one man escapes in the long run ; if any do, they are exceptions on which no law can be based. Many husbands must, when their wives are beginning to suffer from leucorrhoea, continually run this risk, and yet most of those so placed never have anything like true gonorrhoea. Nor do I stand alone in my incredulity. Dr. Durkee, who has had large experience in these diseases, is as hard of belief as I am. 1 His own opinion, he says, coincides with that of Sigmund, that gonorrhoea alone produces gonorrhoea ; an opinion shared to the fullest by Bonniere and Gosselin, and almost as fully by Cullerier. 2 Auspitz, too, in a work dis- tinctly devoted to the study of venereal contagion, says 3 that the balance of evidence is in favor of there being a specific virulence in gonorrhoea ; tes- timony at least equal in value to some of the frivolous anecdotes on which the non-specific theory of the disease is based. 1 A Treatise on Gonorrhoea and Syphilis, p. 17. 1864. 8 Nouvean Dictionnaire de Medicine, tome v., p. 132. 1866. 3 Die Lehre vom Syphilitischen Contagiuna, S. 68. 1866. 16 ON QONORRHCEA. The argument that, though contagion proves the presence of a poison in gonorrhoea! secretion, it still does not show that this poison is specific and incapable of being produced by simple inflammation, became a muco- purulent conjunctivitis, so strictly analogous to gonorrhoea, the inflamma- tion originates in simple causes, and yet sets up a secretion which is con- tagious and can be inoculated upon a series of persons, is of very doubtful value. In the first place, in some of the cases relied on as evidence, the affection was pretty clearly not simple but strictly specific at the very out- set, as much so as any epidemic. Secondly, I presume the supporters of this doctrine will scarcely maintain that chancroid is not specific, while they at the same time accept the case related by Dr. Taylor, whose great reputation is a guarantee for the accuracy of the history, as showing that chancroid may spring from a simple affection. Dr. Bumstead quotes l from Dr. Fordyce Barker a brief description of a disease affecting the interior of the womb, which, while quite innocently acquired, is capable of producing purulent discharge in the male. Dr. Barker considers it to be a peculiar inflammation of the lining membrane of the uterus, under the influence of which the secretion loses its natural alkaline reaction and becomes acid and acrid, as a consequence of which it irritates and excoriates the mucous membrane of the vulva. He has re- peatedly known this state induce uretbritis in the male. One case would have been enough if it had been shown that the disease, thus originated, was not simple urethritis, but real gonorrhoea accompanied by chordee, swelled testicle, irritable bladder, sympathetic pains, and so on ; and especially that it was capable of giving rise to identically the same affection in another person. But unless the evidence be to this effect, it is beside the question so far as identity is concerned. "We want to know, not whether such a state of the uterine system will set up dis- charge in the male, for that might be granted, but what the nature of that discharge is. The belief in the specific nature of gonorrhoea will receive a rude, if not a fatal, shock, when it is shown that an acid state of the uterine mucus produces the same results as the laudable pus of gonorrhoea, and the curdled albuminous discharge of leucorrhoea, formed by the mingling of the free alkaline secretion from the glands lining the cervix: uteri with the complex acid of the vaginal fluid. Admitting that urethra! discharges do appear in men as the result of connection with women laboring under leucorrhoea, in whom there is no reason for suspecting a present or previous blennorrhagia, it must, I think, be equally admitted that the facts supposed to establish this are, when we come to sift the matter closely, generally vague and few ; and in no in- stance that I have read of is there anything to show that the surgeon had satisfied himself as to the previous state of the organs in both persons, yet 1 The Pathology and Treatment of Venereal Diseases, p. 63. 1866. PATHOLOGY. 17 without such evidence belief must remain mere conviction ; it cannot be raised to the stability of a truth. Whether it be the first infection, or one of many, and in whatever kind of constitution it may occur, a discharge thus set up is, I must repeat, usually much milder than gonorrhoea in its symptoms, and rarely inveterate in its nature. But the infecting power of the latter disease is a matter of every-day experience ; it can be demon- strated by experiment ; severity, at the first infection at any rate, is the rule rather than the exception, and out of many cases some are sure to be obstinate ; infection is almost a certain result when no precautions are taken to guard against it ; and lastly, this infection may be, and is, re- produced to almost any extent, even under much the same circumstances which seem to interfere very materially with the diffusion of it from the first-named class of causes. Moreover, those who support the prevailing view, seem not to notice one point which involves something like a contra- diction or an inconsistency. It is at once conceded that a man who .gets gonorrhoea from a prostitute, has derived it from the same disease in her ; but only too often, in narratives of infection due to other kinds of illicit connection, a deus ex machind must be evoked to clear up the mystery. I suppose most medical men have heard of cases where discharge from the urethra resulted from connection, when there was no reason to believe that the female, supposed to have communicated the disease, had ever been infected. One patient, whose truthfulness I never saw any reason to doubt, assured me that he had three times attempted to keep up connection with his wife, and had on each occasion been obliged to desist owing to gonor- rhoea coming on. But even supposing such an affection were genuine gonorrhoea, the evidence would count for nothing unless the previous history of the par- ties, and especially of the husband, was carefully investigated. Few facts in the pathology of this disease are more certain, than that a slightly inflamed, sensitive state of the urethra may remain for many years uncured, and not revealing its existence by any visible sign, and yet upon the stimulus of connection with even a perfectly healthy woman develop at once into a purulent running. That true gonorrhoea, however, was ever thus set up in a man never previously infected, I must, judging from experience, respect- fully decline to believe. In every case such a gonorrhoea, when I have seen it, ran a different course from the genuine complaint. It may have some- times resembled a mild attack of the latter, never a severe one. If the prevailing theory, too, be correct, how does it happen that, in every case of very severe results from gonorrhoea, swiftly progressing retrac- tile stricture, bad swelled testicle, cystitis, inflammation and suppuration in the prostate and seminal vesicles, severe gonorrhoea! rheumatism, and the serious complications of this, pyaemia and endocarditis ; in gonorrhoeal peritonitis, phlegmonous inflammation and nephritis, we always find, when there is a history at all, one of distinct gonorrhoeal infection? 2 18 ON GONORRHCEA. Numerous histories of cases are to be found, showing, in the opinion of those who relate them, that gonorrhoea can be innocently generated. I believe these accounts are put forward in all good faith ; but while I un- reservedly admit the veracity of the authors of them, I demur to their con- clusions. I do not say that gonorrhoea never arises in this way, but that they have not proved that it does so. Possibly enough they may be quite right and I may be as far wrong ; my contention is that their evidence does not go so far as they assume. Their cases are, no doubt, numerous ; but unless the issues can be narrowed to points bearing vitally on the question, unless the cases are individually so convincing as to count for positive tes- timony, they carry no more weight collectively than singly ; merely adding to the bulk of weak evidence will not do away with the radical vice of its quality. "When it can be shown, in even a very few instances, that both persons could be proved to have been free from all previous disease at the time when the gonorrhoea was thus engendered, then, I apprehend, the believers in its specific nature must give up the cause for lost. Till then, I think we are justified in assuming that, so far as the evidence on behalf of leucorrhcea is concerned, the matter by which gonorrhoea is communi- cated may be of as specific a nature as the lymph of the cow-pox vesicle, 1 and that the supply of the infecting material is kept up in the same way in both cases namely, by propagation from individual to individual. Of course, this does not mean asserting that it is never generated spontan- eously in the female ; possibly such may be the case at times. The disease must have begun with some individual, and accordingly there is nothing so very improbable in its beginning again in the same way. Neither is it impossible that a simple leucorrhcea or vaginitis may, by some peculiar state of the health, be intensified into a contagious form. We are, after all, dealing to a great extent with probabilities, and I am as ready to accept the new doctrine when it can be proved to be the more probable of the two, as I am at present to abide by my own. During a four years' apprenticeship to a surgeon, who, though living in a very small town, had one of the largest practices in Cumberland, I saw but very few cases of gonorrhoea, certainly not a dozen, though every in- stance of such a disease must have come to my knowledge. Of these, I know that some were caught from sources foreign to the place, being either contracted in a large town, or from intercourse with some strolling player- girl, or some young woman who had recently been in a large town ; and this might easily have been the case with the others, as girls, known to be of loose character, though not avowed prostitutes, of whom there were only 1 ' ' The common cause [of gonorrhoea] is the application of gonorrhoeal matter during sexual intercourse. Although the existence of this animal poison has only been in- ferred from the effects, yet there can be little doubt that there is such a poison of a special nature, and that it does not arise simply from indiscriminate sexual inter- course." Tanner: Op. citat., vol. i , p. 306. PATHOLOGY. 19 iwo or three in the place, were every now and then returning home from such parts. I had ample means of knowing that this paucity of gonorrhoea cases occurred also in the practice of other medical men. Yet the town ought to have furnished its quota of gonorrhoea, for certainly the morals of the lower classes, and indeed of all the young men as a rule, were as lax in respect to connection as they could be, and I never heard of any person taking precautions against infection ; every one, lay and medical alike, be- lieving that the disease was always imported. In a paper by Dr. Rocchi, 1 comment is made upon the fact that this is noticed also in Italy, gonorrhoea, except when imported from some populous part, being quite unheard of in the country places, where yet the conditions mentioned by Eicord, and those who support him, as requisite for its generation are present, especi- ally during the heat of summer, and among a class of people not remark- able for cleanliness. The microscope, from which we might fairly expect help, leaves us completely in the lurch. According to Dr. Tyler Smith, 2 it shows the products of gonorrhoea in the female, and of leucorrhoea springing up spontaneously, but capable of giving urethritis to the male, to be almost identical. But then, on the same showing, there may yet be a very marked difference ; for there is no positive distinction between the discharge of leucorrhoea " accompanied by sterility," and that " attended by the usual aptitude for impregnation," conditions evidently thought by Dr. Tyler Smith himself to be widely distinct. This gentleman, whose painstaking researches and cautious inductions entitle all he says to our respect and confidence, gives 3 an account which is calculated to make us pause - before accepting the modern doctrine. Al- though he defers to M. Ricord's authority, although he starts with an ex- pressed wish to find evidence that gonorrhoea may be generated by leu- corrhoea, his strong love of truth compels him to leave the question unde- cided. He had great opportunities of observation ; he was ably assisted ; he tells us that it was his habit to interrogate the husband strictly about his early days ; he did not forbid connection when the wife was suffering from leucorrhoea unless the symptoms were very severe ; 4 yet all his experi- ence only furnished one case of infection, and that one very incomplete. He tells us that a lady, in whom epithelial leucorrhoea arose spontaneously, gave her husband urethritis, and afterward blennorhagia, but there is not a single word to show what the course and symptoms were in either attack. In order to follow up this part of the argument, I will give two instan- ces showing, it seems to me, the contagious nature of true gonorrhoea, one in its rise, the other in its decline ; and I think, taking all the facts to- gether, that they fairly represent somewhat common occurrences. 1 Giornale italiano, vol. ii., p. 196. 1871. - Pathology and Treatment of Leucorrhoea, p. 133. 1854. 3 Op. Citat., p. 126. 4 0p. Citat., p. 213. 20 ON GONORRHOEA. A young girl, of respectable family, formed an illicit connection with a gentleman who, after a time, gave her gonorrhoea. This was her first wrong step. Before she became aware that there was anything amiss with her, she had connection with a relative, a man holding a good post in a public office, and who was very much attached to her. She had gonor- rhoea in a severe and obstinate form, and her relative had the same disease, accompanied by gonorrhoea! rheumatism ; in the end, he too got quite well All intercourse with the first paramour was at once broken off, but I did not feel so sure that the connection with the second ceased entirely. Some months after this she had connection, once, with a man whom she met at a ball, at least this was her version of the story, and very shortly after with her relation. Three or four days after, she came to me in great alarm at finding herself again infected. She had, in the interim, met her ball-room friend, and violently upbraided him. He did not deny the fact of previous infection, but justified himself by saying that he quite believed there was nothing left of his complaint to do any mischief. Within two hours after her visit I was consulted by her relative for what was evidently the begin- ning of a discharge. He had gonorrhoea, again complicated by gonorrhceal rheumatism, and the girl had a pretty sharp attack of gonorrhoea. A gentleman had connection with a young person whom he had long known, and whom he had excellent reasons for believing above suspicion. It was followed by a discharge, which a noted specialist considered to be gonorrhoea. The surgeon examined the girl, and stated that there wa8 nothing beyond slight leucorrhceal gleet, scarcely more than the natural mucus; in fact, he more than hinted that she could not have given the dis- ease. Three times did this patient renew his intercourse with the girl, each time getting previously cured of his old discharge, and each time get- ting a new one. The surgeon still persisted in asserting that the girl had nothing but a little redness of the upper part of the vagina with some glairy mucus ; however, with the view of making all safe, he cauterized her thoroughly. Soon after this she married, and within a few days her hus- band began to show unequivocal signs of gonorrhoea, from which he suf- fered long and severely. His wife had, as before, little the matter with her. I now learned that, three years previous to all this, she had been infected with gonorrhosa, but that she had, as she believed, got thoroughly well and remained so. I had good reason to believe that neither of these two men had ever had gonorrhoea. Judging, then, from this and similar cases, I am disposed to believe that even a slight amount of gonorrhoea is more likely to excite the same dis- ease in another person, than a pretty high degree of leucorrhcea is to bring on even simple urethritis. Gosselin thinks that in many of these cases the real secret is that the female has not been examined at the proper time, six or eight hours after she has made water, as on waking in the morning for instance ; and Dr. PATHOLOGY. . 21 Howard throws further light on this point by maintaining ' that the dis- ea,se will linger in the small glands of the female urethra, first described by Dr. Skene of Brooklyn, and that these will continue to pour out true gonorrhoeal pus although the patient presents no other evidence of the dis- ease, a view corroborated, he considers, by the fact that in a woman, who thus infected her husband, applying carbolic acid crystals to these glands put an end to the communication of the gonorrhoea. Ulceration of the neck or mouth of the womb, even accompanied by the formation of a stringy plug of mucus, occurring in a woman who has never been infected, I should be inclined to set down as incapable of exciting gonorrhoea ; the case assumes a very different aspect when she has been exposed to the risk of disease, and I have never myself seen this state in the female under other conditions. In the careful examinations made at the Lock Hospital, it is found that women, having no outward discharge, and yet infecting men, are seldom without this morbid secretion from the os uteri or ulceration of the os or cervix. 2 If it could be shown once that such an affection had sprung up in a woman prior to her having any sexual congress, and then given a discharge to another 'person, the non-specific character of gonorrhoea would receive most strong support ; but I suppose most persons familiar with hospital practice of this class agree in the belief that this affection, which I look upon as pathologically distinct from the secretion of mucus that in the normal state plugs the canal of the cervix .uteri during pregnancy and the intervals between menstruation, 3 is in nearly every case the sequel of gonorrhoeal vaginitis ; which means in other words, that women of this kind, without any visible discharge, give gonorrhoea, not because some natural secretion is in them in a morbid state, but because they have had gonorrhoea. Dr. Tyler Smith gives an admirable description of the secretion sometimes seen in leucorrhcea, which might easily be confounded with the foregoing, but which yet seems to be quite distinct. It has been stated that the plug has been found in some instances to contain " neither pus-corpuscula nor granule cells," but I as- sume that it is then incapable of conveying infection. We could scarcely, however, expect to find pus corpuscles in cases of leucorrhcea when the secretion consists of mucus, and where the white color is due, not to the presence of inflammation, but to' the action of the vaginal acid on the mucus. Under the head of ulceration are included here cases of conges- tion with detachment of the epithelium. Purulent discharge from the interior of the womb, or, to speak more cor- rectly, from the interior of the canal of the cervix, innocently acquired, sometimes wears such a serious look, especially if accompanied by vaginal discharge, that we might suspect it to be an agent of disease, and I have 1 Chicago Medical Review. Quoted in London Medical Review, p. 329. 1882. 4 Medical Times and Gazette, vol. i., p. 9. 1868. 3 Pathology and Treatment of Leucorrhcea, p. 36. By W. Tyler Smith. 1854 22 ON GONORRHOEA. been consulted in one or two cases where a slight puriform running had, judging from the evidence, been set up in this way ; but I have not yet mtet with an instance of anything, thus generated, which could be set down as gonorrhoea, and indeed I have seen but little of the affection. "Where there has been previous disease, a certain amount of infection may re- main and become a source of mischief. I have not noticed any full obser- vations on this affection individually. Mr. Berkeley Hill says, 1 that a purulent discharge from the uterus is an almost universal condition among prostitutes, but I apprehend that he refers rather to the complaint de- scribed in the foregoing paragraph. There is reason to believe that connection during or directly after men- struation produces purulent discharge in the male sometimes of rather a severe character. I have met with a few cases where, though disposed to be skeptical, I could -not shut my eyes to the fact that such might have been the case. There is, however, always this difficulty in the back- ground when the female is of loose character ; a person in such a posi- tion may have an uncured gleet hanging about her, and a woman who would not be sufficiently particular on the one point, is just the most likely person to be negligent on the other. Women with a strong sense of self-respect do not usually allow such approaches. Any one might, of course, be surprised into such a mistake once, especially when young and newly married ; and it is possible, from the fact of menstruation being often succeeded by leucorrhcea for a longer or shorter time, that the close* of the monthly discharge leaves the organs in a state closely akin to that of the first stage of gonorrhoea. In some forms of dysmenorrhcea an at- tack of vaginitis complicates every catamenial period. But I am led to rate the infecting power low. I have been applied to four or five times by men who had been alarmed by finding that they had had connection with their wives at too early a period after menstruation, so as to cause a return of the discharge, and even when it had come on again during con- gress ; but beyond the feeling of uneasiness and irritation, I never knew any ill results follow. In one of these there was ample reason for know- ing that the patient was liable enough to infection in the other way, seeing that I had attended him for a most severe gonorrhoea, ending iu obstinate gleet, which had lasted between six and seven years when he came under my hands. In none of the few cases where I have had to treat discharge from the male urethra, stated by the patient to have arisen from intercourse at the menstrual period, was it complicated with orchitis or irritable bladder, and in one only was chordee present, and then in a very mild form. Neither have I met with an instance where, either through accident or imprudence, the contagious nature of the discharge thus called forth was established by the fact of its being conveyed to a third person. Mr. de 1 Op. citat., p. 376. PATHOLOGY. 23 Meric, however, in his answers to some questions on this head, following upon a paper read by him before the Harveian Society, distinctly, as I un- derstood him, stated that the conveyance of infection under these circum- stances had been noticed. We now come to the most singular cause of all, that of a perfectly healthy state of the organs in the female. I wish to avoid tiring my read- ers with more references than I can help, and therefore confine myself mainly to the statements of M. Kicord, who asserts the fact in the most unequivocal manner. What is equally extraordinary, he tells us ' that a man acclimatized to his wife has connection with her and escapes, while the lover who follows, not being acclimatized, pays the penalty of his indiscre- tion. Mr. Henry Lee reproduces 3 this view, but rather as emanating from M. Bicord than as according with his own experience. Some other eminent writers seem to have adopted it unreservedly ; and M. Fournier improves so far on M. Ricord's view as to maintain, that more frequently than otherwise a woman, who gives gonorrhcea, has not got it ; while M. Linas asserted 3 before a medical society that "history teaches us" that gonorrhoea may be given by the most chaste of wives. That gonorrhoea may arise without any outward signs of disease in the female we have just seen, but I understand M. Ricord to go far beyond the cases I have spoken of. His theory is, that a woman who has been examined with the speculum and found to be perfectly free from disease, either of the outward parts or of the womb, will yet give gonorrhcea, al- though she has never had it, to a man who has got neither gleet nor a dis- position to it. Either he means this, or he means nothing beyond what is generally known. I must leave it to others to affirm or controvert a tenet which is in flat contradiction with my experience, while I pass on to the discussion of one which seems equally in contradiction with general expe- rience, and that is the escape of the husband. How comes it that he gets off? He was not always acclimatized, and ought, on M. Ricord's own showing, to have one time or other shared the lover's fate. I am therefore afraid that the theory of acclimatization, as M. Ricord calls it, and which may remind some of my readers of the old belief that husband and wife often grow to be like each other in features, will hardly help us here. Even those who so unreservedly accept M. Ricord's version, must admit that it is hardly suited to England, where thousands of virtuous girls marry every year, with their organs in the state described by him, and yet do not com- municate gonorrhcea. M. Diday does not go quite so far as his illustrious teacher ; he tells us 4 that any woman may give gonorrhcea, and that he makes no excep- 1 Lettres sur la Syphilis, p. 48. 2 Holmes's System of Surgery, second edition, vol. v., p. 187. 9 Union Medicale, tome i. , p. 102. 1868. 4 Exposition critique, p. 515. 1858. 24 ON GONOREHCEA. tions. Let her be ever so healthy at the time of her first liaison, she may be potentially fit to do any amount of mischief in this way, and carry with- in her a predisposition to communicate the infectious property to any dis- charge she may acquire, however innocently. The list of affections which may thus become tainted is appalling, but still the vehicle is visible, and we understand that such a thing, however improbable, might happen. M. Ricord's account is simply incomprehensible. But this is all the merit that can be conceded to M. Diday's statement. It is put forth in a form which robs it of half its value. True, the picture is graphically drawn, in- deed, he yields here in no way to M. Ricord, or perhaps anyone else ; the terms are trenchant and incisive enough, and the facts arrayed in a way which does credit to his skill as a writer ; but after all, it simply expresses a conviction which may be very well founded, but which may equally, as regards the evidence offered, be a truism or an error. Had he told us that out of every hundred women who marry so many have a morbid dis- charge, and that out of every hundred women who become liable to such discharges so many communicate gonorrhoea, we should know what to say. As it is, his account is more alarming than valuable. Let me, however, render one tribute of justice to both these charming writers. If they do not untie the knot they promote the interests of morality, for it is over the head of the erring lover, not the husband, that they hang the impend- ing sword. 3. The third class of causes need not detain us long. Those who have seen true gonorrhoea brought on by eating asparagus or over-fatigue have been more favored than myself. I have noticed yellow purulent dis- charge from the urethra in an elderly man who, I have very good reason to think, was strictly continent ; and I have seen a thin, yellowish, dirty> and rather profuse discharge come on in a young patient suffering from bad influenza. Such discharges, too, come occasionally, but rarely, before us, reported by the patient to be the effect of a sprain. Again, I suppose most practitioners have now and then been consulted about a thick, white secretion and scalding, occurring in gouty persons, especially if the urine should happen to be loaded with urates and uric acid. As to M. Four- nier's statement, that venereal excess is the most frequent cause of gon- orrhoea, I meet it by saying that I have repeatedly had to deal with men of unbridled passions, who indulged such passions to any extent with im- punity, never, indeed, had a sign of such an affection so long as they kept aloof from prostitutes, and whom I have treated over and over again for gonorrhoea contracted in the natural way. Respecting all the other agen- cies I have no experience, except as to two or three, and these in a nega- tive sense. These remainders, then, are passing a bougie, masturbation, scrofula,' dentition, piles, and ascarides. The influence of the first I 1 Johnson: Op. citat., p. 39. PATHOLOGY. 25 should be inclined to deny, unless the patient was suffering from gleet or a tendency to urethra! discharge set up by stricture. I have passed the bougie hundreds of times for spermatorrhoea, and never saw anything of the kind ; on similar evidence I question the power of masturbation, though I have recorded a case where free purulent discharge used to come on in a young man suffering from spermatorrhoea. In one elderly gentleman, who had never been affected in any way, passing a bougie only gently, even though it had been done several times previously without any such result, was followed by slight discharge with a good deal of excite- ment of urethra and bladder, and later on very slight orchitis ; symptoms apparently as much due to excessive fatigue and thundery weather as to the instrument. Microscopic examination showed considerable prepon- derance of mucus ; discharge had almost entirely subsided spontaneously in fourteen days, having been pretty clearly prolonged by the fatigue and thunder. Of piles and scrofula I have seen a pretty round number of cases ; in not one of them was there ever a discharge innocently acquired. Of ascarides I have not had so many cases under my care, except in chil- dren ; in adults I have not found anything like urethritis from such a cause, and the question of dentition I consider to have no bearing on the point. But granting that urethritis is now and then evoked by such factors, it is, under these circumstances, as remote from true gonorrhoea as ordi- nary conjunctivitis is from purulent ophthalmia. It is usually of so mild and transient a nature, that in no instance where I have met with it, has it required a remedy of any kind. Dr. Francis Cruize long ago pointed out ' a clear practical distinction between discharges produced by gonor- rhoeal matter, and those induced by non-specific causes. While the former tend to run into obstinate gleet, the latter pass away spontaneously. I believe this rule holds good as to the agencies included in the third class of causes ; with regard to some of those in the second, especially menstru- ation, it is possible that there may now and then be an exception to the rule. Mr. T. W. Nunn calls attention to another distinctive mark. In a com- munication to Dr. Tyler Smith, published by the latter in his work on leucorrhcea, detailing a case in which this disease caused repeated attacks of balanitis, he says he is inclined to believe that when urethritis is pro- duced in this manner, it makes its appearance immediately after connec- tion, that is to say, within twelve or fourteen hours ; whereas the urethritis produced by a specific animal poison has a period of incubation of from four to fourteen days. As to the suppression of any skin disease being ever the cause of gon- orrhoea, I must go still further and say, not only that I have never seen it, but that I can scarcely conceive it possible. I have made hundreds, I 1 Dublin Quarterly Journal, vol. xxxix. , p. 342. 26 ON GONORRHOEA. may safely say thousands, of attempts to check cutaneous eruptions, es- pecially eczema, and never yet saw any disturbance of the health follow. Between the 16th of May, 1863, and the 18th of the same month, 1873, I treated at Si John's Hospital alone 2,148 cases of eczema on this princi- ple, with results which justify me in asserting, what I believe I was the first English author to assert, namely, that we cannot suppress eczematous or any cutaneous discharge at will ; that, if we succeed in time, arrest never produces any injurious results ; and finally, that we only succeed by the use of means which improve the health, and I cannot conceive that the use of such means can bring on gonorrhoea. However, as the possibility of gonorrhoea arising from this cause is admitted in a pathological work of high standing, a work where every line seems to have been weighed, and. which might be fitly spoken of as " finished with illustrious toil," I assume that such an occurrence has been noticed. Taken as a whole, I imagine that the creed does not gain many prose- lytes at the present day. Now that M. Kicord's precepts no longer carry the weight they once did, now that they are no longer promulgated by some of his disciples as if not to accept them were gross, prejudiced igno- rance, to doubt them, blasphemy, I am inclined to think that the old belief, that gonorrhoea is derived only from gonorrhoea, will little by little assert its supremacy. It is scarcely to be expected that those who have all along taught the contrary will renounce views which they have so sedulously inculcated for so many years, and which are, no doubt, founded on honest convictions, but we may fairly anticipate that with the lapse of time, any such opinions will vanish as completely into nothingness as a belief in the non-specific nature of syphilis ; both of them being specimens of the " ex- traneous idols " described by Bacon, which, " begotten of the dogmas and schools of philosophers worm their way into the minds of men," and are therefore fitly ranked by him as impediments to learning. B. Tn the Female. 1. Judging solely from what I have been able to observe, I should say that true gonorrhoea, capable, as a rule, of infecting the male, is always in the other sex, even when only assuming the form of vaginitis or vulvitis, the result of the contact of matter derived from a per- son suffering under gonorrhoea, generally, of course, communicated by sexual intercourse. Dr. Gaillard Thomas takes ' the same view of the case : he considers that gonorrhoea in the female altogether arises from a specific contagion. In newly married women a good deal of purulent inflammation, pain and swelling of the vulva, redness and heat of the vagina, ardor urinae, and uneasiness in sitting or riding on horseback, may make their appear- ance, and in some cases excite suspicion that gonorrhoea has been commu- nicated. But the course of the disorder soon reveals the difference, for though in a few rare cases the symptoms rise to such a height as to require 1 Practical Treatise on the Diseases of Women, p. 154. 1875. PATHOLOGY. 27 medical attendance, yet for the most part they pass off spontaneously, or at the worst yield to any mild, simple treatment ; whereas true gonorrhoea is a more severe and infinitely more obstinate affection, generally demand- ing, in the long run, a decided and sometimes prolonged course of treat- ment. At the same time I feel bound to admit that this view is in direct opposition to that held by some writers. Dr. Bumstead, for instance, says he has had reason to believe that the frequent repetition of the sexual act has produced gonorrhoea in women free from any previous disease. Again, an affection due solely to repeated and unwonted intercourse rarely extends to the urethra, bladder, womb, and ovaries, as sometimes happens with genuine gonorrhoea. I know cases are cited in which such symptoms were found, and where the husband most strenuously denied having had any infection at the time of marriage. Were the denial always well-founded, the beh'evers in the non-specific nature of the disease would have a strong case here ; but it is as certain as any fact can be that many men marry without being perfectly cured some from natural laziness and neglect, some because they really believe they are cured, and a third class because they must fulfil the engagement at a stated time, etc. ; and I have seen cases which amply justify me in thinking that this uncured state is not unfrequently the cause of gonorrhoea put down to a more innocent origin. When, in a female, the signs of infection are seated in the urethra, the specific nature of the affection is admitted by those who oppose it when the affection shows itself in other parts, and notably by M. Ricord himself. 1 It is therefore just as well to bear in mind that, as one form of gonorrhoea, is always due to a specific cause, other forms may also be due to the opera- tion of the same law. We know that they often are so. The next question is, can a man, who has contracted a discharge from a woman laboring under leucorrhcea, or simple vulvitis, or who is not quite free from the catamenial flow, give another woman true gonorrhoea ? My reply must be that I have never been able to satisfy myself, in my own practice and observations, of such a fact, and the reader will see farther on the reasons I have to offer for exercising caution before a decision is formed. 3. Lastly, we have to consider the possibility of transmitting to the fe- male a discharge set up in the male urethra by any of the mechanical or other irritants spoken of in the third class enumerated previously. It will, perhaps, conduce both to clearness and brevity if we take the two last sets of causes together. In the first place it is to be remembered that we must often deal with a very suspicious class of facts. Trustworthy men, the men on whose evidence we could best rely, are the most likely, when they find themselves suffering under a discharge of this kind, to abstain from connection, and 1 Lettres sur la Syphilis, p. 61. 28 ON GONORRHCEA. very properly too. Consequently the proof most wanted is the most dif- ficult to get. Secondly, we have to separate facts which have been confounded to- gether. For instance, it seems to be assumed by some authors, that when symptoms run high, infecting power must be present. But the two ques- tions are quite distinct. Severity is not evidence of contagious power. Take the case of Swediaur. He gave himself as bad urethritis as a man could well have, by injecting ammonia into the canal, but as evidence of such a disorder being able to infect the female, his experiment is worth- less. Yet who can doubt that some of those who speak of his case have not kept the line of demarcation so clearly in view as they might have done ? Some of the causes assigned may at once be rejected ; they are far too improbable for any rational being. Thus, e.g., Dr. Tanner was present when a surgeon suggested that making water in the night air might bring on gonorrhoea ; and Mr. Johnson relates ' that a patient wanted the stu- dents at St. George's Hospital to believe that in his case gonorrhoea had been brought on by the exertion of lopping a tree ; he having nothing the matter with him when he began his task, and finding the discharge fully developed when he came down ! A medical man credulous enough to fancy that night air could exert any such influence would not be likely to investigate facts with proper care ; and a patient who had the effrontery to tell such a barefaced false- hood would be just the person to conceal the fact that he had had inter- course with a prostitute. The possibility of late hours, too, having any such effect is one I should be very much inclined to question. It is, there- fore, only against the more probable of these causes that any arguments are directed. It must always be kept in view that many patients are possessed with a desire for finding any reason but the right one. It is not that they wish to deceive the surgeon. Most probably it arises as much as anything from a desire to extenuate the responsibility of the female, or to set up a higher standard for her health and physique than they are entitled to. Be that as it may, it is quite certain that they will snatch at a straw to save their -drowning theory, and are only too happy to find the surgeon concur with them in ascribing the disease to such innocent causes as a strain, a cold, etc. Still, making all allowance for bad logic, for the morbid desire to im. pose on medical men on the one hand, or on their own judgment on the other, it must be granted that cases of discharge from such causes are met with. And first, I have to urge that a very slight gleet, a tender state of the urethra left behind by a gonorrhoea suffered to die out of itself, or only 1 Op. citat, p. 27. PATHOLOGY. 29 treated with medicines, meaning really uncured gleet ready to break out again at any moment, and sometimes even incipient gonorrhoea, are often at the bottom, not only of the disease conveyed to the female, but of the symptoms set up in the male also. I have been consulted in several cases where the urethra had remained free from visible disease for a pretty long period, owing apparently to the patient leading a quiet life, and abstaining from connection ; and where yet the disease soon ripened into dangerous activity under the influence of sexual indulgence. As to gonorrhoea itself, I believe it to be, both in its decline, when there is scarcely a speck of dis- charge left, and in its nascent stage, when the most timid might think there was no ground for alarm, infectious in a very high degree for some persons. A lady, whose husband had brutally assaulted her, left him in conse- quence. As her womb was thought to be injured, I carefully examined her, and certainly I had every reason for saying that she was at this time perfectly healthy. Some time afterward she became attached to a gentle- man who had been very kind to her in her troubles, and who occasionally consulted me for a very slight gleet ; so slight, indeed, that sometimes it left no mark on his shirt, sometimes a pale one not bigger than a sixpence, but never more than this. This fluid was simply whitish mucus. Had the patient asked me the question, I should have said that such a dis- charge, albeit the relics of a gonorrhoea contracted two years previously, was innocuous ; fortunately, he took this responsibility off my shoulders. The attachment was followed by connection, of which I first became aware in consequence of the lady presenting herself in great distress, with every symptom of a violent gonorrhoea, from which she suffered very severely. Of course, the infection might have been derived from another source ; but knowing her family intimately as I did, having always heard, even from her husband, that her character was up to this time irreproachable, and that her disposition was averse to anything like sensuality or impropriety, I think it may be inferred that she caught the gonorrhoea from my pa- tient. When, however, there are no pus-corpuscles in the discharge, there is most probably no danger. I need scarcely say that it is not very easy perhaps it is impossible, to prove such a point, especially as one source of observation, the existence of pure mucous gleet in the male, is not very common. The only evidence I have to offer is simply that I have never been able to find, either in the practice of others or in my own, a single complete history of a case of gonorrhoea being communicated to the female, unless there was positive proof of, or very strong reason to suspect, the ex- istence of a certain amount of pus in the discharge by which she was in- fected. Dr. Durkee says, 1 that if there be no pus-cells in the discharge, there is no danger of infection, and the reader will see that I agree with 1 Op citat , p. 29. 30 ON GONORRH(EA. him. The requisite amount, however, seems in some cases to be very small. Mr. R consulted me about the middle of December, 1873. His ac- count was, that owing to protracted absences from home, and the disincli- nation his wife had long shown for sexual intercourse, he had remained almost always continent for the last five years ; that, three days previously, he had in the evening a suspicious connection, which was followed, two nights later, by intercourse with his wife ; and that he had been alarmed by noticing, the morning after, that is to say the morning of his visit to me, a slight discharge, which he distinctly stated had not shown itself before. On examining, I found the lips of the urethra wet with a sticky secretion, which looked more like thick serum than mucus ; there did not appear to be any pus in it. Within a few days his wife began to complain of uneasi- ness in the private parts. I examined her, and found considerable dis- charge from the vagina ; there was also some swelling with tenderness in the right groin. The next day, the discharge being thoroughly washed off, I cauterized the vagina pretty freely, and two days after repeated the process. The affection, whatever it might have been, yielded to this treat- ment, which was seconded by the use of aperients, preparations of potass, rest, and low diet. In the husband the symptoms developed into distinct purulent running. I may add that this lady was not in any way subject to leucorrhcea, having had no symptom of the kind. The urethra was not implicated in her case. Contrast this with the f ollowing case, in which there was as great a de- gree of incipient inflammation from a mechanical irritant. A gentleman, who had suffered severely from spermatorrhoea, married. Finding that connection only made him worse, he came up to London, and placed him- self under my care. I found the tendency to emissions as strong as ever, the urethra excessively tender, red, and secreting mucus freely. On placing a little of this under the microscope, it was seen to be swarming with inflammation corpuscles (cells). There was, however, no pus, nor had there been any, and there was no history of gonorrhoea. This condi- tion seemed to have been brought on by masturbation, followed by exces- sive connection. As he had got the fancy into his head that he must have given his wife the same disease as himself, I examined her at his request. The most careful search with the speculum revealed only a perfectly healthy state. Some time after he again consulted me, and stated that she had remained quite well It does not, however, follow from what has just been said, that every slight gonorrhoeal discharge, in its first or its last stage, must necessarily convey infection. Just as there are some men so constituted that they are almost certain to catch gonorrhoea nearly every time they commit an im- prudence, while other men repeatedly court risk and yet escape again and again, or if they do in the long run, as perhaps always happens, become PATHOLOGY. 31 infected, the gonorrhoea dies out of itself, or yields to such simple reme- dies as a few injections of cold water ; failing, however often the attack may be repeated, to bring on any of the more severe results, or to entail more than some slight inconvenience, so does the susceptibility vary in women. Some will suffer most severely and for a long time where others would probably get off safe ; or again, a woman may here and there be found so constituted as to expose herself with impunity to contagion in its worst form. I have known instances where men, with some amount of gonorrhceal discharge still remaining, had not communicated any disease to young women, whom one might have thought susceptible enough ; I am speaking, too, of cases where the argument about frequency of inter- course having something to do with the power of resisting infection could not be urged ; and M. Robert says that women having connection with men in the first stage of blennorrhagia, constantly avoid infection. But supposing that we can look upon both these positions as established, they are only rare instances of a disparity in receptive power which extends itself to all diseases and both sexes. The reader has most likely pretty well anticipated what I have to say about the probability of urethritis, brought on in the male by any of the irritants mentioned in the third class being conveyed to the female. I have already given my reasons for saying that the disorder is mild, and that the cases are fewer than are sometimes supposed ; that it is really quite an occasional event when running is set up by such causes as cold, gout, strains, etc. Still, as they are met with, we have to investigate the fact of their transmission. Now though I have once or twice known men so infected have connection, not only with their wives, but with other women, I have never seen any discharge whatever thus brought on in the female ; or rather, I ought to say that the answers to my questions have been in the negative, for I never had an opportunity of hearing the evi- dence on the other side. At the same time I ought to add that my ex- perience here has been small, although I have seen so many cases of gonorrhoea. It is quite certain that some of those women who have suffered from gonorrhoea and discharge produced by other causes than connection, draw a broad and practical distinction between the two. Among other cases I may state the following : A lady was infected with gonorrhoea by her husband. After being under the care of two surgeons, one of whom practised chiefly in this special branch, she consulted me. I had great difficulty in curing her, and only succeeded by means of repeated blistering and cauterizing the vagina and mouth of the womb freely. She now separated from her husband. A considerable time after this she married again, and again contracted gonorrhoea, which also required a considerable time to remove. Seven years subsequently she consulted me for a muco-purulent discharge from i32 ON GONOKRHCEA. the vagina. Knowing how severely she had suffered on the two former occasions, I gave a guarded opinion as to the time it would require for a cure, but, to my surprise, she avowed her conviction that she would soon be well, as the discharge had not arisen from connection, and as she had three years before suffered from a similar, but a more severe attack, after long exposure to great cold when travelling, which, though accompanied by considerable pain and even the formation of abscess, got quite well in a few weeks, with very simple treatment. It was a very different affair for all that, she said, from either gonorrhoea. The result in the present case proved that she was right, as she was well in ten days, though she only took some saline and merely used a lead lotion. Against this we have to set the experience of Dr. A. Hiller, who, it seems, 1 inoculated his own wife with the muco-purulent secretion brought on in the urethra by a mechanical irritant, and succeeded in reproducing the discharge. I have not seen his pamphlet, and trust entirely to the abstract of it in the German " Archives of Dermatology," which does not contain any account of the experiment. Without contesting the accuracy of the conclusions drawn by Dr. Hiller, I am yet forced to say that an ex- periment, designed to succeed, is a very different affair from the facts of every-day life ; and that it would require not one, but several trials to es- tablish the fact of communicability, and a separate series to show that the disease, so generated in the female, was identical with gonorrhoea. Inoc- ulation is, no doubt, a valuable means of observation, but it has more than once led to serious error. Point at which Infection takes place in the Male ; Seat of Gonorrhoea in the Male. Infection most probably takes place at the reflection of the mucous membrane from the urethra over the glans ; the lips of the urethra. I imagine no fluid from the female can possibly enter the urethra during connection, owing to the turgescence of the penis completely closing the passage ; and were any introduced, it must, one would think, be forced out again when the semen is expelled. The glans seems in no way implicated in the process, as gonorrhoea is met with often enough in Jews and others who have the glans uncovered from youth upward, and in whom the skin covering it is so dry as to be apparently quite insusceptible of infection. Moreover, the symptoms at the commencement are, I believe, invariably limited to the neighborhood of the lips ; chordee, pain in the perineum, irritable bladder, and swelled testicle never appear till the inflammatory symptoms near the mouth of the urethra have lasted some little time. I shall perhaps be told that the presence of chancre in the male urethra is fatal to such a view, as in this case discharge from the female must be carried down the urethra. There is, no doubt, a good deal of force in the argument. I am myself disposed to think, from the presence of chancre 1 Archiv. fur Dermatologie, etc., B. 4, S. 555. PATHOLOGY. 33 manifesting itself so generally within a very limited range of space, that the chancrous action begins at the mouth, and, when it does not expend its force there, spreads in a diffused form, like the gonorrhceal action itself, till it reaches a part of the urethra where, owing to peculiarity of tissue or tendency to take on an ulcerative action, it can develop itself. My reason for assuming that something of this kind occurs is, that chancre has been found so low down the urethra that it really requires a stretch of the im- agination to believe any fluid from the vagina could be propelled so far along a narrow and, at the same time, swollen canal ; especially consider- ing how strong the disposition is of the urethra to extrude everything in the shape of a foreign body, and even its own secretions when more co- pious than usual. The seat of gonoiThcea varies most materially, both according to the date after infection at which the patient is seen and the disposition of the urethra to take on the purulent action, a disposition which is not always alike in the same individual, and which is certainly widely different in different persons. At the outset the seat of the disease is, as I have said, limited to the very vicinity of the mouth of the urethra, but after a few days have elapsed we find every degree of severity as to extent. In some persons the inflammation spreads rapidly, in others slowly, backward, reaching in succession the bulb, membranous, prostatic portions of the urethra, the bladder, and so on. I tried hard for a long time to make out if there was any law under the influence of which this extension takes place, but after collecting a number of observations I gave it up. These views were made public several years ago at a meeting of the Medical Society of London, and again at more length in the third edition of this work, published in 1871. Some years ago an important paper on the subject appeared from the pen of M. Ledeganck. 1 This gentleman, who has examined the urethra in the living subject by means of a cylinder of thin glass, says that in the majority of cases the disease begins in the fossa navicularis. Fifteen or twenty hours after infection, he tells us, the vessels of the parts are injected, the seat of the hypersemia being strictly limited to the frsenum, and stopping almost at the borders of the meatus. On the second day the injection has extended to the interior of the navicu- lar fossa. When the urethra is examined with the glass, it is found that the mucous membrane presents a port-wine hue, which springs from the anterior lip of the meatus and extends down the canal in the form of two or three descending and diverging striae. On the third day the port- wine hue has become intense, and the part so colored has the form of a myrtle- leaf, with the base at the anterior border of the meatus, and the apex about three-quarters of an inch down the passage. After the third day the in- 1 Journal de Medecine, November, 1871. Quoted in the Practitioner, vol. viii., p. 183. 3 34 ON GONORRHCEA. jection extends rapidly toward the deeper parts, and its limits can then 110 longer be accurately fixed. According to Desormeaux the disease has by the eighth day engaged the anterior half of the urethra, the mucous membrane being red, rough, and presenting the appearance of superficial ulceration, the exfoliations of Fournier, like those sometimes seen in bal- anitis. In this case the endoscope is an insufficient guide, as I have known the prostatic part of the urethra and the bladder affected within the first week. Dr. Cruize concludes that in true gonorrhoea the inflammation spreads backward over the whole length of the canal, and then either contracts the area of its operation toward the orifice, or fastens upon the posterior tract of the urethra from the bulbous to the prostatic part. When it fixes itself near the bulb, which is its seat of predilection, it brings on a gran- ular state of the urethra, which has no tendency to get well of itself. De- sormeaux maintains that after a time the disease tends spontaneously to contract its area. The anterior part of the canal may reassume a healthy appearance, and in many persons the prostatic portion may recover its normal state, while the bulb and membranous part of the canal are still affected. In some rare instances the inflammation is limited to the navic- ular fossa. Therefis no such thing as " the specific seat of gonorrhoea." In a dozen successive cases the area and seat of the disease may not be alike in ajiy two. How and when the idea originated that the disease is confined to the first two inches of the urethra, I have not been able to make out. Hunter, who has been saddled with the responsibility, never said anything of the kind ; he certainly looked upon it as the part most commonly af- fected, 1 and contended that the inflammation does not usually go farther than two or three inches from the meatus, 2 a doctrine taught by at least one surgeon, 3 though, perhaps, not very clearly, long before the appearance of Hunter's work ; but he never expressed such a view as that the inflam- mation is always confined to this part ; so far from it, he distinctly says 4 that " we sometimes find the irritation and inflammation exceed the spe- cific distance and spread through the whole of the urethra." Cockburn, too, in the fourth edition of his work on gonorrhoea, published in 1728, if not in his earlier productions, expresses 6 his conviction that the inflammation extends to the neck of the bladder. Again, Sir Astley Cooper examined the body of a man executed at the Old Bailey while suffering under gonorrhoea, and found that the inflamma- tion was greatest in the first three inches of the urethra, but that the lin- ing membrane was inflamed up to the membranous portion. 6 The doc- 1 Treatise on the Venereal Disease, p. 50. 1786. s Ibid., p. 47. 3 Venereal Gonorrhoea, p. 18. By James Neville. 1754. 4 Op. citat., p. 51. 5 Page 271. 8 On the Structure aud Disease of the Testis, Part II., p. 15. 1830. PATHOLOGY. 35 trine of limitation to a specific seat was also opposed, long ago, by an ex- cellent observer, Dr. Egan, who as far back as 1848 stated ' that gonorrhoea sometimes engages the "whole extent of the urethra, and by Mr. Colles in 1850, who maintained " that the inflammation may spread as far as the bladder, and even at times to the ureters and kidneys. He found the urine loaded with pus from the bladder in two or three days from the beginning of the gonorrhoea. Post-mortem examination reveals little for or against M. Ledeganck's account. I have only twice examined a gonorrhoeal urethra after sudden death. Both patients committed suicide. It was difficult to say exactly where the inflammation, which was principally shown by a punctiform reddened state of the membrane, really stopped ; but it could not be said to extend beyond three and a half inches in one case and three in the other. Hunter simply says that in such cases he found the urethra a h'ttle bloodshot. Dr. Stoll, of Vienna, examined very carefully the urethra of a man who died in his hospital while suffering from "a virulent clap." He found the internal surface preternaturally red, two of the lymphatics white and enlarged, and puriform matter oozing out from the internal membrane, especially at the lacuna. 3 Drs. Jones and Sieveking only state that the mucous lining becomes swollen, injected, and covered with mucus or muco-purulent secretion, the follicles and lacunae being attacked, particu- larly the lacuna magna. Dr. Charteris, in his account 4 of a post-mortem held on a lad who died in six days of pyaemia from gonorrhoea, says " the interior of the anterior part of the urethra was congested, with a small longitudinal thickened red patch, a quarter of an inch long, on the floor of the urethra, three inches from the anterior orifice." Fournier gives among the post-mortem signs tumefaction of the mucous membrane, " linear arborization," punctiform injection of the canal, redness of the urethral sinuses, granulations developed at certain limited points of the passage and most frequently united into groups, and exfoliation of epithe- lium very much akin to ulceration. M. Bonniere, who unequivocally maintains the specific nature of gonor- rhoea, examined 5 the bodies of several soldiers who died of Asiatic cholera in 1854, while suffering from gonorrhoea in its most developed form. He found very slight traces of inflammation in the navicular fossa ; the sur- face was punctate, red, and robbed of its polish. In the spongy part the mucous membrane was thickened but scarcely reddened ; the appearances in the membranous part resembled those in the fossa. But everywhere he noticed that the foramina were visible, and that the circumferences of their orifices were of a violet red and deprived of epithelium. 1 Dublin Quarterly Journal, vol. v. , p. 404. * Ibid. , vol. x. , p. 103. 3 Swediaur: Op. citat., p. 24. 4 British Medical Journal, vol. ii., p. 712. 1876. 5 Archives Generates de Medecine, tome i., p. 405. 1874. 36 ON GONOKRHCEA. According to him the parts capable of taking on gonorrhceal action are the glans, prepuce, urethra, especially the navicular fossa and prostatic region, excretory canal of glands of Littre, conjunctiva, anus, mouth vulva, vagina, os uteri, lower portion of cervix uteri and the prostatic utricle ; those refractory to infection of this nature are the rectum, lachrymal canal, body of uterus, seminal vesicles, vas deferens, prostatic canals, bladder, excre- tory duct of glands of Cowper and Bartholini. The susceptible parts are carpeted with pavement epithelium, provided with papillae and a superfi- cial subepithelial mesh of minute lymphatic ducts ; the others are paved with cylinder epithelium, and have a superficial vascular network. The congeries of epithelial capillary lymphatics is not to be confounded with the mesh of lymphatics described in anatomical treatises ; it is a capillary network of small vessels, the outer wall of which is formed of pavement epithelial cells. He therefore holds that in gonorrhoea there is a change of a virulent nature in the epithelial cells of the superficial lymphatic sys- tem of the mucous membrane, with pavement epithelial system, and that the virus acts primarily upon the lymphatics and epithelial cells, inflam- mation of the surrounding tissues being only secondary. He considers that the contaminating pus passes through the epithelial cells by imbibition, and comes in contact with the interior of the superfi- cial capillary lymphatics ; specific action, perhaps a primitive necrosis of epithelial cells, is thus set up ; this action propagates itself along the cap- illaries ; the epithelial surface is invaded nearer and nearer ; the secre- tion of mucus is augmented ; the epithelial cells of the deeper layers are incompletely developed ; the superficial cells are detached ; the lymphatic network is destroyed, and the mucous membrane is more or less denuded. In the secretion are found cells of pavement epithelium, little many-sided cells, granular globules showing multiple nuclei when treated with acetic acid, blood-globules, and fine yellowish granular bodies. The disease continues to spread in surface and depth from the superfi- cial to the submucous network. In the deep or submucous lymphatics blennorrhagia is seldom suppurative or destructive ; it is really an internal lymphitis of the submucous layer. The acuteness and violence of the disease are in direct relation to the number of the canals and the close- ness of the meshes. Very intense superficially in the navicular fossa and the prostatic region, where autopsy always reveals the most vivid redden- ing, it is milder at the surface in the spongy region, but more intense again in the submucous tissue of this region where the deep mesh is closer. It is here that we find a certain degree of resistance in the mu- cous membrane, resistance which is looked upon as due to plastic infiltra- tion, but is only the result of irritation set up in the mesh and surround- ing connective tissue. The epithelial necrosis extends neither to the bladder nor to the glands of Cowper, to the prostatic canaliculi nor the ejaculatory ducts. It stops abruptly at their borders where it forms a sel- PATHOLOGY. 37 Tage. On the other hand, the disease constantly invades the glands of Littre, the excretory canal of which is laid with pavement epithelium. Blennorrhagia terminates in necrotic destruction of the epithelium and the lymphatic canals, and the reproduction of these by the generation of a normal epithelium, but probably in smaller quantity ; the latter fact being the cause why a second gonorrhoea is milder than the first. Relapses are explained by the persistence of diseased action in the deep lymphatic bed, from which it again reaches the superficial mesh when this has been re- generated ; or it may happen that a portion of this mesh hitherto healthy is tainted by an infected part. The reason why abortive injections do not succeed is that 'they do not reach the submucous lymphatics. The gonor- rhoea! infection, following the route indicated, may reach the dorsal trunks of the lymphatics of the penis, and there excite lymphitis ; it may also ex- tend to the ganglia of the groin and pelvis, the layer of pavement epithe r lium, which constitutes the wall of the capillary lymphatics and forms the internal coat of the lymphatic vessels, being the conducting agent. This much relates to the course of simple uncomplicated gonorrhoea at the outset. The question of extension of the morbid action, us the first stage in the pathology of orchitis, will necessarily come under discussion in the part treating of that affection, as also in that relating to gleet. Period of Incubation. This has been so variously stated that if we al- low equal weight to all who have given us the result of their observations, no time can very well be laid down. It is, of course, very often a most important question for the patient's peace of mind to know at the expira- tion of what term he may fairly calculate on escaping from the results of indiscretion ; but really the question is not very easily answered, and I be- lieve the only safe way of dealing with it is, if we include after-infections, to extend the limit beyond that often laid down in works. In the case of a first gonorrhoea, the symptoms, though slight, usually set in quite unmis- takably at the end of three, four, or five days. The contention that there is no proper period of incubation in gonorrhoea, that what is so called is only a time of latent action, in which the morbid phenomena are develop- ing without being intense enough to make themselves visible, is one of the most extraordinary I ever heard of ; for what is this latent action without visible results but incubation itself, and what proof is there that the very same action is not going on from the time of infection in small-pox and scarlet fever ? According to M. Le Fort, 1 out of 2,070 patients suffering under gonor- rhoea, 778 noticed the initial symptoms of the disease within the first four days, 50 of them at the end of twenty-four hours after exposure to infec- tion, and 869 in the second four days ; 276 noticed the earliest signs be- tween the close of the eighth and of the twelfth day ; 112 in the fourth 1 Medical Times and Gazette, vol. ii. , p. 52. 1869. 38 ON GONORRHOEA. period of four days, and only 17 in the fifth of these periods, or from the sixteenth day to the twentieth, including the latter. Supposing these sta- tistics to represent average results, the first symptoms must be considered to appear, in upward of seventy-eight per cent, of all the cases, in the time extending from the first to the ninth day. But often enough in after-at- tacks the symptoms appear much later, and not infrequently in so insidious. a manner that both surgeon and patient at first look upon what is destined to ripen into a true gonorrhoea, as " a mere touch of gleet." Hunter gives l the time as varying from a few hours to six weeks, and if no regard be paid to the difference between a mild and a sharp case, a first attack and one preceded by many others, this rough estimate may hold good. I have, how- ever, never seen any approach to such a long duration. An opinion that gonorrhoea is more liable to relapse at certain times of the year than at others has been advanced by some authors. M. Robert says that the spring seems greatly to favor relapses, and I have fancied I detected something of the tendency myself during the prevalence of cold, dry east winds. The question, however, is difficult to settle till we have much better data. If the mere revolution of seasons influenced the num- ber of cases, we might expect a regularly recurring increase in spring, and of this I have not as yet seen any proof worth notice. Seat of Gonorrhoea in the Female. As concerns the seat of this disor- der, and, by implication, the relative frequency of its different forms in women, I should say, judging from my own practice, that the vagina is the chief place of action in the first attack ; that in some instances the morbid action spreads to the urethra, and fastens on it with such severity as to make this the predominant affection ; and that in neglected cases, or after repeated infections, some degree of mischief will usually be found near or on the os uteri, most likely with some exudation from the canal of the cer- vix. Dr. Ashwell held that gonorrhoea in women is chiefly seated in the vagina, and Dr. Tyler Smith agrees with him. Out of 112 cases, Egan found 2 the vagina more or less inflamed in 98, granular erosion on the cer- vix in 38, erythematous condition of the os or cervix in 57, and the uterus participating in 97. Dr. Graily Hewitt considers 3 that when the vagina is attacked with acute gonorrhoea, the urethra frequently shares in the mor- bid action. According to the opinion of Dr. Barnes, a most truthful and la- borious observer, quoted in Jones and Sieveking's " Pathological Anatomy," gonorrhceal vaginitis more particularly affects the fundus of the vagina, with some implication of the vaginal portion of the uterus ; the redness is much more intense than in the simple form, and the gonorrhceal variety yields a copious muco-purulent secretion of greenish or yellowish tint. Hagemann contends * that the urethra and glands of Bartholini most fre- 1 Op. citat., p. 31. 8 Dublin Quarterly Journal, vol. v., p. 408. 3 British Medical Journal, vol. i., p. 57. 1862. 4 Wiener mediziuische Wochenschrift, S. 606. 1879. PATHOLOGY. 39 quently of all parts take on the gonorrhceal action. In 703 cases of gonor- rhoea he found urethritis in 409 and Bartholinitis (sic) in 383. The state- ment is in direct conflict with the experience of M. Bonniere, 1 who could never in acute blenuorrhagia, even when it had lasted several days, detect any pus in the glands, all he could extract by pressure being a little stringy viscid mucus. The latter writer maintains that the inflammation of the interior of the neck, however virulent, does not extend beyond the part covered with pavement epithelium, that is to say, the lower portion. It is sharply arrested there, the boundary being quite definitive. In front of the os tincse the lymphatic network is loose, and the gonorrhceal action there is mild ; behind, the meshes are closer and there it is more virulent and persistent, an anatomy which needs confirmation. Period of Incubation. The time at which the signs of infection appear in the female is by no means easy to decide. The hidden site of the part, and the ignorance of many women as to the nature of the complaint, and, indeed, of such things in general, make it more difficult to fix the era of its outbreak with exactness ; but the probability is that it is much the same as in men. Milder Nature of Gonorrhoza in Subsequent Attacks. Hunter held 2 that most men suffer more severely in the first gonorrhoea, and that " the suc- ceeding ones generally become milder and milder till the danger of infec- tion almost vanishes." Many authors have accepted and repeated the first part of this view, but I am satisfied that on both heads the statement is fre- quently at fault. It is true enough that a man who has caught one sharp gonorrhoea, with a good deal of scalding, chordee, pain, and perhaps swelled testicle and irritable bladder, does not often present himself with exactly the same symptoms ; partly, it may be, because, warned by what he has suffered, he takes more care about his next attack, and exposes himself less to infection. In such a patient the symptoms will probably enough be slighter, but often matters do not go on in this way. Some persons suffer more in the second attack than in the first. One of the most refractory cases I ever had under my care was a second gonor- rhoea ; according to the patient's account, which was perfectly consistent throughout, all the symptoms were worse than in the first. I have notes of two or three similar cases, including one in which the fourth attack was worse than the first, and one where the third gonorrhoea was more severe and obstinate than the second. Some men always have the disease in a mild form, others the very reverse. I had a gentleman three times under my care for this complaint ; it went away very quickly in each in- stance, and he assured me that, though he had often exposed himself to contagion, he had never had a discharge which lasted more than a week, nor was the complaint ever attended by such symptoms as chordee. On 1 Op. citat., p. 408. ! Op. citat., p. 37. 40 ON GONORKHCEA. the other hand, I treated a patient for eleven gonorrhoeas in three years, in none of which did I notice any symptoms of abatement, there being a good deal of running, redness of the urethra, scalding, and disposition to chordee at each attack. All were cured very quickly, but for anything I could make out to the contrary, the last attack was as bad as any of the others. Irrespective of this evidence that we cannot always rely on the danger of infection " almost vanishing," I may add that I was once con- sulted about a case where the patient, in his written account, roughly com- puted the number of his infections at thirty. Does Gonorrhoea Infect the System. ? Dr. Tanner says that the occur- rence of such a disease as gonorrhceal rheumatism can only be explained on the supposition of systemic infection. I am not quite clear that I un- derstand exactly what systemic infection is. Extension of the purulent inflammation, Hunter's sympathy of continuity, either in all its integrity or in a modified form, may be imagined as possible all along the mucous membrane of the genito-urinary tract ; indeed, there is every reason to believe that it takes place sometimes. Again, inflammation of the con- tiguous parts (sympathy of contiguity) is clearly excited by gonorrhoea, and is comprehensible enough ; while endocarditis, rheumatism, and puru- lent deposit in distant parts show that a series of different and yet very serious actions may be set up. But I see neither proof nor possibility of the whole frame being affected ; of the lungs, brain, heart, liver, muscles, and bones being enveloped in one common mass of disease, and yet this is what systemic infection must mean, if it mean what it professes to do. Possibly Hunter's " remote sympathy," of which he gave some instances, and of which I think many more might be given, offers a clue to the solu- tion of the problem, the action indeed being strictly reflex. MM. Pidoux and Guerin believe in the existence of a species of gonorrhoea! lues, and M. Fereol rather leans ' to this opinion, which seems to me about as un- founded as anything in the shape of an opinion can well be. Prognosis. According to some writers, gonorrhoea is so mild a com- plaint as scarcely to require any rules for treatment. I heard a consulting surgeon, in large practice, assert that he always cured his patients in a week or ten days. Dr. Chambers, of St. Mary's Hospital, considers 2 that gonorrhoea is never obstinate or of long duration, unless rendered so by bad treatment on the part of the surgeon, or folly on that of the patient Like a mild, catarrh it passes off of its own accord, if the patient will only be reasonably quiet and the surgeon abstain from mischievous interference. The reader must bear in mind that these assertions are not made by any mere tyro, but by a physician to a large hospital, a Lumleian lecturer, and a well-known author. 1 Archives Generates de Medeciue, tome ii., p. 208. 1866. 1 Lancet, vol. i., p. 582. 1861. PATHOLOGY. 41 This view does not in any way harmonize with my experience, which is that many cases of gonorrhoea are only subdued with great difficulty. It is in direct conflict with the experience of Lee, 1 Astley Cooper, 2 Bumstead, 3 Durkee, 4 Hunter, Johnson, 6 Robert, 7 and Fournier ; in 'fact of every one who has carefully studied the disease and written honestly about it. They tell us that, with rare exceptions the disease requires, under the best man- agement, three or four weeks, often as many months, to cure, and that it is impossible to fix a reliable average date for the duration of gonorrhoea. Results of Gonorrhoea. As it formed no part of my plan to describe the symptoms of this affection, inasmuch as they have been fully and carefully laid down in many excellent works, so for a similar reason, I did not intend to touch npon the results it induces. But as accounts of the effects pro- duced by this disease have appeared, which are enough to make one's hair stand on end, I have been obliged to break through the rule laid down. They are from the pen of Dr. Noeggerath, of New York, 8 who informs us that gonorrhoea, in man as in woman, once contracted, is, as a rule, incur- able ; that it renders every man who has suffered from it to a great extent sterile, and that eight out of every ten men have gonorrhoea. The wives of men who have contracted this disease either remain barren, or, if they become pregnant, abort or bear only one child. He gives the cases of eighty-one women thus situated. Out of these only thirty-one conceived. Five of the thirty-one aborted, and three were prematurely confined, thus reducing the number of child-bearing women to about one-fourth of all who married. Of the twenty-three who went their full time, twelve had one child during married life, seven had two children, three had three, and one had four. I am indebted for a knowledge of these startling facts to a review of the work in the Edinburgh Medical Journal, 9 for I have not seen the original, and I may observe that the reviewer seems rather favorably disposed toward Dr. Noeggerath's opinions, and speaks of the work as a thoughtful and important essay ; a sentiment evidently shared by the re- viewer in the Dublin Quarterly Journal, 10 who describes the book as inviting "the most careful consideration of the subject." But the troubles of women who have the misfortune to marry the vic- tims of gonorrhoea do not end here. Nine out of ten of them fall into some incurable kind of disease such as perirnetritis, acute, chronic, or recur- rent ; oophoritis, and catarrh of the genital passages. Finally the infection of gonorrhoea is so intense, that it may be conveyed when the disease is latent. Complaints are sometimes made that we get nothing new about this disorder. Here at any rate is novelty enough. It does not seem to have struck Dr. Noeggerath that, had his facts been 1 Op. citat., p. 195. 2 Lancet, vol. iii., p. 104. 3 Op. citat., pp. 63, 100. 4 Op. citat., p. 43. 6 Op. citat., p. 69. 6 Op. citat., p. 86. 1 Op. citat., p. 81. 8 Die latente Gonorrhoe im weiblichen Geschleclite. 9 Vol. xviii., p. 648. 10 Vol. Ivii., p. 326. 42 ON GONOERHCEA. correct, gonorrhoea would have long ago depopulated every country into which it had penetrated. According to him eighty out of a hundred men catch gonorrhoea, and we have just seen that eighty-one such men have thirty- one children. Suppose that, for convenience sake, we take eighty-one out of a hundred, instead of eighty, as representing the proportion of infected males ; doing so will not materially affect the issue, and a second calcula- tion by the reader will at any time set all right. If, to the remaining nine- teen we allot an aggregate of a hundred children, which is, I believe, quite up to the average, this will give us a total of a hundred and thirty- nine children born to every two hundred grown up persons. It needs no reference to an actuary to show that, with such a state of matters, the dis- appearance of the entire population is only a question of time, and of a very short time too. Again, out of every hundred married women, seventy-two must, accord- ing to Dr. Noeggerath's theory, suffer, sooner or later, under incurable dis- ease of the womb, the surrounding parts and appendages, and the genital passages. This is the percentage from gonorrhoea. Add to this the cases where either such affections, or other formidable diseases of these parts, are brought on by more innocent causes, and we are driven to the conclusion, that out of every hundred married women, nearly eighty at least are suffer- ing under severe or hopeless uterine disease. I think I may safely ask, whether there is a man living whose experience agrees with that of our author. His statement, too, about the sterility of men who have once had gon- orrhoea, does not harmonize with what I have seen ; on the contrary, I know cases enough which prove the very reverse. I attended a gentleman who had, he told me, been repeatedly infected. He had gonorrhoea to a cer- tainty ; I saw the pus coming out of the urethra, and injected him with my own hands. Two or three years after this he married, and his wife had twins at her first confinement Both lived, and are now fine sturdy lads. When I last saw him his wife was again pregnant. I was consulted about the case of a gentleman whose brother, himself a surgeon, told me that this patient had in his younger days so repeatedly suffered from gonorrhoea, that he believed it was rather the rule than the exception for him to have one. After marriage he had four healthy children, the somewhat advanced age of his wife seemingly alone preventing any further increase of family. I attended two gentlemen, friends of each other. One of them had as bad a gonorrhoea as ever I saw and extremely rebellious. He has now five fine children, one of them growing up quite a type of manly beauty. His friend had eight attacks of gonorrhoea, for three of which I attended him ; he has since married twice, and had children by each wife, the number amounting to six when I last heard of him. My opinion was asked about a case of somewhat alarming bleeding from the urethra, owing to chordee from gonorrhoea. The patient married directly after he was PATHOLOGY. 43 cured, and has had fourteen children, twelve of whom are now living, and so on. Nor am I any more in accord with this gentleman as to the serious state of health induced in the female by marriage with a man who has been infected. In many cases I have, of course, had no chance of learning the history of the case after my attendance on the husband came to an end ; but in several others I know that, GO far as their own repeated state- ments can inform me, the wives have remained free from not only uterine but any other grave disease. I have not heard that one of them aborted or was prematurely confined, and I am sure that many have not done so. Dr. Angus Macdonald, who thinks Dr. Noeggerath has got hold of " a grand idea," has gone ' very carefully into his views, and quotes from his own practice cases which he thinks support the theory. Want of space will not allow me to reproduce these, and I must therefore refer the reader to Dr. Macdonald's paper, and especially to his fourth and fifth cases. So far as I can understand the question, he seems only to establish the fact that gonorrhoea, even when of long standing and almost cured, may be communicated, a fact which I, for one, never denied. In a former edition of this work I called attention to the possibility of the disease being trans- mitted by a discharge seemingly innocuous. Dr. Macdonald also shows that gonorrhoea, thus conveyed, may set up very serious if not fatal con- sequences in pregnant women. Not having had much experience of such cases, I can offer no opinion on the matter. One, about which I was con- sulted, rather supports Dr. Macdonald. The husband was certainly laboring under recently contracted gonorrhoea, and infected his wife about the mid-term of pregnancy. Shortly after she was attacked by serious symptoms, which the medical* gentleman in attendance upon her seemed to have considered as inflammation of the womb, but I did not receive the account from him, and could not get any more definite statement. But while I readily admit the contagious power of even a very slight amount of pus in the secretion of the male urethra, I entirely demur to such a doctrine as that of latent gonorrhoea, in the strict sense of the word, being conveyed by sexual intercourse ; for by latent I understand that state in ivhich there is no discfiarge existing. I have already given my rea- sons for coming to this conclusion. Dr. Macdonald, however, interprets 2 latent as chronic gonorrhoea, and from what Dr. Noeggerath says, of its be- ing a common practice to sanction the marriage of young men stih 1 suffer- ing un:ler stickiness of the urethral opening, accompanied by such an amount of discharge as to cause spots on the linen, it is possible that he means the same thing ; but I must take the liberty of calling this gleet, not latent gonorrhoea, and of adding, by way of rider, that any medical man sanctioning marriage under such circumstances takes upon himself 1 Edinburgh Medical Journal, vol. xviii. , p. 1086. - Op. citat. , p. 1101. 44 ON GONORRHOEA. a most dangerous responsibility. Rightly or wrongly, I have always under- stood by latent gonorrhoea, or latent gleet, a disposition in the urethra, unaccompanied by the presence of purulent secretion, to,take on the character- istics of gonorrhoea, or gleet, when the system is excited by the stimulus of much connection, indulgence in beer, etc. I do not see how Dr. Noeggerath's assertion about gonorrhoea being in- curable is to be met at all. A man might say the same thing about any complaint, without its being possible for another person to refute him ; but I believe I am warranted in affirming that morbid anatomy does not come to his assistance here, as it does not demonstrate any change of tissue induced by uncomplicated gonorrhoea, when cured in the ordinary sense of the term. What proof of cure is to be required, beyond a return to natural appearance and natural state of secretion, I do not know. Dr. Thorburn, who investigated the subject, and for this purpose col- lected the statistics of eighty-one private families, found ' that there had been thirty-three per cent., or twenty-six in all, of gonorrhoeal infection in the male ; and taking all the cases of abortion, sterility, uterine and pelvic inflammations which had occurred in these eighty-one families, he showed conclusively that there was the merest fractional difference in their pro- portion between the previously and not previously infected classes. As regards inflammatory pelvic affections, the balance was fractionally in favor of the "free gonorrhoeic cases; "in other respects equally fractional in favor of the non-gonorrhceal ; results which I do not feel quite assured about understanding very clearly. Dr. Thorburn's conclusion is that the latent gonorrhoea of Dr. Noeggerath is a myth, and not an impervious bar- rier to marriage as it otherwise would be. Dr. Bantock, who was present when this paper was communicated to the 'British Medical Association, agreed on the whole with Dr. Thorburn ; and added that he did not find that women, who had contracted gonorrhoea, went through pregnancy any worse than those who had not had the disease. I am glad to find that Dr. Thorburn has refuted the theory from this point of view, but with all be- coming deference I must urge that my own arguments, long previously made public, appear to me quite sufficient to subvert it ; for that which is shown to be impossible could never have occurred. A case in which serious nervous symptoms followed gonorrhoea is fur- nished by Dr. Althaus." The urethritis was obstinate, and, having long resisted injections, seems to have been at last arrested by tannin bougies. Some months after, the patient having married and had connection with his wife, was seized with intense pain in the back part of the urethra, and on one occasion the semen was tinged with blood. This was followed by wearying pain occupying the whole of the lumbar region, which fre- 1 British Medical Journal, vol. ii., p. 259. 1877. 'Medical Times and Gazette, vol. i., p. 385. 1807. PATHOLOGY. 45 quently radiated into the groins, hips, and thighs. It never left him, and was liable to be increased by all kinds of exercise. Then followed perma- nent pain in the urethra, irritability of the bladder, and occasionally retention of urine ; bad appetite, imperfect assimilation, pain in the back, lassitude, tremor, frequent jerkings, pains shooting through the legs, and sense of numbness in the feet. The treatment consisted of catalec- trotonus of the spine and passes with the cathode over the entire lumbar region, while the anode was placed upon the perineum to act on the pain- ful part of the urethra. A rapid cure followed, the pain especially being quickly relieved. Such results as these are so rare as to make their classification unde- sirable, and it is not quite certain that they were really due to the gonor- rhoea at all ; I have therefore preferred to take the case here rather than among the complications of gonorrhoea, which I need hardly say are in reality results of this disorder. Some very serious diseases, however, such as gonorrhceal peritonitis, sub-peritoneal inflammation, endocarditis, etc., which appear to be extensions of common well-known complications, will be considered further on in connection with gonorrhceal rheumatism, affec- tion of the seminal vesicles, and so on. Origin of Gonorrhoea from a Fungus. As most of my readers are no doubt aware, this disease has at different times been ascribed to the oper- ation of a fungus, and especially by Dr. Salisbury, who tells us ' that the species which produces gonorrhoea consists of spores, which are found in pairs and sometimes in fours, and develop rapidly in and among the pa- rent cells of the mucous membrane. These spores unite and run into fila- ments. He also maintains, that if this fungus be once planted in the raucous membrane, it " extends from cell to cell, if not prevented by re- medial means, till it has invaded all the mucous surfaces in continuity with each other." I presume this really means, that in every case where gonorrhoea is not checked by art, it spreads to the bladder, ureters, and epididymis. I ask the reader to weigh this, and say, whether he has not often seen a neglected gonorrhoea where nothing of the kind took place. The purely microscopical view of the question is carefully considered, and I think refuted, in the first volume of the Archio far Dermatologie, where also the statements of Hallier on the same subject are discussed. Long ago indeed M. Jusseaume, in his inaugural thesis defended before the Faculty at Paris, 1862, maintained 2 that gonorrhoea is clue to a vegetable parasite, ftn alga, consisting of long filaments ten to twenty millimetres in thickness, and often curved or bent at an angle. He described minutely the changes which take place in these bodies, as also their reproductive organs, showing to what an extent self-deception may be carried by means of the microscope. 1 American Journal of the Medical Sciences, vol. lv., p. 22. 1 Archives Gent-rales de Medeciue, tome i. , p. 353. 1863. 46 ON GONORRHCEA. Micrococcus Peculiar to Gonorrhcea. Dr. Albert Neisser, of Breslau, reports l that he has discovered a body of this nature which may be found by the following process. The thinnest possible layer of gonorrhceal mat- ter having been dried on the slide, and colored by pouring over it watery solution of methyl-violet, is then examined by means of a high power with the largest diaphragm opening (mit wenigst moglich abgeblendetem Licht). Neisser himself uses for the purpose a Zeiss microscope with Abbe's lighting apparatus, one-twelfth oil immersion lens and four or five ocular, a clearer view being thus obtained than with the best immersion of Hartnack and Siebert. At the first glance may be seen, besides the dark violet blue of the pus-corpuscles appearing in the most varied shape, and revealing even their dull tinted protoplasm, a number of more or less thickly set heaps of micrococci, which have a perfectly character- istic form and can be immediately recognized. The individual bodies composing these masses are circular, and strik- ingly large ; they very readily take the stain of methyl- violet. They are also colored by strong solution of eosin, but do not in this state contrast so markedly with the nuclei of the pus. corpuscles, which Ehrlich indeed proposes to call eosinophilous. They are not affected by methyl-green and indulin. With objectives of lower power the micrococci are seen girdled with a ring of light, which perhaps represents a mucous envelope. They are, however, seldom met with solitary ; generally we find two packed close to- gether, so close in fact that they give the observer the impression of a single body shaped like a figure 8, a biscuit, or a german roll. The seem- ing diversity and multiplicity in the arrangement of these composite bodies are best interpreted by attending to the history of their development. Thus the isolated micrococcus is round, but is soon transformed into a short corpuscle of lengthened oval shape, which quickly undergoes constriction in the middle and divides into two micrococci. Up to the date of Dr. Neisser's memoir it had not been possible to say, whether the preponderance ob- served of micrococci of the german roll (Semmel) shape is due to the acci- dentally long cohesion of two individual bodies, or whether multiplication by change is so rapid that the individual is seldom seen in its isolated stage. Finally the micrococci part company, and a small space, equal to about their own bulk, separates them from each other. Each individual body, however, speedily divides again, but this time exactly at a right angle to the first Hue of scission. In this way each half breaks up into two, so that frequently groups of four are met with. For the most part the micrococci agglomerate into columns of ten, twenty or more, each segregated by a mucous envelope, easily made out when the field is somewhat less clearly illuminated. In these colonies the micrococci never lie very close to each 1 Central Blatt. f iir die medizinische Wissenschaft, S. 497. 1879. pjrriiOLOGY. 47 other, being always kept apart by large spaces (sic) ; tliey are generally found on the upper surface of pus-cells, seldom on epithelial cells. Some- times the nucleus was found wanting in certain pus-cells which were beset with micrococci ; in others a distinct lessening of the nucleus could be made out, corresponding to an in-growth of micrococci on the nucleus. For all this Dr. Neisser considers that the hypothesis of these growths, depend- ing for their existence on the destruction of the nuclei, must be sum- marily rejected. These micrococci, recognized not only by Dr. Neisser but also by other observers, were found in thirty-five cases of gonorrhoea selected for exami- nation, the date from the commencement of the disease varying from three days up to thirteen weeks ; in one case of chronic gonorrhoea which had lasted eighteen months he could not find any. In general they were met with indifferently, whether the case had been treated or not ; in five cases persistently treated with sulphocarbolate of zinc he could not detect any, although the secretion was very profuse. With the exception of one case in which there was a strong suspicion of soft ulcer of the urethra, every specimen of gonorrhoea! pus which he examined contained only this kind of bacteria. On the other hand, this form of micrococcus was absent in every other kind of pus examined, how- ever rich such specimens might be in bacteria ; balano-posthitis, soft sore, hard sore, bubo of every kind, whitlow, etc., yielded nothing of this sort. The micrococci were also wanting in thirteen cases of fluor albus selected at random, but were found numerous enough in the vaginal secretion of two girls, who had evidently been maltreated by a man suffering from gonor- rhoea. Exactly similar typical micrococci were found in nine cases of puru- lent urethritis in women, also in seven cases of acute purulent ophthalmia in new-born infants, of one to six weeks' duration of the disease. In one case of fourteen days' standing, where very energetic treatment had left only a minimum of secretion, the micrococci were wanting, as they also were in every instance of simple purulent conjunctivitis. They were dis- covered in two cases of gonorrhceal ophthalmia in the adult. Dr. Neisser sums up by observing that the micrococci, which he has described, offer an unfailing test of the gonorrhceal nature of affections of the urethra, as also of the eye, and thus enable us to diagnose the specific character of the discharge. There is, moreover, no connection between them and the micrococci of the urine, which are developed after a per- fectly different and typical fashion in long chains and rows. Dr. F. Weiss has verified ' to a great extent the statements of Dr. Neis- ser, examining the pus with diameters of 2,200, 1,100, 1,000, and even 900, methyl-violet having answered best as a re-agent in his observations. He describes the isolated bodies as almost spherical, ten to thirteen tenths of 1 Gazette Hebdomadaire, p. 751. 1880. 48 ON GONOKRH(EA. a millimetre in diameter, each being encircled by a hyaline band visibly striped ; they are, however, rarely seen solitary. He found these bodies in the pus of twenty-three women and nine men suffering respectively from gonorrhoea! vaginitis and gonorrhoea, but never in that of simple urethritis, balanitis, chancre, bubo, leucorrhcea, or suppurative orchitis. I suppose it is now universally admitted that Jusseaume and Salisbury were mistaken, and perhaps this has made men rather skeptical about ac- cepting the discovery of Neisser, for that great skepticism exists there can, I think, be no doubt ; and it will not be very satisfactory to find that time has justified it, and that the microscope has at least thrice led careful in- dustrious observers into error. For my own part I quite admit that, had I found out what any of these gentlemen did, I should have trusted to the microscope and contended for the truth of the discovery. Mr. Watson Cheyne ' conveyed (under certain conditions which, how- ever, he does not specify) gonorrhoea! pus into infusion of meat and cu- cumber. " In these flasks," he says, " inicrococci grew in large numbers, and also sometimes bacteria, showing that these organisms were present in the gonorrhoea! pus." He also says, alluding to Dr. Neisser's discovery, that " the presence of large numbers of micrococci in gonorrhceal pus has since been confirmed by several observers ; " it will be noticed, however, that he is silent as to the question of these bodies being peculiar to gonor- rhoea! pus. So far as the evidence yielded by Dr. Neisser's observations goes, it points to the specific nature of gonorrhoea. Mr. Cheyne's view is that gonorrhoea may be due to the spreading of the organisms which he describes, and then asks where these are to be found ; so that both the first and second positions in his argument are purely conjectural. Probability is, he thinks, in favor of the presence of organisms in this disease, because micrococci have been found in the mar- gin of an erysipelas patch, because gangrene of the tissues in mice is due to the presence of the streptococcus, and lastly because Professor Lister has come to the conclusion that " the organisms " are present, not only in the canal of a sinus, but in the granular tissue lining it. Having on these grounds ascended from conjecture to probability, he in the next page dis- misses all doubt, for after describing his treatment, he distinctly speaks of "the specific cause of the disease being eradicated by these means." The remedies he employs are antiseptic ; but in this case either all remedies which equally arrest the' discharge, including such substances as water, green tea, honey, and glycerine, must be included among the antiseptics, or else the fact of the discharge being arrested must be looked upon as equally favoring any other theory. Tested by the results of practice the theory breaks down, as antiseptics have no particular control over this dis- ease. 1 British Medical Journal, vol. ii., p. 124. 1880. PATHOLOGY. 49 Varying Duration of Gonorrhoea ; Connection between Inveteracy and Diathesis. If twenty cases of gonorrhoea were treated by the same surgeon in exactly the same way, the disease would almost certainly not run the same course in any two of them, and in all probability would not be cured in the same number of days in any two out of the twenty. Very likely, too, one of the number would suffer from obstinate gleet, while one would perhaps be cured in a visit or two. Of the first of these two anomalies various explanations have been suggested. Wallace says, " gleet may arise from rheumatism, scrofula, venereal poison ;" and again, 1 " such per- sons as labor under gleets are sometimes of rheumatic or scrofulus habit." Howard expresses himself to much the same effect. He says : 2 "It is always more troublesome in a robust sanguineous than in a phlegmatic habit. . . . And the difference of habit is still more conspicuous when a disposition to scrofula or scorbutic acrimony is joined to a young, robust, sanguineous temperament ; " and again : 3 " When a person laboring under a gonorrhoea is subject to redness, tenderness, and increased secretion from the eyelids, has a thickened upper lip, or redness, tenderness, and increased secretion from the glandulse odoriferse, such person will proba- bly suffer more, and be cured with greater difficulty than another who has not any of these affections, and that whether his habit be weakly or robust." Mr. Johnson thinks 4 he has observed that " they who have actually suffered from scrofula or display the characteristics of that disease are difficult to cure," and M. Robert b cites lymphatic temperament and scrofula as incon- testably predisposing to gleet ; while Fournier says that in blond and lymphatic patients the disease may remain obstinate for months. Dr. Bumstead also tells us s that "gleet is peculiarly frequent and obstinate in persons of a strumous diathesis ; " and Dr. Dick says, " the first thing a practitioner has to do, when consulted for gleet, is to examine well his patient with respect to antecedents, to ascertain if he had a scrofulous or cutaneous affection in his early life, or has been subject to gout or rheu- matism." Of all these authors not one adduces a scrap of evidence in support of his opinions, not one says that he is prepared with cases and statistics to back up his convictions. The reader who reflects upon the question must, I imagine, think this rather strange, while it is at least equally strange that these various causes should so often produce one common effect. Gout, rheumatism, and scrofula, when they exist in other parts of the frame, run a definite course, and exhibit a definite series of symptoms and appear- ances, which we can usually influence to some extent by medicines. Con- sequently, we ought to have, among others, a gouty, rheumatic, and scrof- ulous gleet, amenable to the remedies which most surely act on their re- 1 A Treatise on the Venereal Diseases, ,p. 283. 1838. * Op. citat., vol. i., p. 211. 3 Ibid., vol. iii., p. 42. 4 Op. citat., p. 66. 6 Op. citat., p. 128. Op. citat., p. 102. 50 ON GONORRHOEA. spective diatheses. Yet we cannot define or recognize any such divisions ; \ve find no diagnostic marks pointed out by which we may distinguish one kind of discharge from another, no attempt to treat any one in the same way as a medical man would treat a case of gout, rheumatism, or scrofula. Half a dozen cases successfully managed by means of colchicum, lithia, and potass, salicylates, or cod-liver oil and iodine, would constitute a body of evidence which the most skeptical would scarcely dare to reject ; but so far from anything of the kind being forthcoming, I have never seen any reason to believe that even an attempt had been made to cure gleet on such a basis, looking rather as if these gentleman had scarcely so much confidence in their own opinions as to put them to so severe a test as that of practice. It will be observed that there are irreconcilable differences among the authors themselves. Most of them agree to admit scrofula among the causes of inveteracy, but they do not agree upon any other point ; the robust, san- guineous habit, assigned by Howard as a reason, is the very opposite of the lymphatic temperament which M. Robert cites. But not merely do I dispute the adequacy of the causes enumerated by the authors whose names I have given ; I must respectfully question the greater prevalence, as a rule, of a particular diathesis among the sufferers from obstinate gonorrhoea, and expressly state, as the outcome of my ob- servations, that any such constitutional tendency, so far as it exists at all, may be seen quite as strongly developed among those who throw off the disease quickly enough. Indeed I cannot in any way accept the conclusions arrived at by these gentlemen. While solicitous to avoid saying a word that might give offence, I am compelled to remark, that the principle from which they start is essentially vicious, and that their views seem to me rather moulded in conformity with traditions long current, than upon exact sta- tistical proof, and in order to probe the question thoroughly, I will select two or three of the factors and examine their operation. And first as to scrofula, the belief in which, as a cause of inveteracy, is one of those vague elastic opinions which, while they have the advantage of harmonizing with current theories and modes of speaking, possess the still greater one of being so intangible that it is well-nigh impossible to deal with them as we can with an argument reduced to a definite form. It must be obvious that any one assailing so shapeless a doctrine does so at a great disadvantage, seeing that he might almost as easily attack a phan- tom or a ghost. Men may go on repeating such assertions in proportion as books are multiplied, till what was at first a loose statement becomes a law from which no one but a person desirous of being distinguished for his crotchets would venture to dissent ; but however well such a system might suit the requirements of science, it would not bring us any nearer the truth, which is quite a different matter. To do this, we must first of all define with sufficient strictness what is really meant by a scrofulous diathesis ; and then, in the second place, ascertain what proportion persons PATHOLOGY. 51 so affected bear to the entire male population. Having agreed upon the solution of the former point, a comparison of the numbers in the latter with those of strumous and non-strumous persons suffering under gonor- rhoea, would enable us, by a simple sum in arithmetic, to get at the facts of the case. But, to begin, difficulties beset the question of definition. If, as is pretty clearly the opinion of some medical men, inveteracy is in itself, even when all other signs are absent, to be looked upon as decisive testi- mony that the patient is of this temperament, I give up the point. There is no arguing against such a faith. It is weighing the wind and counting the sands to spend time upon a creed like this. If the term be narrowed to those cases in which we find the accepted and unmistakable marks of scrofula I can meet it, and I say at once that it does not in any way har- monize with my experience to find inveteracy associated with visible signs of struma. Considering that struma is by no means such a very rare disor- der, it is not to be wondered at if we occasionally see gonorrhoeal patients suffering from it. A scrofulous person exposes himself to infection the same as a healthy man does, and pays the same penalty. Many years ago, in some remarks on this question, I stated that I had entirely failed to connect inveteracy with scrofula. Since then I have seen a pretty large number of obstinate gleets, and have rarely, on a single occasion, omitted to question the patient carefully as to the possible rea- sons for the persistence of his complaint, without, except in the instances to be presently mentioned, finding evidence of the strumous diathesis. I never could trace anything of the kind. One patient, who was also the subject of abscess in the perineum, had, in early life, been afflicted with scrofu- lous ophthalmia of the eyelids. The patient, whose rheumatic affection was complicated with inflammation of the conjunctiva, was described by Ms medical attendant as having a scrofulous disposition ; but the opinion seemed to be based on the fact that the ophthalmia continued to resist the treatment employed, and that the patient was thin and pale. All the others seemed quite as healthy as the average of men, and presented every variety of temperament, nor was there a single sign by which the presence of scrofula could be recognized. The patient spoken of later on as having had gleet nearly thirteen years was a remarkably tall, straight-limbed, well- made man, with a mixture of red and brown in his face that betokened the best of health. One man who had had gleet twelve years was a power- ful person quite six feet high. A patient, with prostatic gleet of more than twenty years' standing, was a compact, square-set man, wearing every appearance of health and strength. One gentleman, a famous runner, also a picture of health, always had gonorrhcea, when he was unlucky enough to contract it, in a most obstinate form. Are we then, with such facts as these before us, to accept the creed that inveteracy must mean scrofula ? In the same way I would deal with rheumatism and gout. I suppose we should scarcely err in saying that two persons at least out of five suffer 52 ON GONOKKHCEA. more or less from rheumatism, and in that case we cannot be surprised at finding forty patients out of every hundred to be rheumatic. If the first part of the calculation be erroneous, that only proves more strongly the need of such a preliminary inquiry as I have just hinted at. As to gout, I could not make out anything to my satisfaction. In the obstinate case of prostatic gleet spoken of as lasting more than twenty years, the patient said there was a history of gout in the family ; but I suppose half the edu- cated people in England might say the same thing ; and I know that I have cured, and very easily too, patients suffering under gonorrhoea and gleet who did say the same thing, as I have done with patients not only liable to rheumatism, but actually rheumatic at the time they contracted the affection. On one occasion I treated, for bad urethra! discharge, a patient whom I had not long before injected six times with morphia by means of the hypodermic syringe for severe rheumatism. Yet his case did very well and showed no signs of obstinacy. A medical man, who con- sulted me for a long standing gleet, unhesitatingly put it down to his father having gout ; but it seemed to me that if such were the case, then every son of a gouty father, if he catch gonorrhoea, ought to have gleet in a re- bellious form, which does not happen. Subsequently this patient had very bad rheumatism for three or four years, and then I wondered which of the two agents was now to be blamed. As to temperament, I have already said that the patients laboring under rebellious gleet presented every variety of it, and having at least twice previously given my reasons for distrusting the coarse formulae by which its varieties are to be distinguished, I trust to stand excused for not repeating them here. Such a method of parcelling mankind out into sec- tions may have its advantages. For my part, I at once confess that I have never been able to see them, any more than I have the bearing of tempera- ment upon the enigma we have been discussing. Supposing any one of the theories I have been enumerating were cor- rect, how are we, by means of it, to explain the varying severity of gon- orrhoea at different times in the same person ? what light does it cast upon the problem of one attack of the disease being more obstinate than another in the same individual ; of the second being worse than the first, or the third worse than the second ? Are we to assume that, on these less fa- vorable occasions the diathesis is in the ascendant, and that its malignant influence, after a lull, is again permeating the patient's frame ? And if a diathesis be the cause of inveteracy, on what principle are we to account for the peculiar mildness gonorrhoea displays through every successive attack in some persons ; on that of such favored mortals having an anti- strumous diathesis ? The reader may think such a question frivolous, but I put it with no such meaning attached to it. If there be any truth in the theory that obstinacy is due to diathesis, then marked exemption from obstinacy must mean marked exemption from that diathesis. If there be PATHOLOGY. 53 any foundation for the theory it merits examination, but for an examina- tion to be of any value it must embrace both sides of the question. To all objections of this nature the constant reply is, that some expla- nation must be suggested, and that even a very erroneous or fanciful theory has sometimes prompted men to further inquiry, and thus opened the way to truth. I must entirely dissent from such a doctrine, preferring to admit that I am only stumbling blindfold through a maze of conjecture, and have not reached even the threshold of inquiry ; and doubting very much whether an erroneous hypothesis ever yet assisted in the discovery of a truth which men would not have found out equally well without it CHAPTER ni. TREATMENT. Variety of Remedies Recommended. Gonorrhoea has been successfully treated with purgatives and diuretics, corroboratives, 1 astringents and laxatives, demulcents and alexipharmics, mercury and iodine, acids a and alkalies, anaesthetics, 3 tonics, 4 specifics, and treatment on general princi- ples ; so that the puzzle must be, not to find out what will cure it, but what there is in the wide domain of therapeutics that does not possess this power. An old author complains that the specific for this disease had not yet been found ; had he lived in the present day, he might have la- mented that there were rather too many, always supposing we are to put faith in what we are told about some of the medicines recommended. As to injections, the variety is quite as great, at least eighty different sub- stances and combinations having been recommended for this purpose within the last few years. External applications do not offer the same scope for diversity, yet it can scarcely be said that they have lagged much in the rear. If their narrow bounds do not admit of much choice, they leave the way open for sufficient difference of opinion as to the mode in which they are to be applied. Maceration for five or six hours in a hot bath has been strongly recommended, while Ricord and some of the French surgeons tell us that the hot bath, even in the usual form, is highly calculated to de- velop gonorrhoea ; authors have even gone so far as to interdict it. Some practitioners apply evaporating lotions to the penis for the purpose of re- ducing the inflammation, perhaps it would be more correct to say, in the hope of doing so ; others have resorted to ice with the same view. Men with views opposed to this treatment sedulously caution the patient to avoid anything in the shape of cold getting to the part, or even sanction the use of india-rubber bags, which, though they prevent the linen from being stained, keep the organ hotter than the bath would do. Swediaur carried prudence so far as to deprecate making water in the street when there was a cold wind blowing. It is gratifying to find that, with all this warfare of opinion, we are 'Swediaur: Op. citat., p. 65. s Essays on the Venereal Disease. By William Blair. Pp. 36, 72, etc. 1798. J Archiv fur Dermatologie, B. S., 593. 4 Lancet, vol. ii., p. 428. 1870. TREATMENT. 55 really making progress, and that we cannot only cure the disease in many different ways, but cure it with a rapidity which leaves the feats of past days, and the most audacious assurances of quackery, alike in the back- ground. Our fore-fathers were content with removing gonorrhoea in a week or two, and the boldest charlatan, who undertook the same task, re- quired a few days to do it in. But now we have remedies which cure the disease in nearly ninety per cent, of the cases at a single sitting, leaving the impartial reader quite at a loss to know why we ever meet with bad gonorrhoea at all, and why every patient who may happen to catch it does not insist upon being treated according to one of these speedy and infal- lible methods. Continuance of the same Fundamental Principles of Treatment. What may, I think, be called the fundamental principles of treatment, of that treatment which is most largely adopted in each successive age, have, ex- cepting the use of injections, changed less amid ail this disparity of opinion during the last century or two than might be supposed. The handling of the subject is more scientific, but possibly not so much more likely to promote success, the grand test after all. The vague and elastic rules of treatment laid down in text-books and dictionaries, the want of tangible proof as to the proportion between cure and failure, mean, in plain words, old results in a more modern dress and phraseology. Judging from what I see and hear, treatment is rather regulated by the impression some striking case of cure or failure has made at the out- set of the surgeon's career, or by the views some favorite teacher or emi- nent specialist may have inculcated, than by conclusions drawn from long and carefully watching the action of medicines. If this be the case, then I think matters have gone on long enough in this way to excuse me for saying, that there is no cure for the uncertainty in the present state of things, and that the remedy would be a more full study of the therapeu- tics of the complaint, even supposing we had for this purpose to exclude many interesting points in etiology and pathology, coupled with a system of observation on a simple, uniform plan, ivhich dealt only with certainties, which admitted no case as cured or uncured unless the surgeon saw it for him- self, and where the history comprehended the beginning and ending of the disease. But of such a step I have no hope. The tendency of the age is to exalt scientific experiment, however useless it may be, and to 2^ass by the teaching of experience, as if to gather these did not demand as much toil and self-sacrifice as the other. One consequence of this is that time is spent on experiments which settle nothing, while we cannot get at data for establishing rules of treatment. In support of this statement let me ask the reader to take any of the more recent works on venereal diseases and to compare what is said on the management of gonorrhoea, especially the part contributed by the author, that is to say what is new, with the bulk of the section on this disease. I think he will admit that I have not over- 56 ON GONORRH(EA. colored matters in saying, that the treatment is made quite a subordinate question to those of causation and pathology. The point appeal's to me of so much importance, that at the risk of ap- pearing ever so tedious, I will take an instance of the vagueness of the rules laid down by our teachers. I select it from the writings of an emi- nent surgeon, the late Sir William Fergusson. He tells us that gonorrhoea must be treated on general principles, and that, though it must be admitted that the disease is now and then cut short by an astringent or caustic so- lution, it is more the result of chance than judgment ; and in many instan- ces, where it has been supposed that this was the case, gonorrhoea has in reality not been present. This is all en regie ; but what a picture of uncertainty, what a maze of doubt it reveals ! How much better it would be to say at once to the pupils : " Gentlemen, you must first of all check the inflammation by an- tiphlogistics not that I ever convinced myself by experiment that these remedies have any power to effect this purpose, but because so many ex- cellent authorities have insisted upon their efficacy. Perhaps they knew no more about the matter than you or I do ; however, that is no business of ours ; the orthodox plan is to pay them due respect, and quote them on all fitting occasions. Then if you think it right, and I have no rule to offer you, specifics may be given ; they may cure the case, or, which is just as likely, do no good. I use the phrase general principles much as it has al- ways been used, without attaching any very distinct meaning to it ; and must admit that, if pressed for a strict definition, I might feel rather em- barrassed. As to injections, I cannot say that I have myself seen an in- stance in which stricture, abscess, or swelled testicle resulted from them when properly given, even in the acute stage ; but then the authorities I have consulted very naturally dread the result of imprudent haste. If these remedies fail, you must use your own discretion about trying others. When you have exhausted your stock, send the patient to the sea-side, or anywhere else, so long as you only get rid of him. Do not worry your- selves about failure. You have done everything sanctioned by the legiti- mate practice of surgery, and have therefore nothing to reproach yourselves with." I am continually asked if I have tried some new remedy the specific of the day to which I simply reply, that I am very glad to try. anything recommended upon good grounds, anything that holds out the hope of exhibiting greater curative power than is possessed by the remedies I know ; but that I entirely object to wasting the patient's time and my own ; to running the risk of causing him unnecessary suffering, and reaping for myself only discredit and vexation, for the purpose of testing the virtues of any novelty, unless these are supported by the history of a sufficient number of well-observed cases. There may be too much of a good thing, and I think we have had too TKEATMENT. 57 much in the shape of novelties for many years past ; merely adding to the list of remedies, already long enough, many of which are just as useful as a "beane putte into ye harte of a black cat," can do no good whatever. Any simple remedy and mild injection will cure most cases of gonorrhoea. One or two of these may be found every year in some of our medical repertories, and a reader, tempted to go into the literature of this subject, might be interested and amused to see how many are periodically intro- duced as though they had never been heard of before. Those fond of new modes of treatment are therefore able to gratify their taste ; but unless it could be shown that the newly discovered specific really cures more cases out of a given number than the remedies every person is fami- liar with, or is specially adapted to a particular class of cases which can be diagnosed at the outset, its introduction would merely add to the existing confusion. I therefore propose to examine only those which seem excep- tionally entitled to notice. It is perhaps this incessant supply of novelties that has rendered men so inattentive to the few improvements which have been suggested in the treatment of gonorrhoea, such as the addition of long tubes to syringes, the use of fresh-ground cubebs suggested by Mr. Norman, 1 and the sepa- ration of the effete and nauseous parts of copaiba from the more useful constituents by Mr. Thorn. 2 The discoveries of Mr. Norman and Mr. Thorn may have been useless. I have had no opportunity of making such observations as to enable me to form an opinion, and therefore offer none. What I have to deal with is the total neglect shown by the medical public on both occasions. Judging as well as I can, I should say it is much more likely that they were of value ; there was quite evidence enough in their favor to have recommended them to the notice of medical men. Yet they were honored with no more attention than if they had belonged to the class of trashy and ephemeral papers on such topics so often seen in our journals. Mr. Thorn's preparation was carefully tested by the late Mr. Tyrrell, and found most efficacious. Yet his work was received with so much coldness, that he soon after threw up the subject in disgust, and left England in consequence. It was represented to me that a work of this kind would be incomplete without a history of the treatment of gonorrhoea. The suggestion is no doubt founded on a correct view of the case, but on going into the litera- ture of the subject, I found that to execute such a plan thoroughly would carry me too far. Besides, after all, a history of this nature would be more amusing than instructive. It might be made to present a curious picture of bygone times, but it would convey little real information ; for it must necessarily be a narrative of the same principles of. treatment, re- 1 Lancet, vol, i., p. 631. 1856. 2 On the Treatment of Gonorrhoea by a new Preparation of the Balsam of Copaiba. 1827. 58 ON GONORRHOEA. curring again and again under almost countless changes of form and au* thorship. The reader was probably startled by an observation in one of the pre- ceding paragraphs, viz., that treatment had not altered so much in the last century or two as might have been expected ; yet there seems no other conclusion to arrive at. It is true the outward form, the husk, so to say, has somewhat changed ; prescriptions are less complicated, medicines are given in milder doses and rather less nauseous forms. The language of medicine is no longer what it was, and old terms and old formulae have died out, while new ones have sprung up ; but beneath all this the essence of both practice and theory has remained much the same. The discrepan- cies of to-day are but amplifications of those which prevailed when Howard commented on gonorrhoea " having been so often cured in a great variety of different ways." In this instance we might say of medicine as of lan- guage, that while the outer semblance is in a state of perpetual mutation, its radical structure undergoes but little change. With the reader's permission, I will endeavor to illustrate this by means of a few instances, beginning a little later than the middle of the seventeenth century with the famous Sydenham. Sydenham's Treatment. Although this great man separated the treat- ment of " gonorrhoea virulenta " from that of venereal disease, he never discovered that there was a fundamental distinction between the two. He describes gonorrhoea as beginning with " an uncommon pain in the parts of generation and a kind of rotation of the testicles," while in those who have not been circumcised, " a spot not unlike the measles appears on the glans ;" then the discharge from the urethra comes on, and " when this disease is more virulent and degenerated into the pox," "this matter becomes green, and is mixed with a watery humor streaked with blood." The description is anything but full and clear ; indeed, were it not by so eminent a person, I should say it was as bad as it could be. The first thing that strikes us in Sydenham's treatment is a feeling of astonishment that he did not kill a good many of his patients, or give them bleeding piles, tenesmus, and excoriation of the anus. Possibly, like How- ard,' he looked upon the occurrence of piles as rather a favorable inci- dent, calculated to " draw off irritation from the urethra." He directs 3 " three drachms of cochia (colocynth) pill, a drachm of extract of rudius, half a drachm of resin of jalap, and half a drachm of resin of scammony," with "sufficient of opobalsamum " 3 to make them into a mass. Of this 1 Practical Observations on the Natural History and Cure of the Venereal Disease, vol. iii., p. 26. 1787. J The Works of "Thomas Sydenham, vol. ii., p. 453. 1788. 3 Balm of Gilead, procured from the Balsamodendron Gileadense, one of the Terebin- thaceae. Physiological effects similar to those of copaiba and the turpentines. Disused in Europe. TREATMENT. 59 mass two scruples, in the form of four pills, were to be taken every morning, till the running had grown considerably paler and the scalding abated ; I fancy the patient must often have grown paler under such handling. Those who were " hard to purge," and I should say they must have been decidedly " hard " when their intestines resisted snch a stimulus, were directed to take, in addition, his "purging potion " now and then, with two drachms of the syrup of buckthorn and the same ( quantity of the electuary of the juice of roses. If the cure went on slowly, eight grains of " turbith min- eral " were given every five days, or half a drachm of " pills of two princi- pal ingredients " and a scruple of " sweet mercury " made into a mass with opobalsamum ; not a bad dose. In addition to these remedies he gave opobalsamum in doses of twenty-five drops every night, or " the quantity of a hazle-nut of cypress turpentine. " Sometimes he gave every second day half a drachm " of the pills of two principal ingredients," and three drops of opobalsamum. He also gave half an ounce of Venice turpentine occasionally in a clyster. The patient was also to be " blooded " once or twice toward the middle of the course : rather a bold step, for generally speaking men at that time dreaded the idea of venesection and antiphlogis- tics, for fear of inducing absorption of the peccant matter. Sydenham used also to order his patients a " cooling or thickening diet," one item of which was " emulsions of the four greater cold seeds." For swellings of the penis or testicle he advised elaborate fomentations of marshmallow, white lilies, mullein, elder, camomile, melilot, flax and fennel seeds, for the particulars of which I must refer the reader to his works. Supposing the drugs used in Sydenham 's time were pure, we must be- lieve that his patients had greater powers of endurance, or more faith in their physician, than those of the nineteenth century. A scruple or half- drachm dose of such pills as he prescribes would produce a rather startling effect on a patient in this degenerate age, and nowadays the " turbith min- eral ".(the yellow subsulphate of mercury) causes vomiting of the most vio- lent kind in half the quantity prescribed by Sydenham. I now proceed to examine the practice of a somewhat later date, select- ing as specimens Moyle, Marten, and Turner. Moyle's Treatmyit. Moyle directs ' his readers to purge well for the running, but not to give anything to stop it, "lest it mingle with the Blood, and so become a confirm'd Pox ;" and not to bleed, for the revul- sion thereby occasioned " makes for the malign Atoms or Fumes to ascend from the Pocky ferment in the Inferiour parts and teints the blood in the Superiour." His purgative consists of pil. rudii 3j. ; resin, jalap, gr. v. ; $ dulc. gr. x. ; every second day for five times. The patient is to " for- bear strong liquors," and when "the Malignity is carried off" he is to take 1 The Sea-Chirurgion. By John Moyle, senior, one of Her Majesty's Ancienl Sea- Chirurgions. 1702. 60 ON. GONORRHOEA. two drachms of cypress turpentine in an emulsion night and morning " for five times going." This generally cured the patient, but if a "Gleeting" remained he was to purge again. Marten's Treatment. Marten belonged to quite as rough a school as Moyle, but one evincing a much lower grade of professional feeling ; for the old " sea-chirurgion " is honest and open, whereas Marten kept his remedies to a great extent secret. He is communicative enough about some of his affairs, snch as the presents sent to him by grateful patients, the premium which he received with his apprentice, the price for which he sold his " general Business," or his benevolence in curing the poor gratis, 1 but the reader is left in the dark as to his real treatment. He says, with an air of innocence which might well call forth a smile, in speak- ing of some infallible liquor, " But what this Liquor is or how it is to be prepared, the Reader, I say, must pardon me at this time that I do not reveal." Indeed, the surgeon of that day, albeit he might boast of belong- ing to the " Worshipful Company of Barber Chirurgions," or stood at the top of the tree in some specialty, was often little better than a mountebank or fortune-teller. The most arrant empiric was much on a par with his diplomaed rival. A regiment of the first class was handed over to one charlatan ; the piUs of another were sold at a guinea a dozen ; nobility and even royalty availed themselves of the vaunted skill of a third ; and the public here, at any rate, openly sympathized with any man who professed to wage war against chartered monopoly. Sir William Read, the queen's oculist, had been a mountebank. 2 He was so ignorant that he could hardly read, 3 and even after his appointment continued to sell nostrums. Dr. Thomas Saffold, spoken of in the Taller as "my ingenious friend," had been a weaver and a fortune-teller before he became undergraduate in physic. The infamous quack, St. Andre, the associate of the notorious Mary Toft, was, in 1726, chirurgeon to the king's household. To quote almost literally from Marten, when a man, a Mohawk for in- stance, or a "looser sort of Spark," had "conversed with a Slut," and had caught "a pocky Running," with "a Stupidity of the Yard," he came to the conclusion that he was " inflicted with the Pox," and sent for his medical man, who forthwith came in a mighty periwig, and after a preliminary rail- ing at the "Quacking Empirical! Fellow" in the "Darl Entry," or at the sign of " the Hand and Urinal," or the "Frying Pan ;" diversified, it may be, with a warning narrative of some " Gentleman who was blowed up to the Planets," owing to his having taken too strong a dose from one of these worthies, he proceeded to strike a bargain with the patient as to his terms for effecting a cure, and this done he set to work. 1 " The poor I cure gratis, no less I believe than to the value of 100 per Ann. , dis- charging both to Poor and Rich, as near as I can, an honest conscience." A True and Succinct Account of the Venereal Disease. By John Marten, Chirurgion. 1700. The Tatler, vol. i., p. 84. 1797. * Ibid., vol. iv., p. 218. TREATMENT. 61 Marten's practice consisted "in cleansing and destroying the Malig- nity," in giving " gentle Specificks, appropriated suitable to the Distemper." For " Scalding of Urine " he gave " two or three quarts a day of proper Liquors," which "radically extinguished and destroyed the very Seed of the Disease." He had a great horror of stopping the discharge by " Emplas- tics and Restringents," lest by using them " the Venereal Malignity abscond- ing itself in the Liminary or Spermatic Parts," might degenerate into "a radicated and ill-contrived Pox," or " a Tumor Humoralis happen upon the testicle." But how he effected all this I leave to be explained by those who can gather anything definite from his book. Has the reader ever heard this theory about purging off the malignity, not stopping a discharge lest it might be absorbed, or be thrown into the system, or something of that kind, repeated under another form in the present day ? because if not, I have, and very frequently too. Turner's Treatment. Turner clearly separates : gonorrhoea from syphilis in so far, that while he admits the possibility of a neglected or badly treated blennorrhagia being transmuted into syphilis, he carefully points out that it may run, or rather that it naturally runs, its course without anything of the kind happening. The treatment of gonorrhoea is accordingly kept tol- erably distinct from that of the more serious disease, or, as he quaintly terms it, " the second Infection called the Pox." His treatment consisted of purgatives given perseveringly till the more severe symptoms had passed off, or, to use his own words, till " the Cacoch- ymy was discharged," and " the Stillicidium was lessened in Quantity and had grown better conditioned." He began with "Ext. rud.," "Pil. coch. min." or "Pil. ex duobus," 3j. to 3 ss. of the latter, or, if the patient were strong, 3ij. along with 3ss. gr. xv. or 3j. of calomel. After this he gave powdered rhubarb with some preparation of turpentine, and followed these up with copaiba, on which he placed great reliance. Injections he avoided, except very mild ones, such as barley-water, " a small solution of the Troch. Alb. Rhus in aq., Plantag. vel. Ros.," or " a small Aq. Calcis c. Syr. de Ros. sice, vel Mel Ros." For phimosis and paraphimosis he recommended that " the Humour should be revulsed by an Emetick," and that " a good dis- cutient Fotus should be apply 'd to breath out the impacted Humour." Scalding he tried to alleviate with sedatives, such as poppy and hyoscyamus and " edulcorants," e. g., gum arabic and milk of almonds. When chordee was present he added five-grain doses of sugar of lead and the same quan- tity of camphor for painful micturition. His remedies for orchitis were " a suitable Bag Truss " and warm cataplasms, at the same time directing that " all Restringent or Balsamic Medicines be entirely forborn." For the sym- pathetic bubo of gonorrhoea he had no separate treatment. 1 Syphilis : A Practical Dissertation on the Venereal Disease. By Daniel Turner, of the College of Physicians. 1717. This work contains, in accordance with a good old fashion, a well-executed likeness of the author. 62 ON GONORRHCEA. Turner was evidently a sound, careful physician. He held that the way to improve treatment and gain a better knowledge of disease was to study symptoms and observe the action of medicines. " The new way by Arithmetic, Algebra, and Elementa Mathematica ! " he considered only fit to amuse young heads, and fill them with what he plainly calls " gibber- ish." According to him gonorrhoea, like syphilis, arises from an unknown infecting property in the discharge of the person who communicates it, "a Poison of a peculiar Nature, and acting upon the Blood and Humours of humane Bodies." Treatment he therefore thought must be, for the time being, empirical, and he counsels the reader to "take his Indications chiefly, if not solely, a juvantibus et Isedentibus." Cockburn' s Treatment. Cockburn seems 1 for he words his opinions here very obscurely to have used "Purging, Astringent and Healing Medicines," such as turpentine with lemon-juice and sugar, opobalsamum, Peruvian balsam and copaiba, along with rhubarb, acetate of lead, pulp of cassia, syrup of marshmallow, and sal prunella. He had great faith in purgatives and injections, though he believed that the improper use of the latter might bring on " the Lues." He held that diuretics effected a " mere washing of the Urethra," and were apt to be very injurious by causing too great " an Afflux of Humours to the stimulated Part." To relieve scalding, the volatile salt of amber, sugar-candy in tincture of tea, or whey, along with crystal mineral, nitrate of potass and tragacanth, remedies perhaps as useful and pleasant as most of those used nowadays for this symptom ; for " Cording of the Penis " cold bathing and internally warm milk, sugar of lead, white lily root, etc. He treated phimosis, which he thought only merited the title when the " Choaking of the Prseputium " gave pain, with a vast variety of remedies, such as bryony, and thought the method which prevailed in his day, of draining the water from the foreskin by " insinua- ting green Gentian Roots, the pith of the Wayfaring Tree, or a bit of Sponge between the Glans and Foreskin " was bad ; a view in which my readers will possibly concur. Astruc's Treatment. We now come to the practice of an author whose views seem to have been pretty extensively adopted in England, where sur- gery had been getting on slowly ; for Mr. Pott tells us, that when he be- gan his studies, a little before the time that Astruc's writings began to be known here, there was not, with the exception of Cheselden, Wiseman, and Sharpe, "an English writer on surgery fit to be read," and that no lectures were given in London " on the Materia Medica, Chymistry, or the Practice of Physick." Perhaps it was a deep sense of contrition for their short- comings in this way that impelled the surgeons of that day often to weep disconsolately at the bedside of their patients ! Disgusting as such an ex- 1 The Symptoms, etc., of Gonorrhoea. By W. Cockburn, M.D., Fellow of the R.S., etc. 1728. TREATMENT. 63 hibition must seem now, it appears to have been quite a common occur- rence in Mr. Pott's time, for we are told, as a striking instance of his up- rightness, that " he never would consent to whine over a patient ! " Astruc's general plan seems ' to have been in the first stage to bleed, give ptisans of cooling plants, such as chiccory, wood-sorrel, lettuce, etc. When the bowels were to be moved he gave the ptisan in the form of .a glyster, with a drachm or two of " Crystal mineral or an ounce of fresh pulp of Cassia." He poulticed the perineum with " crumb of bread, milk and Saffron," and injected into the urethra " Saccharum Saturni in Frog- spawn water," or " Goat's milk diluted with a decoction of Marsh mallow." He gave " Camphire and Saccharum Saturnum " internally " to ass wage the heat of the parts," and prescribed a "light moist diet," with absence from ah 1 peppered or preserved meats. In the second stage he " purged gently " with cassia, or gave ten or twelve grains of jalap or " Diagridion," possibly an old name for scammony, or a scruple of calomel, which I should think must have purged very gently indeed, though it was certainly quite a common dose in those days. This was followed up by mercurial inunction. In the third stage, that is to say when the dysuria, erections, etc., had passed off, he gave " Chio Turpentine," powdered rhubarb, and copaiba or Canada balsam in moderate doses, accompanied by a host of other reme- dies, among which we find nine astringents, such as catechu, dragon's blood, etc., to be taken internally. Mucous gleet he treated with " deter- sive" injections of decoction of bugloss, geranium, etc., mixed with solu- tion of honey of roses. In the "oedematous kind" he bled less, purged repeatedly and freely, and gave a sudorific ptisan of guaiacum and sassafras woods. When there was much phlegmon he ordered frequent bleeding, with diluting, softening, and anodyne medicines. For the Venereal tumour of the testicles, or the Venereal Hernia (or- chitis), which he warns his readers may degenerate into schirrus, sarcocele, or cancer, he bled, gave aperients, laid aside all astringent and "repelling" medicines in favor of warm sedative applications, such as decoction of marshmallow or lily roots, henbane, etc. ; when the pain was severe, he prescribed narcotics internally, such as laudanum, " Tinctura Anodyna," or syrup of diacodium, "in a convenient dose." He recommends that an attempt should be made to relieve the hardness of the testicles by mer- curial inunction, or the application of emplastrum Vigo ; the testicle was also to be supported. When abscess of the perineum threatened, he or- dered cooling ptisans, cooling and anodyne fomentations of bear's breech (branca ursida), with clysters of quassia and some anodyne. In a stillici- dium it was, of course, necessary " to correct the acrimony of the semen," 1 A Treatise on the Venereal Disease, vol. i. 1737. 64 ON GONOKRHtEA. and this was effected by means of softening remedies, such as " cooling broths and apozems," after which the relics of the ulcer were to be deterged with " vulnerary " and balsamic remedies. Hunter's Treatment. Hunter thought ' the soothing plan the best at the beginning. When the violence of the symptoms had abated, astrin- gents might be employed. He considered diuretics had their advantages, and that injections might be used. He employed as an injection, corrosive sublimate, one or two grains to an ounce of rose-water, also opium and lead as soothing injections. He doubted the power of "the vegetable mucilages " to remove scalding. He seems to have made little use of in- ternal medicines, and not to have had much faith in them. Possibly he was too much occupied in his vast anatomical and physiological researches to have had time to establish any fixed principles of treatment, even in his own mind. Howard's Treatment. Howard, the confidential assistant, as he puts it, of Percival Pott in his " large general business," gives 2 a very careful ac- count of the practice of his day, as also of that for a considerable space of time previous. He draws attention to the great discrepancy of views as to treatment, and remarks that gonorrhcea " has not only been frequently but successfully treated in many different ways." Howard bled 3 in almost every case, leeched when there was much in- flammation, kept the bowels moderately open, recommended warm baths, opium, and a cooling and well-regulated diet. He considered the period following the decline of chordee the proper one for administering mercury. If the irritability of the membrane did not diminish he gave bark ; he also speaks in favor of blistering the perineum. Cases treated in this way rarely required balsams, such . as copaiba, turpentine, colophony (pix grseca), mastic, and so on. For orchitis the horizontal position, and sus- pension of the testis, with cooling applications of lead. Inflamed prostate was to be met with antiphlogistic treatment. Perineal abscess was to be freely opened. He dreaded injections at the early stage, lest, " by smoth- ering chancrous infection for a time," they might produce " future symp- toms of lues," or stimulate metastasis. Perhaps the reader has heard this kind of thing about injections from men of a later school than Howard. According to this author Pott used injections freely. Foot's Treatment. Foot injected 4 with a preparation of blue vitriol precipitated by means of lixivium tartari, the precipitate being subse- quently dissolved in a saturated solution of volatile sal ammoniac. This was used of a strength of five grains to an ounce of water. With it he gave daily one grain of calcined mercury and half a grain of opium. If the inflammation extended along the urethra, he advised soothing applica- 1 Op. citat. Op. citat. 3 Ibid., vol. iii., p. 51. 4 Origin, Theory, and Cure of the Lues Venerea. 1792. TREATMENT. 65 tions, such as constant injections of warm milk and water with the appli- cation of the steam of hot water. He thought no method protracted gon- orrhoea so much as giving purgatives. For gleet, to which term he allows a pretty wide latitude, he prescribed bark, steel, the cold bath, and injec- tions ; if these did not succeed, copaiba was to be taken. Chordee he seems to have left pretty much to time. For phimosis, poppy fomenta- tions and poultices containing spirit ; internally, calcined mercury. If in this complication the fever ran high, the patient was to be bled and to take antimony. For swelled testicle he counselled rest, lotions of liquor ammonias acetatis, etc. If the running did not return, and the testicle continued to swell, he resorted to bleeding, leeches, fomentations, etc. ; giving at the same tune mercurius calcinatus, opium, and small doses of antimony. Sir Astley Cooper's Treatment. Sir Astley Cooper purged his patients freely with salts and senna, calomel and colocynth. He gave carbonate of potass or soda as a drink, or liquor calcis. He recommended warm bath- ing of the penis ; he also prescribed liquor potasses with conium in cam- phor mixture. When the inflammation had subsided, he ordered balsam of copaiba with injections of sulphate of zinc and liquor plumbi. If the disease had existed some little time when he first saw the patient, he gave balsam of copaiba at once. He also gave cubebs when the inflammation did not run high ; and it appears from his account that this medicine was so little known at that time, that Cooper had never heard of it till a patient brought him some to try. Yet it was used in London nearly six hundred years ago, a toll on every pound of it carried over London Bridge having been levied as far back as 1305. l In old-standing cases he passed bougies. Sir Astley had the courage to say that the man who gave mercury in this disorder deserved to be flogged out of the profession, and to stigma- tize in the strongest way the practice which then prevailed at Guy's, of sending every patient affected with gonorrhoea into the foul ward, where he was pretty sure to be drenched with mercury. Judd's Treatment. I have not been able to make out on what princi- ples Mr. Judd treated his cases, or what he considered to be the most use- ful remedies. He sometimes gave 2 calomel and colocynth, with fifteen- grain doses of extract of cubebs, sometimes injections of nitrate of silver, 3 j- to j. ; in other cases tincture of muriate of iron as an injection, with sulphate of magnesia internally, and again in a third case a zinc injection gr. x. to j. He also prescribed, in combination with purgatives, essence and balsam of copaiba and essence and spirit of cubebs, without assigning any reason for the variation, except such as his readers can make out from the history of the case, which, so far as I can see, throws no light on the point. 1 Pereira's Elements of Materia Medica, p. 754. 1840. * Op. citat. 5 66 ON GONORRHOEA. From this time forth it gradually grows more impracticable to give such an analysis as shall faithfully reflect the views of those, who might naturally be supposed to represent the leading opinions in matters of medicine. The subject has become too bulky to allow of anything like a full account in any ordinary work, and incomplete reproductions are worse than use- less. What I have to say of their views may. I think, be more fittingly appended to the remarks on the different remedies used for this dis- order. At one time I purposed examining the various plans of treatment adopted by modern authorities in gonorrhoea ; but I soon found it was im- possible to carry out this idea, for as many of them are exactly alike in great part of their details, the same arguments would require to be urged each time the separate elements of treatment came to be discussed. In the interval between the date of Judd's work and the present time thirty- five methods have been recommended to public notice ; and I am speaking here, not of mere suggestions in some journal, founded perhaps on the evidence of two or three cases, or of some novelty in the shape of a new injection, but of more or less complete systems of both internal and exter- nal therapeutics, most of them taught by men of great experience and ability, attached to important, often special, hospitals, and enjoying large practices. Many of these methods, it is true, resemble each other strongly, such divergence as there is relates chiefly to matters of detail, but others again differ so widely that it is not easy to understand how the same dis- ease can. be cured by means so opposite. Let any one contrast the plan pursued by Kuchenmeister ' with that laid down by Fournier, that of Prettyman or Dupouy with that of Ricord, the method of Gamberini with that of Bumstead, and say if such diversity as the subject admits of can well be carried farther. These methods embrace, as may very well be supposed, most of the means yet recommended against this disorder. Treatment on general principles, unbounded reliance on specifics, combinations of the two, local treatment now elevated to the first rank, now subordinated to medicines or just tolerated under protest. Yet from all this collision of views, from this vast aggregate of experience, not one fixed principle, one single gen- eral rule of treatment can be deduced, not one unerring clue to guide the practitioner an inch on his path ; out of the many items of which these various systems are composed, not one can be found respecting which the observations of one author are not refuted by those of another. If amidst these conflicting views we could find some secure basis for drawing conclu- sions, if an analysis of each separate system would place us in a position to ascertain how many cases are cured by it out of every ten or every hun- dred subjected to it, and in what space of time, we might arrive at some defi- nite opinion ; as it is we are left to infer that each surgeon is equally satis- 1 Deutsche medizinische Wochenschrift, S. 305. 1880. TREATMENT. 67 fied with his own plan, and that all these various modes of treatment are equally successful. Whether the surgeon uses injections or not, whether he give specifics or treats on general principles, seems a matter of indiffer- ence ; methods diametrically opposed to each other conduct to one common goal. The proper mode of giving the same medicines, and the account of what follows from employing the same treatment are quite as conflicting. I suppose no one who has read the works of the two authors can doubt that Mr. Acton borrowed his treatment chiefly from M. Bicord, and in- tended his readers to understand that it never failed. M. Fournier's view of therapeutics agrees very closely with that of his illustrious master ; but the two last famous men tell us that failure is but too frequently the result with them ; that only too often they find they can do no more, and then they say the secret is to try to do nothing. Here, then, we find irreconcilable difference of views about the most simple facts, and ever-recurring conflict of opinion. I suppose it is a natu- ral and therefore inevitable result of the different constitution of the hu- man brain, Nature having designed that men should no more exactly think alike than that they should exactly resemble each other in features ; and there is nothing left for us but to conclude, that were a perfect system of medicine established to-morrow, it would at once be assailed more or less actively on all sides until it had been overthrown. Nor is this tendency in any way peculiar to any given state of our art to any particular era. Possibly it may become more developed with greater cultivation of medi- cine. Lord Bacon well observes, that " empirics and old women are more happy many times in their cures than learned physicians, because they are more religious in holding their medicines," and I am inclined to think that multiplicity here proves something in favor of his assertion ; or, at any rate, that if physicians nowadays treat gonorrhoea better than empir- ics, the system is still subject to that fatal defect which in Bacon's day often reduced their skill to the level of that of old women, and which is still such a source of weakness a constant desire to try new remedies and other systems without sufficient grounds. How we are to deal with those authors who give no opinion on the point I am at a loss to make out ; I suppose they too are satisfied with their own systems. In a former edition I gave an analysis of nine different methods then quite recently recommended. Of these eight represented the prac- tice at as many of the leading hospitals in London. ' With the exception of that at St. Bartholomew's, where the treatment was said to be invariably successful, no opinion was offered on this point, and the only conclusion to arrive at was that seven opposite methods must be equally efficacious, and that had ten times the number of hospitals been reported upon the result would have been ten times as much conflict of testimony. Under these 'Condensed from reports in the Lancet, vol. i., pp. 331, 362, 458. 1867. 68 ON GONORRHCEA. circumstances, it appears to me, that to extend such observations can only increase the bewilderment which the reader must necessarily feel on notic- ing such a uniformity of effect from such a diversity of causes. We may as well once for all admit that the question of treatment is gravitating into a state of hopeless confusion ; and that the surgeon who has mastered all the literature of the subject, will, so far as reading goes, scarcely be better qualified to treat his patients successfully than the student who confines himself to the first book which his teachers recommend to him. I have now endeavored to give the reader chapter and verse for the three postulates I ventured to bring forward, namely : 1. That except with respect to injections treatment has not changed so much within the last century or two as might have been expected. 2. That there prevails an irreconcilable discrepancy as to the best method of coping with this disorder. 3. That the ordinary method of stating the results of treat- ment does not enable the reader to form a positive opinion as to the rela- tive value of the remedies actually employed. Consequently I see no way of getting at the truth but by the most rigorous search into the qualities, real or supposed, of each substance experimented upon, and this I have at- tempted to the best of my ability. There are, however, one or two points in connection with this subject, such as the expectant treatment, which had better be discussed before taking up the subject of the remedies for gon- orrhoea. Expectant Treatment. This system has at one time or other had advo- cates of such capacity that it cannot be passed over. Some few years ago it found a champion in Dr. Chambers, of St. Mary's Hospital. This gen- tleman says ' that gonorrhoea is naturally a most mild disease both in the male and female, and if left to itself will get well in a short time, occa- sionally in four or five days, while the simplest treatment will remove it in a fortnight if it be not made severe by the folly of the patient or his medi- cal attendant. "I consider," he says, "all primary heroic treatment of urethral discharges a most unjustifiable interference with nature." It is not very easy to imagine how any one could argue in favor of a more hopeless cause. There is no evidence brought forward in support of a statement which runs quite counter to the experience of the greatest men who have studied the disease. What they, after mature deliberation, say, utterly negatives the idea of gonorrhoea being so easily managed by the simple process of letting it alone. I shall state further on my reasons for thinking that this kind of dis- belief in the powers of medicine is unfounded, and that the treatment I have ventured to recommend will on an average always cure gonorrhoea in less time than it requires to wear itself out. I regret that I cannot give a fuU account of what Dr. Chambers's treatment is, but the fact is that the 1 Clinical Lectures on Gonorrhoea. Lancet, vol. i., p. 582. 1861. TREATMENT. 69 part of liis lecture devoted to gonorrhoea only occupies half a column of the Lancet. I have collected a good many cases in which the expectant treatment had been pretty fairly tried, by the patient, however, rather than the sur- geon, and where the gonorrhoea disappeared quickly of its own accord. But in all these I had to depend on the unsupported evidence of the patients, which I need scarcely say is, with all conceivable good faith on their part, almost useless in a scientific point of view. When a man, on whose truthfulness we feel able to rely, tells us that a discharge went away in a few days without his doing anything for it, we at once admit the fact ; but it would be a step of a totally different nature to accord to such a fact any value in determining the average duration of gonorrhoea under the influence of expectant treatment. Yet this is the only evidence I have been able to procure, and so far as I can make out it is the only evidence employed by those who recommend this system. Though I have often heard of such events, I have never yet seen a gonorrhoea run its course and get quite well ; indeed, I need scarcely say that the vast majority of patients would not give a surgeon the opportunity of trying such an experiment. They go to him expecting he will do his best to free them from a disagreeable complaint, and any patient who found his surgeon doing nothing would naturally imagine he could do that as well himself. Hospital in-door practice would alone afford a proper opportunity, and in that department I believe the experiment has not yet been tried. But for one case where, according to the patient's version, so fortunate a termination as spontaneous extinction of a gonorrhoea thus treated took place, there were at least ten where the result was widely different, where the patients had, according to their own statement, taken all possible care not to aggravate the disorder, abstaining carefully from stimulants, etc., and where the cases had lasted months and even years, and might have in all probability lasted much longer were it not that even the most indifferent persons generally get wearied in the long run of seeing the hateful dis- charge forever hanging about them, and at last make up their minds to do what they should have done first, go to some surgeon who will set them right. Indeed, I suppose it is difficult to limit the length of time gonor- rhoea might sometimes last if systematically neglected, and even where very carefully attended to. Kicords relates ' a case where the patient had suffered from gonorrhoea for more than forty years, and I have seen several where the patient had had it for five, six, or seven, and in two instances for upward of twelve years. True, in all these cases there was not much running, but it was distinctly purulent ; the severity of the first symptoms, too, had long passed off, but it was evident that a slight irritant would speedily rouse them to very unpleasant activity, a fact of which the pa- ' Lettres sur la Syphilis, p. 120. 70 ON GONORRHOEA. tients were quite aware. Mr. Johnson very justly remarks, that " the sur- geon who calculates in a sanguine manner on the natural cure of gonor- rhoea will probably be more remarkable for patience than success." It is, according to him, repeating the old story of the rustic by the bank of the river, waiting till the stream ceases to flow ! Gonorrhoea as a Cause of Stricture. Again, it is to be borne in mind, that should the experiment of leaving gonorrhoea to itself fail, and should the disease in consequence last a certain time, it will, in a given percentage of cases, certainly be followed by swelled testicle and stricture. In many old-standing gonorrhoeas the surgeon, on passing the bougie, finds a certain degree of contraction, with tenderness of the urethra at different spots, and often, even when there is no discharge from the urethra at the moment of examination, small clots or strips of pus and mucus will be found adhering to the bougie when it is withdrawn. There is indeed reason to believe that in some persons a tendency to stricture takes place almost as soon as the gonorrhoea has well established itself, and that up to a certain degree, at any rate, it constantly and uniformly tends to get tvorse. Hunter's old rival, Jesse Foot, pertinently says, "that a gonorrhoea may cease to be a gonorrhoea if left to its own action may be true, but it may also be as true that it might not cease to be a gonorrhoea till it had reduced the organism within the urethra to a condition which could not afterward be restored to a sound state." Hunter and many other surgeons have, it is true, considered the theory of stricture arising from gonorrhoea as a mere prejudice, and as I was anx- ious to investigate this subject carefully, and had no theory to serve, I made for a long time a careful collection of cases, going into the most minute details.. I was at last obliged to confess that the mere history of the case, as given by the patient, always offers insufficient and doubtful data. How- ever, after carefully weighing what facts I could collect, I think myself fairly warranted in drawing the following conclusions, which, after all, con- tain nothing new : 1. That strictures arise in persons who have never had a gonorrhoea, and in some at such an early age as to preclude all probability of gonorrhceal infection. 2. That occlusions of a similar character occur in mucous canals, with- out being preceded by any inflammatory and purulent discharge. 3. That the progress of the stricture seems to bear no sort of proportion to the duration or severity of the gonorrhoea. 4. That the proportion of patients attacked by stricture to those who suffer from gonorrhoea is extremely small. 5. That gonorrhoea appears to develop the tendency to stricture in per- sons who would otherwise never have been assailed by it. But I need scarcely point out to the reader how untrustworthy such conclusions are. To get at the truth we require information which we are never likely to procure ; for, first of all, it would be necessary, before at- TREATMENT. 71 tempting any deduction, to divide the whole male population of a given dis- trict into a, those who had had gonorrhoea, and b, those who had not ; sec- ondly, the males must be again separated into c, those suffering from, and d, those free from stricture. The proportion of c to a and 6 would give us something like data. The following table is taken from the Edinburgh Medical and Surgical Journal. ' It contains, as the reader will observe, cases of gonorrhoea treated in different ways in the hospital of the Castle of Edinburgh by Messrs. Johnston and Bartlett : TABLE L Cases of Gonorrhoea treated in different ways. CASES TREATED WITH REST AND ABSTINENCE. No. of Cases. Result of Treatment. 3 Discharged cured in 3 days. 2 " 5 " 4 " 7 " 4 " 10 " 1 " 18 " 1 23 " Or an average of 8 days. Cases treated with Cubebs. 2 were cured in 4 days. 2 " in 5 " 4 " in 6 " Average 5 days. Cases treated with. Capsicum. 4 were cured in 8 daya 4 " in 12 " 2 " in 24 " Average 13 k days. Cases treated with Camphor. 1 was cured in 5 days. 1 in 8 " 1 in 14 " Average 9 days. To these may be added the cases tabulated by Mr. Macfie Campbell, of the Dreadnought Hospital, 4 who found that the average duration of gonorrhoea, treated with copaiba or cubebs, was thirteen days. It will be observed that of these cases fifteen treated with fasting and quiet were cured in three to twenty-three days ; eight by cubebs, in four to six days ; three by camphor, in five to fourteen days ; ten by capsicum, in eight to twenty-four days ; whereas twenty treated with injections of lapis infern. 3 j. to | j. were cured in three to forty-two days. 3 With the excep- tion of the cases in which cubebs and injections were given, these figures may be held to represent pretty well the effects of expectant treatment, as it is difficult to believe that either capsicum or camphor would materially shorten the course of gonorrhsea ; any rate, we do not as yet know that 1 1818, p. 264. 5 Lancet, vol. i., p. 73. 1871. 3 Op. citat., p. 263. 72 ON GONORRHOEA. they do. I have cited this list, as it is the only thing in the shape of statis- tics bearing on this point that I have met with. The results of treatment, as given in it, by no means harmonize with my experience, the time for cure appearing to me much too short. Homoeopathy. Of that singular compromise with expectant treatment called homoeopathy I have no personal experience to record beyond what I have learned from patients, and their report is to the effect that the ac- tion of the remedies is so slight as to elude the closest observation. I fancy, too, that even the supporters of homoeopathy would be puzzled to bring forward a series of cases showing that gonorrhoea was cured more quickly by infinitesimal doses than by active allopathic treatment. Till that is done, or at any rate attempted, it will be unnecessary to pursue the subject farther. CHAPTER IV. TREATMENT (CONTINUED). X Classification of Remedies. The most practical arrangement of the various means of treatment for gonorrhoea appears to me a division into A, internal remedies ; B, external applications, such as lotions and fomenta- tions ; and 0, direct applications, comprising injections, caustic, bougies, and so on. A. INTERNAL REMEDIES. L Copaiba. Perhaps without exception the most potent and generally used of all the internal remedies for gonorrhoea is copaiba, one of the most nauseous drugs ever found out. Excepting, perhaps, the plan devised by Mr. Thorn, no method of really disguising its taste without impairing its efficacy has been discovered, and other objec- tions apart, this alone is an insuperable drawback. I have heard scores of persons say that they would rather leave a gonorrhoea to itself than again take copaiba. Besides, in a certain percentage of cases, copaiba, if given in sufficiently large doses to influence the discharge, brings on nausea, retching, and vomiting, griping and purging, great irritability of the stomach and often of the temper too. Symptoms of strangury not unfre- quently follow its exhibition. Mr. Johnson has seen ' acute inflammation of the bladder, extensive suppuration in the thigh, severe gastro-enteritis, and even death follow the use of it. M. Ricord has seen 2 serious effects on the nervous system, such as partial paraplegia and temporary hemiple- gia, follow from the same cause, and Mr. Lee suggests 3 that organic dis- ease of the kidneys, thickening of the coats of the capillary tubes, etc., may be caused by giving it for a lengthened period. In several instances, when taken during an epidemic of cholera, it appears to have determined an access of this complaint. Dr. Durkee mentions 4 an instance where a patient was attacked with a species of cholera, the symptoms being grip- ing, vomiting, and purging, from taking merely half an ounce. Again, in certain constitutions it brings on pain in the region of the kidneys, hsema- turia, severe headache, giddiness. The vomiting, too, it must be remem- bered, which copaiba brings on is horrible, and few but the most resolute, who have once suffered in this way, can be induced to make a second trial. 1 Op. citat., p. 52, etc. * Traiti Pratique, p. 732. 3 St. George's Hospital Reports, vol. vi., p. 52. 4 Op. citat., p. 39. 74 ON GONORRHCEA. One pretty certain result of all this kind of thing is, that some patients give up treatment in despair, others are driven to try some dangerous remedy, such as a very strong or irritating injection, e.g., one of bichloride of mercury, a mistake I have known several times committed ; while a few try to overwhelm the disease by swallowing an inordinate quantity of wine or spirit, a freak of very probable occurrence, inasmuch as probably every patient has in his turn heard some wonderful story of gonorrhoea being cured in this way. When to all this is added the fact that copaiba is never really indispensable, inasmuch as every case that can be cured may be got rid of without resorting to it, I think there are very strong grounds for the views just laid down. It will perhaps be said in reply, that such objections apply to all reme- dies ; that any potent drug taken in excess will produce serious symptoms ; that to discard all remedies for such reasons would be to reduce medicine to a nullity. I have heard such a method of getting over these objections repeatedly put forward, but it does not meet the case. These disagreeable results occur when copaiba is given in doses which very good surgeons have not hesitated to recommend. Even were it an infallible remedy for the discharge, its disagreeable action in so many cases, and the smell it communicates to the breath and urine, would always be obstacles to its use. It is, however, anything but infallible. 1 It fails in a large proportion of cases it is given for ; it fails in every dose and in every form. Half-ounce doses are no more to be relied on than those of half a drachm ; it is often no more to be trusted to in the form of capsules than in that of injections,* enemata, 3 or suppositories. Now, as no amount of experience will enable the surgeon to diagnose at the outset those cases in which copaiba will be useful from those in which it will almost certainly fail, it necessarily follows that every surgeon who treats all cases with copaiba, and there are plenty who do so, must give it in many instances where it is sure to be of no service. It seems to me that there is no getting over this fact. It appears that whatever disadvantages the use of copaiba may entail it still has numerous advocates. My own experience has satisfied me that the practice of giving it is very extensively diffused, and Mr. Wheeden Cooke confirms this. On inquiry at the London Custom House, he found that during the first ten months of the year 1859, no less than 118,396 pounds of copaiba were admitted, or at the rate of 151,075 pounds annu- ally a quantity sufficient to supply five hundred thousand people every year with a strong dose three times a day for nearly four weeks ! 4 1 Johnson : Op. citat , p. 88. Ricord, Traite Pratique, p. 726. 1 Sigmund has found that injections of the urine of persons taking copaiba are inert. Schmitt's Jahrbuch; also Braithwaite's Retrospect, vol. xxxviii., p. 451. 3 British and Foreign Medical Review, July, 1856. 4 Lancet, vol. i., p. 93. 1860. TREATMENT. 75 The following cable, drawn up from cases in my own practice, contains some statistics which may be of value to those really desirous of investigat- ing the subject : TABLE H. Cases treated urith Copaiba. Initials. Nature of Case. Treatment. Result. 1 J. D. Mild gonorrhoea of Copaiba. Injections of Not quite cured at end three months' sulphate of zinc and of 27 days. duration. nitrate of silver. 2 W. J. Gonorrhoea of three Potassio-tartrate of anti- At the end of 86 days or four days' stand- mony, copaiba, tur- left off attending. ing. pentine, and steel. Not quite cured. 3 Gonorrhoea of three Pulv. salin. At the end Cured in 65 days. days' standing. of fourteen days co- paiba, and then tur- pentine. Afterward colchicum. 4 J. S. Ordinary gonorrhoea. Had been treated for At the end of this time seven months with he was still suffering sulphate of magnesia, from gleet, cloudy . copaiba, etc. urine, and pain over the bladder. 5 L. H. Gonorrhoea of a Injections and purga- Cured in 52 days. month's standing. tives for fourteen days. Pulv. salin. and inject, of sulph. of zinc. Copaiba, turpentine, and pulv. salin. Injections. 6 W. Gonorrhoea of a Magnes. sulph., fol- Not quite cured at the- week's duration. lowed by copaiba and end of 3 months. Sub- nitrate of potass. In- sequently he reports- jections of sulph. of that the disease died zinc. out without anything further being done for it. 7 J. W. Gonorrhoea of some Aperients and copaiba Rapid improvement. days' standing. perseveringly used Severe relapse, ap- for seven months. parently from bath- ing. At the end of 7 months scarcely well. 8 Mr. N. Gonorrhoea, second Copaiba, liquor potas- Cure twice deferred by attack, very severe. saj, compound calo- his giving up treat- mel pill at night. ment just as he ap- peared to be getting quite well. 9 Mr. R. Gonorrhoea of four Copaiba and liquor po- Discharge removed in. days' stand ing, tassae with five grains 3 months. complicated with a of blue pill every sore on the penis. night for a short time. Injections of nitrate of silver and sulph. of zinc. 10 Mr. W. Gonorrhoea of a fort- Copaiba, cubebs, zinc Little improvement at night's standing ; injections. Almost the end of 12 weeks. first case. constant rest. 76 ON GONORRH(EA. Initials. Nature of Case. Treatment. Result. 11 Mr. E. Gonorrhoea of four Brisk purgatives, co- Cured in about 7 weeks. days' standing ; paiba, liquor potassse, second attack. pil. hydrarg. chlor. comp. Injections of arg. nit. and zinc. ' sulph. 12 Mr. B. Gonorrhoea of some Copaiba, liquor potas- At the end of 2 months weeks' standing. sae, compound calo- still some gleet re- mel pill. maining. 13 A. T. Ordinary gonorrhoea. Took six drachms of Still some purulent dis- copaiba, and the charge remaining at same amount of spirit the end of that time. of nitric ether, every week for one year. 14 Mr. H. Ordinary gonorrhoea. Took two pints of co- No better at the end of Patient very deli- paiba in two months, the time. cate. under the care of an experienced surgeon. 15 C.S. Simple gonorrhoea. Took half a pint of j Discharge diminished to copaiba a month for a very small amount ; four months. returned directly on the copaiba being left off. 16 Mr. P. Rather severe. Pa- Copaiba in small doses, Little if any improve- tient himself a and then an ounce ment at the end of surgeon. daily for above two this time. months. I could easily lengthen this list, but I cannot see that doing so would serve any useful purpose. If what has been said will not work conviction, I am afraid but a small amount of faith would be gained by constructing a more elaborate table. It is of little use to accumulate evidence when the reader is indifferent or has resolved beforehand that he will not be convinced. I heard a surgeon say before the Medical Society of London, that he did not believe gonorrhea could be cured without copaiba. The reader's experience will possibly supply him with equally striking instances. Of what use then can be the most positive proof in such cases ? It may be supposed that the copaiba here was given injudiciously, and that the surgeon had not waited till the inflammation was subdued, or that the patient was refractory or intemperate. Nothing, however, could be more incorrect ; case eighth excepted, most of them were model pa- tients men really anxious to get well. In the cases treated by myself, every precaution I had ever found of service was used, for at that time I believed in copaiba. Here the reader may object that I am making out a case against co- paiba ; so far from this, however, I am quite ready to admit that it is of ser- vice in a great number of cases, though I myself never had such success with it as some writers have recorded. Graves, for instance, tells us that Dr. Eoe cured his patients in a fraction less than twelve days. I never could do so ; and besides, I think, no one will deny that it does not cure a great TREATMENT. 77 number of cases, which is of far more importance, and any person who, after a long and fair trial, finds such results, is plainly justified in seeking for a more generally useful remedy. Dose and Mode of giving Copaiba. It would be satisfactory if those who recommend copaiba would really come to an agreement as to the most suitable dose, the best mode of giving it, and the period at which it should be used. At present any person seeking for reliable information on these points must be rather apt to get bewildered. Some surgeons give four- and-twenty times as strong a dose as others. Again, it was stated by a reviewer in one of our leading medical journals, that no sensible or experi- enced surgeon would think of giving copaiba in the acute stage of gonor- rhoea ; and many authors, M. Bicord for instance, strongly advocate the necessity for preliminary steps in the shape of antiphlogistics, etc. But it is quite certain that numbers of patients take copaiba" at this stage, not only with impunity but with benefit. Irrespective of the evidence on this head met with daily in practice, some surgeons distinctly recommend it at this period. "It would appear," says Dr. Bumstead, 1 "that copaiba can be administered with safety and to much greater advantage in the acute stage of gonorrhoea, or at an early period of the stage of decline, than af- terward ; and the same is true of cubebs." My own experience quite con- firms this. Dr. Durkee says 2 that patients have taken eight drachms at a dose, morning and evening, in the most acute stage, with entire success and without any preparatory treatment, and Dr. Veale goes so far as to maintain, 3 that the great error in giving copaiba is allowing the acute stage to pass before administering it, and ordering too small doses. As to waiting till the inflammation is subdued before administering it, it is to the best of my judgment simply useless. Moreover, copaiba, when it does cure the disease, cures it more quickly and certainly when given at once than after antiphlogistics. As to any danger from using it in this way, it is imaginary. The few recorded instances of serious or fatal results from prescribing it in the acute stage, when analyzed, seem to have been due to the irritable constitution of the patient, imprudence and intemperance on his part, or to the medicine being continued when it was manifestly acting as a poison, and would probably have occurred, to a considerable extent at any rate, had copaiba been administered under similarly unfavorable auspices at another stage. I have repeatedly known it make strong and temperate patients very ill, when taken for a mere gleet. The most efficacious way of giving copaiba is, to my thinking, in com- bination with liquor potassse. Spirit of nitric ether or nitrate of potass may be advantageously added, as may the compound spirit of lavender, which, mawkish as the last is to some persons, still serves to disguise the more disagreeable flavor of copaiba. Mucilage is useful for the same 1 Op. citat., p. 91. Op. citat., p. 38. 3 Lancet, vol. ii., p. 2. 1855. 78 ON GONORRHOEA. purpose, as well as for suspending the balsam. Mint-water is the best vehicle that I know ; some persons, however, strongly object to the taste of it, in which case cinnamon-water or camphor mixture may be substi- tuted. 1 With regard to the addition of such substances as cubebs, alum, tincture of cantharides, of sesquichloride of iron, and so on, I have had little experience, but that little is decidedly unfavorable. However I give 2 two or three formulae taken from Dr. Bumstead's work. Dr. Durkee recommends that copaiba should be taken in coffee, wine, or compound tincture of cinchona. Other authors have suggested sucking a slice of lemon immediately afterward. It seems to me a great pity, if surgeons will continue to prescribe and patients to take copaiba, that Mr. Thorn's plan is not tried. This gentle- man found that in two ounces of copaiba there are five parts in which all the virtues of the balsam reside, and eleven parts containing only useless and nauseous residue, so that tons of dirt are annually swallowed by patients to no purpose. As I have already said, Mr. Tyrrell obtained the most extraordinary success with Mr. Thorn's extract, and certainly the trial could not have been made by better hands ; but I imagine the subject has now lapsed into oblivion, although, supposing his statements and those of Mr. Thorn are well founded, no subsequent method of prescribing the drug can be said to possess so fair a claim to public notice. But sometimes the question is not what is the most efficacious formula, but what preparation the patient's stomach can bear best. Many persons cannot support copaiba in a liquid form, and the surgeon looks round to see in what solid vehicle it can be got to stay on the stomach. There is no want of variety here ; invention has been racked to produce something which will be pleasant or, at any rate, tolerable. Capsules of all kinds, sizes, and degrees of solubility ; pills, lozenges, dragees, perles, pastes, etc., have been brought forward in plenty some of them ingenious enough. I believe common experience has united to condemn them one and all as more or less unreliable. Perhaps one of the best substitutes for copaiba in the form of mixture is that of the balsam solidified by mag- nesia ; while I think one of the least unpleasant forms is that adopted by the dispenser at University College Hospital, who prepares the copaiba with honey, sugar, etc., so that it resembles "raspberry jelly," though one gentleman who had tasted it spoke of it with horror. The formula is given at full length in the number of the Lancet from which this notice 1 9 . Copaibse 3 ij (ad 3 iij), Mucilaginis acaciae 3 iv, Liquoris potasse 3 iss, Potassae nitratis 3 iss, Aq. menth. pip. ad vj. TTl_. Capiat | j. bis die. 3 . Olei Copaibas, Olei cubebae, aa 3 j, Aluminis 3 ij, Sacchari albi 3 iv, Mucila- ginis 3 iv, Aquae] r ij. TTj_. A teaspoonful to be taken three times a day. IJ. Copaibae 3 x. Tinct. cantharidis, Tinct. ferri chloridi, aa. 3 ij. TT1_. Dose from half a tea- spoonful to a teaspoonful. The following formula is copied from Dr. Druitt's Vade- Mecum, 1870, p. 808: R. Copaibae 3 iij, Olei cubebae m. xx, Spir. aetheris nit., Spir. lavandulae, aa. 3 ij, Olei cinnam. gutt. ij, Aquae fl. 5 v. Dosis 3 j. ter die. TREATMENT. 79 is taken. 1 It is to be remembered, however, that in all these preparations one very important ingredient, which figures in the prescription I have rec- ommended, the liquor potassae, is omitted. It is said that the alkali turns the copaiba into a kind of soap, insoluble in water, but in my experiments this has not appeared to impair the efficacy of the drug. One thing is absolutely necessary, and that is to secure pure copaiba. Most medical men have, I presume, noticed a very great difference in dif- ferent samples of this drug, but generally speaking they have little idea of the extent to which it is adulterated, and possibly some part of the dis- crepancy in the results from using copaiba might be explained by the varying degree of purity in which it is met with. Rape-oil seems to be a favorite ingredient for adulteration ; some specimens contain a large amount of this useless substitute. Dr. Durkee says that this adulteration is easily detected by dropping a little of the fluid into water. The pure copaiba assumes a spherical form, while the other does not. Irrespective of this, two kinds of copaiba are met with in commerce. Although neither of these is known to be adulterated, yet one is naturally much weaker than the other ; the stronger one solidifies with magnesia, but this is not the case with the other. Again, it seems that unobjectionable specimens differ materially as to the amount of volatile oil they contain, the percen- tage being only thirty in some, and as high as eighty in others, 2 and as about forty per cent, seems to be the most useful standard, it has been rec- ommended that only tested balsam should be used. Of the value of this oil, when given separately, I have had no practical experience. It seems generally agreed that we can depend less upon it than upon the balsam, and the resin only of copaiba has been given, it is said, with great suc- cess. The cutaneous eruption which sometimes follows the use of copaiba, "would not, in my opinion, be a sufficient ground for withholding it. For the most part it is a mild form of urticaria, distinguished by diffused red- ness of the neck, shoulders, face, and upper part of the body, accompanied generally by itching, tingling, a feeling of not being well, and disorder of the stomach. It usually passes off under the influence of a saline or feb- rifuge, aided by rest and light diet. Some serious cases have happened. Occasionally this affection has given rise to troublesome mistakes. Simon speaks 3 of a case where the house surgeon pronounced a patient with bal- sam rash to be ill of scarlet fever, and kept him six weeks in doors ; and some years ago a gentleman gave, at a meeting of the Medical Society of London, the particulars of a case where the same error seemed to have occurred, the speaker himself having believed the eruption to be that of scarlatina. 'Vol. i., p. 570. 1871. 2 American Journal of Syphilography, vol. iii., p. 293. 3 Bicord's Lehre von der Syphilis. 80 OK GONORRHOEA. 2. Cubebs. What I have been able to learn respecting the action of this remedy would lead me to place it pretty much on a level with copaiba, but the statements about it are so vague and conflicting, that it is impossi- ble to form any certain conclusions. One observer, Mr. Broughton, re- ports ' that he cured nine cases out of ten with it. Another, Mr. Crauf ord, asserts a that it fails in many cases. A third, Dr. Pereira, found it exert 3 no influence over the disease in the majority of instances, a statement which is much more in unison with my experience than that of Mr. Brough- ton. Again, it is pretty widely known that the use of cubebs in this com- plaint owes its origin in part to the story related by Sir Astley Cooper, of one of his patients having cured himself of a gonorrhea with this drug hi four days, or more strictly speaking, in some space of time between a Thursday and the Monday following ; now I believe this experience has been so rarely verified that it must be looked upon as most unusual. Pos- sibly some part of all this discrepancy may be explained by a fact, which Mr. Norman stated in a very practical paper read before the North London Medical Society ; some other part, perhaps, by a statement of Dr. Frazer's, that he has seen a large quantity of nutmegs, which had been subjected to distillation, sent to be used as cubebs! Mr. Norman brought forward some very strong facts to show that the action of the pepper, when freshly ground, is much more certain and potent than when it has been kept some time. He, however, admitted that even thus used it often fails. To this difficulty must be added an objection made against copaiba, viz., that it is utterly impossible to separate, at the outset of the treatment, those cases in which it is likely to be of service from those in which it is almost certain to fail ; and hence, that a surgeon treating twenty cases with this drug, cannot tell beforehand how many out of this number he is even likely to cure, leaving aside any question of certainty. Cubebs is said in some cases to have exasperated the symptoms of gon- orrhoea ; but this I think is doubtful, and most probably arose from its having exercised no control over the disease it was given for. I am much inclined to doubt if any medicine can aggravate the disease, except in fail- ing to cure it. Behrend, in his " Syphilidologie," says cubebs does not suit an irritable stomach an announcement I can easily credit. There is, how- ever, good reason for believing that in some cases large doses have set up considerable irritation, if not actual inflammation, in the prostate and blad- der. It occasionally cures with marvellous rapidity, but these cases occur in those happily constituted persons who throw off disorders with extreme ease, and who are freed from any severe gonorrhoea by very simple reme- dies. 1 Transactions of the Medico-Chirurgical Society, vol. xii., p. 99. * Edinburgh Medical and Surgical Journal, p. 52. 1858. 1 Elements of Materia Medica, vol. ii. , p. 756. 1840. TEEATME1STT. 81 "When the surgeon has decided to prescribe cubebs, it should, I think, always be ordered in teaspoonful doses of the fresh-around pepper two or three times a day. Mr. Squire suggests moistened wafer-paper as a vehicle. The paper may be flavored with essential oil of almonds. The powder is made into a paste with syrup of ginger, and then laid upon the paper, which is folded over it. The patient takes a mouthful of water, and then tosses the bolus down his throat. It is said in the Pharmaceutical Journal, 1 that " it is surprising how easily patients acquire the tact of bolting these bol- uses, without any convulsive action of the muscles of the throat." The sur- prising part of the matter to me is that they ever acquire the power of doing so, and indeed that they do not choke themselves at the first attempt. I should have thought that it almost equalled the feat of swallowing a clasp- knife. The practice of prescribing copaiba and cubebs together, when one or both have failed separately to cure the gonorrhoea, is, I believe, a useless experiment. After giving my best attention to the facts, I can only conclude that all the instances in which this combination is said to have effected a cure, were simply cases in which the separate ingredients had been of de- fective quality, or taken irregularly, or in too small doses, or where their action had not been properly seconded ; and that it is very doubtful whether this combination possesses any curative power superior to that of either drug given separately. 3. Kava-Kava. The root instead of the berry of another pepper, the pip- er methysticum or kava-kava, is enthusiastically recommended 2 for this com- plaint by M. Dupouy, who does not seem to be aware that it has long been known, and that the disgusting mode of procuring an intoxicating drink from it, practised by the old women at Otaheite, where the " enchantresses of gay Licoo," when age has robbed the charming young creatures of their teeth, are specially told off for this purpose, has been already quite sufficiently de- scribed. The tree is a native of Oceania, and is found in the Society Islands, Samoa, Wallis Island, etc. The fresh root when chewed is bitter, astrin- gent, and sialagogue. It is the dry root which is used for gonorrhoea, and the method of employing it at Tahiti is as follows : Four or five grammes of the root are macerated in a thousand grammes of water for five minutes, and this monstruous potion is taken daily in two doses, indifferently before or after food, till a cure is effected. In twenty minutes after the first dose a pressing desire to make water is felt, which most likely the reader will consider a very probable result indeed. However, this is soon compensated for, as any pain previously felt during micturition disappears and is replaced by a sense of comfort, while urine charged with deposit and coloring mat- ter becomes clear. Ten or twelve days of this treatment always effected a 'Vol. v., p. 503. 2 Journal de Therapeutique. Quoted in the Gazette Medicale de Paris, p. 166. 1876. fi 82 ON GONORRHCEA. cure in the cases which he saw. M. Dupouy therefore considers the kava- kava a powerful diurftic and a remedy " par excellence " for gonorrhoea. It does not derange the digestive organs, induces neither diarrhoea nor constipation, is taken with pleasure by those who have a delicate stomach, stimulates appetite and does not create any distaste. Such is the flattering side of the question, and but too frequently the only side presented to us ; it may therefore perhaps be as well to take an- other, which is to the effect that the kava-kava does not possess a particle of the curative virtue ascribed to it, and that the story seems fated to figure some day in the long list of self-deceptions. Herr Zeissl administered the drug carefully to twenty patients, in not one of whom did it produce the slightest change for the better ! 1 4. Turpentine. In a scientifically arranged treatise, turpentine ought perhaps to have followed copaiba, and not cubebs, but as I aim only at be- ing useful, I trust to stand excused for placing together the two remedies most frequently used and most frequently combined. Turpentine was, however, in its time quite as fashionable a remedy for gonorrhoea as cubebs at the present day. It seems clearly to possess a certain amount of control over the discharge in the later stage, when it has become partly mucous but is still profuse. Some substances of this nature, such as the resin of the spruce fir, act very beneficially when the inflammation of gonorrhoea has extended to the neck of the bladder, and even to the body of this viscus. In all other stages of gonorrhoea, and particularly when it is acute, every preparation of turpentine that I have seen tried has always appeared to me inert. In large doses it may occasion sickness or nausea, but I believe it is quite unnecessary to use it in such a way, and that all the benefit likely to accrue from its use will be obtained by giving it in moderate quantity. Perhaps Chian turpentine will be found as useful as any. It should be simply aUowed to dry to the consistence of an ordinary extract ; it is then rolled in magnesia and divided into five-grain pills, two, three, or four of which may be taken twice a day. Care, however, should be taken to secure genuine Chian (or Cyprus) turpentine, the resin of the turpentine pistachia (Pistachia Terebinthus), as the coniferous turpentines are only too often substituted for it. Kemedies of this kind have been tried by means of inhalation, and I suppose the result has been about as complete a failure as could well be imagined. Two cases of gonorrhoea treated in this way are mentioned in the Wiener medizinische Zeitung* one with rectified turpentine, a cure ensuing in twenty-five days, and one with ethereal oil of pine, which an- swered so badly that at the end of eighteen days the patient was obliged to fall back upon astringent injections. The remedy is therefore useless, 1 Wiener medizinische Wochenschrift, S. 1023. 1879. 2 1873, S. 253. TREATMENT. 83 and any farther attempts in this direction would amount to inflicting need- less suffering. 5. Ngan Plang. 1 Some years ago my attention was called to the value of this medicine in gonorrhoea, and half a pint was sent to me for the purpose of making some trials with. It is a reddish-colored fluid, about the con- sistence of syrup, 'and of a warm balsamic taste, reminding one of a deli- cately flavored kind of copaiba or turpentine. It is, I believe, for I have not been able to obtain such full and precise information about it as I could have wished, found only in Java, where it is considered a specific for gonorrhoea. It is taken in doses of a teaspoonful two or three times a day, no other means being used. No restriction as to diet, etc., is im- posed on those taking it. I gave it in four cases, in drachm doses two or three times a day. All the patients assured me that they took the medi- cine with the greatest regularity, and I have every reason to believe that they would only state the exact truth. The report in every case was that they did not notice any particular effect from the remedy. It was not un- pleasant, they said, to take, and agreed very well with them ; beyond that they had nothing to relate. I examined the patients nearly every day while they were using it, but did not notice any appreciable action on the gonorrhoea. I have since then repeatedly inquired of friends and patients who had been in the East, as to whether they had ever heard of this drug, but never met with any person to whom it was known. I have also examined the medical journals pretty diligently with the same view, but with equal want of success. 6. Matico. As this drug contains a terebinthinate oil, it may very prop- erly find a place here. I have been given to understand that it is used now in many cases of gonorrhoea, but that it is the resin which is em- ployed, and in the form of capsules. My inquiries on this point, however, elicited no reliable information as to whether this is the fact, or how much of this ingredient is contained in each capsule. No mention is made of a resin in the Pharmacopoeia, or Mr. Squire's " Companion." M. Diday tells us that druggists sometimes very judiciously associate it with copaiba, to which addition he ascribes the only power it possesses. I have only had one opportunity of trying these capsules, and there- fore can say but little about them. In the case I allude to, the patient, a delicate-looking, thinly built man, suffering under a moderately profuse discharge, attended with some chordee and irritability of the bladder, in- formed me that he had had gonorrhoea once previously, and that then the disease, after long resisting other remedies, was promptly subdued by tak- ing twelve matico capsules daily. Consequently I thought this a very suitable case for testing the remedy, and advised him to take the same number of capsules. He accordingly procured some, which he identified 1 Pronounced Ne-an-Plang. 84 ON GONORRHOEA. as similar to those used on the previous occasion, and took them at the same rate. At the end of a few days, the discharge being in precisely the same state and his health being quite unaffected by the medicine, I sug- gested raising the dose, and he at once began taking eighteen capsules a day. Four or five days later he reported satisfactory progress, and then, two or three days after that, told me that he was no better than before he took the matico, having thus, in a very short time, twice changed his mind about the action of the medicine. For my part, although I saw the case almost daily, I could not observe that the remedy exerted any influence over the running. I believe the patient did everything in his power to second the opera- tion of the matico ; indeed he was most anxious to get well, the continu- ance of his malady being for him a very serious matter ; at the same time I am doubtful whether the remedy received a fair trial, as I am not quite clear that some degree of contraction was not springing up at the time ; indeed a certain amount of it was found later on, and the case will be sub- sequently related under the head of cases complicated by stricture. 7. Oil of Santal-wood. We are indebted to Dr. Henderson, of Glasgow, fora knowledge of this drug. 1 He gives it in doses of twenty to forty minims, and often notices a most marked suppression of the discharge within forty-eight hours. He recommends it as a pleasant medicine, not liable to cause sickness or to communicate any odor to the urine. Shortly after Dr. Henderson's communications some other reports appeared about the oil, almost if not quite as favorable as his own. A very natural result of this was that it came into general use, and though the demand for it has greatly lessened, yet I am assured there are many persons whose faith in it remains unshaken ; and I need scarcely say that it figures in the prepara- tion made by Messrs. Hewlett, the liquor santali flavi, of which great suc- cess is reported. Many of those gentlemen who have prescribed it largely consider it quite as efficacious as copaiba, and infinitely more pleasant both as to taste and operation. We have the authority of Dr. Otis in its favor. Dr. Atkinson, formerly house surgeon of St. Bartholomew's Hospital, Chat- ham, who was one of the first to employ it in England, and who watched its action with great care, was kind enough, in reply to some questions, to inform me that he had seldom found it fail in acute and subacute cases ; that pain in micturition generally stops after the third or fourth dose, whilst the discharge itself usually ceases after the third day. Dr. Atkinson, however, thinks it as well to continue the oil up to the seventh or eighth day, so as to guard against the possibility of a return. With the excep- tion of very slight griping pains about the bladder, he has never known any unpleasant results from the use of this remedy. The dose he generally 1 Glasgow Medical Journal, p. 70, 1865 ; and Medical Times and Gazette, vol. i. , p. 571. 1865. TREATMENT. 85 gives is from twenty to thirty minims in a little mucilage and cinnamon- water three times daily. A Glasgow correspondent of the Practitioner, l however, has questioned its possessing any curative power, the remedy having failed not only in his hands, but in those of other practitioners, while its other good quali- ties have been equally contested. M. Diday, in his new work, ranks the essence of yellow sandal, which I suppose is the same substance, among the futilities, parmi les insignifiants ; M. Panas also observed ' that an odor was communicated to the urine, and that though the oil rapidly lessened the running, yet in a certain number of cases recourse to further measures was necessary ; and Dr. Purdon found that, so far from occasioning little nausea and having little smell, as stated by Dr. Henderson, he had in many instances to discontinue its use on account of the nausea it brought on, and that the odor was extremely well marked, remaining in the breath and on the hands for hours after being washed, and being evident in the urine. These objections, however, did not deter Mr. Robert Park from espous- ing the cause of the oil, which he has done in a very able and temperate article, 3 showing a sound knowledge of his subject. The oil, he tells us, was first introduced extensively into practice by the late Dr. Milner, of Glas- gow. It is in the case of full plethoric subjects, with thick purulent dis- charge from the urethra, that its specific power is so strongly marked ; in such cases it often effects a cure in from two to five days. He gives five minims every four hours, and says that larger doses are superfluous and even dangerous. If this view be well founded, we must conclude that other authorities are in error about the doses and properties of the oil, that it is perhaps only suited to particular cases, and that our knowledge of the sub- ject must become complete before we can use it in a reliable way. He now says 4 it does not cure the urethritis, but restrains the running at once, very frequently stopping it in forty-eight hours, whereas I have never once been able to effect any such rapid change. Even then it must, he tells us, be continued " quite a fortnight after entire cessation of the discharge, to make sure the latter does not return." It is very probable that some part of this discrepancy might be explain- ed by a fact with which these gentlemen do not seem to have been ac- quainted. The fact is, that oil of santal-wood is so extensively adulterated with balsam of copaiba and castor-oil, that the genuine fluid forms in many cases but a very small part of what is administered. Some years ago I was assured by a gentleman on whose opinion I can quite rely, and who was kind enough to take a great deal of pains in order to procure me the infor- mation I required, that there was not a pint of pure santal-wood oil to be bought in the market at any price, and yet the supply to the retail houses was so regular and large as to seem practically inexhaustible ; a fact which 1 Vol. iii., p. 196. - Gazette Hebdomadaire, p. 843. 1865. 3 Practitioner, vol. ii.,p. 266. 1869. "Ibid., vol. ii., p. 440. 1881. 86 ON GONOKRHffiA. he partly explained by adding, that once, when supplying the oil direct from the still, he had been asked how much copaiba and castor-oil it would require to bring it up to the commercial standard. The pure oil of santal-wood is of a light but clear yellow, without the least tinge of brown, almost exactly the same hue as pure, fresh, sweet almond-oil ; whereas that generally sold has a tint approaching the color of copaiba, and a look like mastic varnish which has lost some of its trans- parency ; but to some extent the color of the oil differs according to the district from whence the wood comes and the age of the tree. The best oil has a slight smell of copaiba, a fact, I am told, from which the first hint of adulteration was taken. The pure oil is intensely strong, and so acrid in taste that I can only compare it to croton-oil. Though I have prescribed the oil as usually sold, I have not made many experiments with it, confining myself, as far as I well could, to that procured from Messrs. Pears, on which I felt assured complete reliance might be placed, and which they sell, I be- lieve, pure as it drops from the still, in sealed bottles. Most of the patients for whom I prescribed genuine oil have assured me that the doses ordered, from twelve to twenty minims, were as much as they could bear. One gentleman took thirty-five minims three times a day, but he was peculiarly insensible to the action of all the medicines I gave him, and even he had to discontinue the remedy at the end of two or three days, as he found it was inducing nausea. Judging from the effect which the oil produced on my own mouth, I should have thought it impossible for any one to support even such a quantity as thirty -five minims. As to Dr. Henderson's statement, that it has a very slight smell, I cannot understand it. I kept a specimen of the pure oil for several months, and yet the smell, when the fluid was even slightly warmed, was exceedingly pungent and most characteristic ; in fact it seemed to overpower that of any material the oil may be adulterated with. With regard to the cures said to have been effected by means of this oil given in combination with liquor potassse, I may say that the latter fluid, given in moderate doses in conjunction with very small quantities of balsam of copaiba, or mucilage of acacia, linseed-tea, veal-broth, or any bitter infusion, will cure a great many cases of gonorrhoea a fact which I briefly pointed out many years ago in the first edition of this work. Some of my first trials with the oil were encouraging. Given as below ' it seemed to agree very well with the patients, who found it rather stom- achic than otherwise, and it certainly appeared to remove slight discharges, particularly when injections were also used. But even in some of them it did not succeed as I could have wished, and in the more severe forms of the affection I could not observe that it exerted any appreciable action. 1 B. Olei santali, 3 j., Ovi vitelli, q.s. ; tere bene et adde, Spir. setheris nitrosi, 3 ij., Syrupi flor. aurant. I iv. , Aquae cinnam. ad 5 vj. M. Cochlearia ampla duo ter quot- idie sumenda. TREATMENT. 87 Certainly at the end of six, eight, and even ten days, the discharge had not ceased. My faith in its virtues has not improved on acquaintance; on the con- trary, farther experiment has only shown that the skepticism set up by the first trials was justifiable. In all, taking those cases which I could watch, I have prescribed the two kinds, the pure and the oil of commerce, for twen- ty-two patients suffering from the acute f orm without effecting a single cure. It may be that I omitted some precaution which I ought to have taken, or gave the oil in too small doses, but if I am to rely upon my own experience, and pass an opinion, it must be that the oil is not possessed of as much curative power as balsam of copaiba. At the same time I think it a valu- able addition to the Pharmacopoeia as a remedy for bronchitis, in which complaint I have repeatedly used it, being more agreeable than copaiba and quite as efficacious, if not more so. 8. Gurgun or Gurghun. TJie Gurgina Balsam or Wood-oil. This rem- edy, the product of the Dipterocarpus turbinatum, was also recom- mended by Dr. Henderson. 1 It is a medicine of the same class as the oil of santal-wood. Dr. Henderson experimented with it for a long time, and then, having exhausted his stock, was obliged to suspend operations. He, however, only used it in cases where copaiba had been tried and had failed. He gave it in large doses, such as a teaspoonful two or three times a day, and found it in every case successful within a week. I have no practical experience of its action, and I have not been able to learn whether any trials, of such a nature as to furnish the means of arriving at any reliable opinion, have been made of its power over gonorrhoea, except by the gentleman just alluded to. 9. Erigeron Oil. Some years ago, Dr. J. S. Prettyman, in a communi- cation to the American Journal of the Medical Sciences, 3 stated that he had tried the oil of erigeron in about fifty cases of gonorrhoea, and found that it arrests the discharge in about seventy-two hours, and effects a cure in from six to eight days. He did not, however, recommend it as a specific, though it seems from such testimony quite as much entitled to the name as copaiba. The patients took the medicine as follows. A gill of an aperient infu- sion of senna and jalap, with some aromatic, was ordered, and so soon as it operated, ten drops of the oil on sugar were taken. This was followed up three hours later by a full dose of spirit of nitric ether in infusion of marshmallow. Then, three hours after this, or six hours from the taking of the first dose of oil, a second dose of oil was given, followed in its turn by a second dose of the nitric ether mixture, and so on. Dr. Prettyman states that he had only so far used the oil reputed to be obtained from the Erigeron canadense, but that he thought that of E. philadelphicum must be equal if not superior. The paper is very short, and contains no account 1 Glasgow Medical Journal, p. 71. 1865. 'Vol. lii. 88 ON GONORRHOEA. of the history, taste, properties, etc., of the oil. I suppose most persons who have read the account would imagine that this substance really pos- sesses some control over gonorrhoea, yet it so entirely failed in the hands of Professor Stein, of New York, who seems to have given it a fair trial, 1 that it is difficult to refrain from supposing its virtues to be imaginary ; while some very briefly recorded cases by Dr. Stark 2 show that it is at best a highly unreliable remedy. This concludes the list of specific agents, so far as my knowledge g9es, and I therefore pass on to the consideration of some which are more com- prehensive in their meaning. Of these the first on the list is 10. Antiphlogistic Means. Of these it will not be necessary to give any lengthened account, the system having, as regards its old complete thorough-going shape, pretty well died out in England, and I believe en- tirely in Germany and America. In France, however, a few vigorous off- shoots from it still survive. In at least two reviews of former editions of this work, the opinion was expressed that all mention whatever of it was superfluous, that the arguments employed against antiphlogistic treatment were out of date, a quarter of a century behind the time. But we know what a powerful influence French teaching has upon English practice. I heard an eminent specialist maintain, before a medical society, that nearly everything we have learned about venereal and urinary diseases was taken from the French ; and when we find a master like Fournier recommending, in the acute stage of gonorrhoea when the symptoms are urgent, fifteen to twenty-five leeches to the perineum, repetition of this, with the very sig- nificant addition that bleeding from the arm is only exceptionally called for, it seems to me that it can be in no way superfluous to point out the inconsistencies and inutility of the method. For I think there cannot be a doubt that, though indisputably proved by sound reasoning to be of the first necessity for saving life and subduing inflammation, though as universally accepted as any canon of therapeutics can well be, it was utterly superfluous in the great majority of cases, and the indiscriminate employment of it was a mistake. Possibly in some few cases it was, especially as regards the depleting process, what its support- ers maintained it to be, a powerful means of relief. I have been told by men in large practice, men not at all prejudiced in favor of old fashions, that the abandonment of the lancet in many affections, pneumonia for in- stance, was an error. Granting this to be the case, I believe the extension of the system indiscriminately to inflammations of all tissues was equally an error, and that the benefits supposed to arise from its employment in by far the most of them were purely imaginary. Equally I believe that, though the system in the shape of leeching may have now and then been useful in some complications of gonorrhoea, such as inflammation of the 1 New York Journal of Medicine, vol. i. , p. 397. 1870. Canada Medical and Surgical Journal, p. 158. 1877. TREATMENT. 89 prostate, the application of such means to the parent disease is uncalled for ; a mistake, and one which a moderate amount of attention would avert. In my early days I saw both bleeding and leeching employed for gon- orrhoea, but in no single instance did I ever notice the least benefit from either ; yet the practice was continued to the end of their lives by men who constantly saw such facts pass before their eyes. Nor do I find that the results, as given by those French medical men themselves, who adhere to a system in which antiphlogistic means play a very prominent part, are at all encouraging. Few authors have treated gonorrhoea more energeti- cally than M. Ricord ; I have no means of knowing what his present prac- tice is, but at one time he used leeches, etc., in a manner bordering closely upon the heroic ; and yet, though it is difficult to ascertain what time he requires for the cure of his patients, there is evidence enough to show that they often remain for weeks under his antiphlogistic treatment, even when seconded by rest, specifics, injections, and cauterization. Fournier and Melchior Robert have evidently to a great extent moulded their treatment on that of Ricord. The former honestly admits that, face to face with a considerable number of refractory cases, his treatment an- swers very indifferently. To my mind, M. Robert's account and some of his incidental allusions look very like a history of failure. He calls gonor- rhoea ' an " interminable maladie ; " speaks 2 of its interminable, its mad- dening, 3 persistence ; of the half-cured state in which the urethra remains when " preceding blenorrhagias have left it in a leaven ever ready to fer- ment," 4 and honestly admits that, except in a few rare instances, when the abortive treatment avails, the disorder is only cured, in the most fortunate cases, by the aid of specifics and injections, at the end of thirty or forty days. In the cases I collected from my own practice and that of my friends, the cures effected by this mode did not amount to more than one in four, and they were both slow and uncertain. Those which yielded were mild forms of the disease, and yet they lasted from thirteen to thirty-seven days ; when injections also were used, antiphlogistic measures proved nearly equal to copaiba, for then out of twenty-three cases thirteen were cured, the aver- age period of treatment being twenty-eight days. 11. Purgatives are another favorite remedy in this disorder. I have not been able to find much evidence of their curative power. Two or three authors speak of them as revulsives, others of their setting up an internal depletion, phrases which sound to me rather like the substitution of a theory for the statements of experience. What I could make out by ex- periment was, that a powerful purgative will, in some very mild cases, or at the beginning of the attack, most materially aid in cutting short the dis- ease, and this is about all it will do. Dr. Bumstead says, 5 " We often meet "with patients who have treated themselves with low diet and purging for 1 Op. citat., p. 70. s lbid., p. 80. 3 Ibid., p. 81. 4 Ibid., p. 117. *New York Journal of Medicine, vol. ii., p. 210. 1859. 90 ON GONOERHCEA. weeks, and are no better of their gonorrhoea." Durkee is strongly opposed to over-purging. "Patients," he says, 1 "of their own accord often pursue a cathartic plan for several weeks, and then report that their urethral diffi- culty is as troublesome as at the beginning." Mr. Whately relates 2 an in- stance in which a purgative was repeated every day for thirty days together, accompanied by a strict adherence to an antiphlogistic plan of treatment ; and all this was done " without producing any material alteration in the complaint, or any considerable abatement in the inflammatory symptoms ! " Rowley one s where the patient was purged and drenched till he looked like "a dead corpse." The result of this vigorous treatment was, that pur- ple spots appeared on every part of the body ; the greater part of the penis "dropped off," and very soon afterward the patient died. I now proceed to give a table of cases in which these remedies were tested with all the care I could exert. TABLE TTT Cases treated wtth Purgatives. Kme. Days pre- viously ill. Character of the disease, and previous treatment when ascer- tained. TBEATMENT. Date of final disappearance of the discharge. Medicines. Injections. 1 W. D. 10 First clap. Strong purgatives. Sulph.zinc. arg. On the 35th day Pot. iod. c. inf. nit. a stricture was rhei. gum. acac. detected. Cure c. pot. nit. in 2 months by bougies. 2 J. B. 3 .... Strong purgatives Nit of silver. Cure in 16 dajs. 3 W. H. Not ascer- .... Ditto. Sulph. of zinc, Cure in 28 days. tained. and occasion- ally nit. of silver. 4 J. S. 60 .... Pulv. salin. Steel For one month Cure in 47 days. and purgatives. none, then a strong injec- tion once a week, and used one him- self occasion- ally. 5 S. C. Not ascer- .... Hyd. chlor. and None. At the end of 15 tained. haust. cath. days no im- provement. 6 H. H. Not ascer- .... Ditto, followed by Injection only At the end of 35 tained. pot. iod. c. inf us. in the latter days still some rhei. part of the running. < treatment. 7 G. Not ascer- .... Purgatives. Ditto. At the end of 13 tained. days still some discharge. 1 Op. citat., p. 31. * Practical Observations on the Cure of Gonorrhoea Virulentain Man, p. 96. 3 An Essay on the Cure of the Gonorrhoea, p. 13. 1771. 1801. TREATMENT. 91 12. Aperients. Aided by injections, aperients will effect quite as much as the most torturing and depressing purgatives ; and could we but dis- criminate the cases at the outset, it would in many instances not be neces- sary to do more than prescribe these two remedies. But this is impos- sible. It will constantly happen that in very healthy-looking persons gonorrhoea becomes so severe or obstinate under this plan of treatment, that other means have to be resorted to after a considerable waste of time and money. Nay, it will occasionally happen that the very same patient, apparently suffering from the very same form of the disease, can be cured at one time by these simple remedies, and yet at another require all our resources. Besides, this plan is slow and uncertain, even when injections are used. I give below a table of cases thus treated. I could easily add to the number, but resist the temptation, as the returns agree so closely with those previously obtained. And here I may observe that the reader will probably enough object to these tables as embarrassing, superfluous, and difficult to carry in the mind. My answer is, that they cannot be dis- pensed with ; that the object in this work is to separate, as far- as I can effect it, certainties from uncertainties. It appears to me that this is the first step on the true road to knowledge, and that, without such a method there can be no real progress. The number of opinions and the aggregate amount of experience may indeed increase, but such increase can only augment the difficulties of those who essay to analyze the mass and extract the truth from it. I therefore hold that the only plan is to reduce obser- vations to such a form as will not merely admit of their being clearly com- prehended and easily tested, but will reduce almost to a minimum the imputation of any vagueness. "When observations are impartially digested down into figures, we can deal with them better than in any other form I know of. TABLE IV. Coses treated with Aperients. Character of TREATMENT. Name. Days previously the disease, and previous Date of final disap- pearance of the ill. when ascer- tained. Medicines. Injections. discharge. R. M. K. Salines, carb. of None. Left at the expira- soda and pnlv. tion of 13 days, jalap. in no way im- proved. A. R. 10 . . . Saline powder, Sulphate of Attheendof35days consisting of zinc 3 i. to the discharge dis- pulv. rhei.pot. oj. appeared, but re- nit.,andsulph. turn ed imme- magnes. diately on leav- ing off treatment. 92 ON GONORRH(EA. Name. Days pre- viously 10. Character of the disease, and previous treatment when ascer- tained. TEATMF.NT. Date of final disap- pearance of the discharge. Medicines. Injections. 3 J. S. 30 Complicated Saline powd. con- Sulphate of Cure complete in with rheu- sisting of pulv. , zinc 3 i. to 19 days. matism. rhei. pot. nit., oj. andsulph.mag. 4 J. B. 21 .... Pulv. sodae c. None. On the 25th day jalap. only a slight gleet remaining. 5 H. B. Not .... Pulv. salin. pot. None. On the 35th day the ascer- nit. c. pulv. discharge was tained. antim. still bad. G J. R. Ditto. .... Pulv. sod. c. jal., None. On the 34th day pulv. salin., there was still mist. salin., some scalding, followed by accompanied by tincture of purulent dis- steel. charge. 7 J. C. Ditto. .... Pulv. salin. Sulph. of zinc. At the end of 75 days there was some improve- ment. He now took no medicine for 35 days, dur- ing which time , there was no fur- ther alteration in the disease. 8 W. B. .... Apparently Dilute sulphu- None. The discharge from over- ric acid and ceased on the 3d walking. aperients. day. 9 .... 30 He had drunk Pulv. salin. Re- Sulph. of zinc. Cured by the 35th beer, and stricted diet. day ; the scald- tried to cure ing ceased on the himself 6th day. with salts. 10 A. D. 30 Be com - Pulv. salin. Ditto. By the 21st day the plained of scalding had the scalding nearly ceased, being very and by the 25th severe. the discharge was gone. 11 .... 3 N 1 o t very Pulv. sod. c. jal. Lotio saturn. On the 30th day severe. No restriction to the penis, there was still in food or some purulent drink. discharge. 12 A. S. Not .... Pulv. sod. c. jal. ; Ditto, followed On the 39th day ascer- mist, salin. by injec. of there was still tained. sulph. of some purulent zinc. discharge. 13 W. S. .... Pulv. sod. c. jal.; Lotio saturn. as On the 61st day pulv. salin. an injection. there was still some purulent discharge. 14 A. S. 4 Pulv. sod. c. jal. Ditto. On the 16th day No restriction almost all well. in diet. 15 A. H. 4 Ditto. Ditto. No improvement at the end of 33 days. TREATMENT. 93 Name. Days pre- viously ill. Character of the disease, and previous treatment when ascer- tained. TREATMENT. Date of final disap- pearance of the discharge. Medicines. Injections. 1C D. F. 6 Pulv. sod. c. jal. Lotio saturn. as At the end of 14 No restriction an injection. days there was in diet. but little im- provement. 17 R. K. 90 He had taken Pulv. salin. Lotio saturn., Cure in 78 days. copai. and and after 24 catechu, dayssulph. and used zinc. injections. 18 S. C. 7 . . . Pulv. sod. c. jal.; Lotio saturn. On the 30th day salines. the chordee had ceased, but scald- ing and discharge were present. 19 E. S. 90 Very mild. Pulv. salin. Sulph. of zinc. Cure in 4 days. 20 M. J. 42 .... Ant. and salines. Ditto. Cure in 30 days. 21 B. B. 42 Cubebs in Pulv. salin. Not Sulph. of zinc On the 40th day mixture. restricted in there had been diet, drank no discharge for beer. a week ; there was still some smarting on mak- ing water. 22 J. P. 270 Thick white Pulv. salin. Lotio satnrn. On the 49th day- discharge, tinct. of steel. there was still no chordee; some discharge. lived regu- larly, took medicine, and no malt liquor. 23 W. C. 3 .... Pulv. salin. None. No improvement at Drank beer. the end of 33 days. 24 A.S.K. 6 .... Pulv. salin. Sulph. of zinc. In 12 days had di- minished to a gleet, and a few injections com- pleted the cure. 25 H. C. 3 .... Pulv. salin. Ditto. Cure in 43 days. 26 G. W. 24 .... Pulv. salin., fol- None. Cure in 16 days. lowed by co- paiba and tur- pentine. 27 H. H. Not Saidtobenon- Pulv. salin. Sulph. of zino. Cure in 12 days. ascer- venereal. tained. 28 J. S. 60 Copaiba and Pulv. sod. c. jal. Ditto. Cure in 12 days. injections. 29 S. W. Not Said to be Ditto, and tinct. None. On the 37th day ascer- from a ferri T^. xx. there was still a tained. strain. ter die. slight gleet, when the tincture was com me n c e d. Cure in 8 days more. 94 ON GONORRHOEA. Here, then, with the exception of four cases, one of them (Case 8) be- ing very likely not gonorrhoea at all, where I began injecting within the first fortnight, the results were of the most unsatisfactory kind. Many of these patients were as bad as ever at the end of thirty, forty, or fifty days, and the treatment had to be exchanged for something more calculated to effect a cure. A few slowly recovered ; and some, who thought the disease gone at the end of a long course of medicines, found it return so soon as ever they left off treatment. The objection urged against copaiba and cubebs holds good here. When once a case proves refractory, no further benefit seems to arise either from increasing the dose or persevering in the use of aperients. Of this, practice affords us every day the most convinc- ing proofs ; and there is perhaps no surgeon, however limited his sphere of observation, who has not seen cases in which patients, attempting to cure themselves, had persevered for months in the employment of these remedies without even materially relieving the disease. 13. Diuretics. The principal diuretics prescribed in gonorrhoea are the spirit of nitric ether, nitrate and acetate of potass, and liquor potassse ; though perhaps the latter ought only to be classed exceptionally under this head, being an antacid. I could never quite satisfy myself about my own reasons for using them, although I am always glad to avail my- self of their employment. A moderately increased action, however, of the kidneys seems so generally to alleviate the disorder, that these remedies have been admitted into almost every plan of treatment. The spirit of nitre is perhaps the most unexceptionable and pleasant to take, as it rarely offends either the taste or the stomach, and even when not beneficial never acts injuriously. As to the nitrate of potass I must give a more qualified opinion, and in the section on scalding, in a later chapter of this work, it will be seen that it was given to the extent of six drachms a day without producing the least effect either on the disease or scalding. The acetate is unquestionably, I think, a much more powerful remedy as an adjunct. It was first introduced, I believe, by Mr. Hilton to the notice of the pro- fession as a remedy for gonorrhoea. Long previously I had used it exten- sively, but I had ceased to place any reliance upon it as a specific, and this is really the only decision I could arrive at. A close scrutiny of Mr. Hil- ton's cases will, so far as such a small number can prove anything, prove this assertion. In the first case the discharge ceased within sixteen days ; in the second on the eighth day ; while in the third instance no very ma- terial improvement took place for the first fifteen days, and it required thirty-nine days to subdue the scalding and discharge. Even then the cure was not complete. Liquor potassse exerts a good deal of control over the purulent discharge, and in women it often, combined with bitters, acts better than remedies which prove more powerful in the male. 14. Alteratives. This part of the subject need not detain us long, and indeed, but for a rather recent profession of faith in the practice, I TREATMENT. 95 should not have mentioned it, as I suppose the treatment of gonorrhoea by means of such medicines is, with a few rare exceptions, consigned to desuetude in this country. But it is not so in France. Mr. Lee says ' that M. Baumes and M. Lagneau are in the habit of treating obstinate gonorrhoea by means of a mercurial course, and with success, the explana- tion of which is that the gonorrhoea is syphilitic. Nor do these gentlemen stand alone among French practitioners. Mr. Lee himself clearly leans to this belief, and considers that the discharge, from which Hunter inocu- lated himself, was of this nature and not chancre larve. Although I have watched, with all the care I could bestow, every case bearing upon the genesis of syphilis, I have never met with any fact showing that it origin- ates except from some recognized form of syphilis itself. I never saw the plan tried but once ; then, however, it was put in force so efficiently that the patient was badly salivated, but without the gonorrhoea being in the least affected either one way or the other. Of the treatment with corrosive sublimate recommended 2 by Dr. Brack I have no experience, nor does it seem desirable to try a medicine the action of which is, according to him, attended by so many drawbacks, and which only effects a cure in six weeks. The iodide of potassium, one of the most powerful alteratives in proper cases, has been repeatedly made a subject of discussion, as a remedy in gonorrhoea. It is, however, inert for such a purpose, except in so far as the potassium may act in the same way as the liquor potassse does ; and any benefit which arose during its use was probably due, either to this cause, to some other part of the treatment, or to the natural tendency gonorrhoea sometimes shows to get well of itself. In a paper by Mr. C. Cornwall, in the fifteenth volume of the Medical Gazette, it will be seen that the author's success in treating gonorrhoea in this way amounted to effecting a cure in thirty-four days, which does not show the plan to be unusually efficient, I assume, however, that faith in the virtue of the iodide, if it ever really existed, is about as extinct as that in venesection. B. EXTERNAL APPLICATIONS. For the sake of accurate examination it will be best to divide these into 1, cold applications, as ice and evaporating lotions ; 2, warm applications, as hot fomentations, baths, etc. ; and 3, sedative applications. We may thus ascertain their comparative value, and see if there are any fixed rules to guide us in making use of them. 1. Cold Applications. How far cold evaporating lotions, particularly when used as they generally are, act beneficially in checking the pain and in- flammation and in abating the heat felt in the penis, and, indeed, in any in- flammation where a mucous membrane is implicated, is a question which I consider to be perfectly undetermined. As yet there is nothing more than individual conviction to show that, were equal numbers of patients 1 St. George's Hospital Reports, vol. vi. , p. 48. 2 Central Blatt fiir medizinische Wisseuschaft, July 1, 1876. Quoted in Medical Times and Gazette, vol. ii., p. 163. 1876. 96 ON GONORRHOEA. submitted to the same treatment, those who were in addition treated with cold applications would derive more benefit than the others ; and therefore, until some evidence of this kind can be produced, the patient should not be subjected to the trouble and expense of using them, and a fair trial should be made to see if the rest generally observed is not the real source of relief. My experience is that they are valueless. 2. Hot Applications. Eicord condemns the hot bath, as Howard did long previously, 1 as being liable to promote the outbreak or occasion the reappearance of the discharge. 2 Fournier maintains 8 the same opinion about any bath. With respect to such a contingency, I would remark that it may be a very possible occurrence in France, among the rather inflamma- ble youths seen occasionally at the Hopital du Midi, in whom I should say being affected with gonorrhoea was rather the normal state than other- wise ; but so far as my own observation goes, I never saw or heard of an authentic instance in which hot baths exerted any prejudicial influence over the course of gonorrhoea. Prior to bringing out the first edition of this work I made a careful series of observations, and could not verify these opinions about the injuri- ous effect of hot baths in a single instance. Blank forms were prepared like the following, and mostly filled up only from cases seen every day ; and it may perhaps save some repetition if I state here, that all the reme- dies, spoken of in this work as having been tested by myself, were experi- mented upon in this way. Form for Calculating Action of Remedies. Name A. B. Date Feels ! Better. Worse, etc. Discharge Lessening. Increased. Much the same. Not lessened. Erections Troublesome. More troublesome. Bladder Not irritable. Irritable. Urine Acid. Acidity lessened. Bowels Open. Costive. Tongue Clean. Foul Has made the running thin- Has not acted. Effects of injections ner ; has acted freely. Moderate heat on making Pain and burning for two Effects of baths water. Thought it relieved scald- hours after. Noticed no benefit. General remarks ing, etc. Patient on the whole pro- No progress. gressing favorably. On such data alone was any reliance placed, and after destroying all the incomplete returns and computing the results, it was not found that 1 Op. citat., voL iii., p. 61. "Traite Pratique, p. 667. 3 Nouveau Dictionnaire, tome v. , p. 152. TEEATMENT. 97 the warm bath had ever- induced the slightest unfavorable change in the character of the purulent discharge. Experience continually tends to rat- ify the verdict first arrived at. I had under rne a patient who took quite forty baths, each one at 100, and I was not able to detect the least ex- asperation of the disease. But I believe the bath to be equally powerless for good, so far as con- cerns the cure of the running. It relieves the uneasy sensations in the urethra, perineum, and testicles which often depress patients, especially nervous persons and delicate subjects, but I never had reason to think that it shortened the duration of the gonorrhoea by an hour. In a report l of the cases treated at the Liverpool workhouse, it is stated that the use of the warm bath has been found to lessen the term of gonorrhoea in the female ; Mi*. Phillips, who seems to have been very successful in his treat- ment, recommends " that hot baths should be used every day for many hours ; and M. Diday, who has had good opportunities for knowing what the success of M. Ricord's treatment has really been, and who is as much opposed to him on this point as one man can well be to another, carries the practice almost as far as Mr. Phillips. In the irrepressible stage, as he calls it, he advises several cold local baths a day. Should the symp- toms become more pronounced, the patient is to take every second even- ing a hot bath for an hour and a half at a time, and two or three times a day a lukewarm local bath of mallow tea ; in still more severe cases he recommends full-length baths daily for two or three hours, and multiplies the mallow-water baths. I suppose, then, these gentlemen have really found some benefit from the practice, but I can only adhere to what I have said ; I admit, however, that it possesses one advantage ; it must help to relieve the ennui entailed by confinement. A patient who has to spend two or three hours daily in a bath, and foment several times with infusion of mallow, to take a fair amount of medicine and two litres of ptisan, has a nucleus of useful occupation provided for him. Contrary to the opinion of the observers just mentioned, I have seen ground for thinking that all the beneficial effect of the practice may be attained by a stay in the bath of two minutes. Thus restricted, I con- stantly employ it, particularly when the patient suffers much from scald- ing, or is very sensitive to the action of injections. I always recommend that it should be taken on an empty stomach, that the heat should be quite 98 to 100 Fahr., and that, if the weather be very inclement and the patient liable to catch cold, he should have the bath in the even- ing and go straight home after it, remaining there till next day. But the external application which I like best, and which is at once simple and useful, while it is more attainable and less expensive than 1 Medical Times and Gazette, vol. ii., p. 335. 1861. 11 A Treatise on the Urethra, etc., p. 88. 1832. 98 ON GONOBEHCEA. the hot bath, is that of very hot water to the penis. To do any good, however, the water must be hot, not lukewarm, and when the case is very severe, it should be used at such a temperature as to make the penis quite red. When thus employed, and especially in the earlier stages of the disease, the weight felt about the testicles soon disappears, the pain on making water and using injections is soothed, and the glans and pre- puce lose their unhealthy appearance. The best plan of employing it is, I think, the following : The patient should stand over a slop-pail, holding a small basin brimful of very hot water in his left hand. With the right hand he should lift up the penis by the skin of the upper part, and just allow the lower surface to come in contact with the fluid, which must be of such a temperature that the patient cannot bear the contact of it for more than an instant at a time. When there is uneasiness about the perineum, he should roll up a piece of rag, flannel if possible, into a ball about the size of a walnut, tie this firmly to a small piece of firewood, dip the ball in almost boiling water, dash off the drops, and press it against the perineum ; or sit lightly down upon a sponge, just taken out of boiling water and put on a cane-bottomed chair over a slop-pail. This practice, recom- mended in the earlier editions of this work, has since then received the approval of Bumstead, 1 Durkee," and Lee, 3 who distinctly state that its merits have not been overrated. Were it no way superior in its effects to other applications, it would far surpass them in point of convenience. No smell, no mess, no cumbersome apparatus. A piece of sponge, or a rag, and a little hot water suffice. 3. Sedative Applications. This simplicity, on which its value is in some measure dependent, vanishes the moment we essay to increase its efficacy, by adding such things as decoction of poppies, solution of opium, lauda- num, etc. Now as one grain of opium taken internally will really allay any pain the patient may feel more effectually than the most elaborate messes, I should be glad to know if it is not high time that the employment of such filthy concoctions should be summarily put down. Why will surgeons per- sist in trying again and again some useless compound which has failed a thousand times, which can only add to the patient's discomfort, complicate treatment, and waste time ; which must dirty the linen, sheets, etc. ? Is it because routine, tradition, and authorities say that something of this kind must be done ? I wish some of our physiologists would condescend to be useful, and, leaving off the elaborate experiments on dogs and cats, frogs and guinea- pigs, would try at least to give us a satisfactory explanation of some mat- ters we know very little of, such, for instance, as the action of heat and cold on inflamed surfaces* All I have been able to make out is, that in slight 1 Op. citat., p. 79. 2 0p. citat., p. 32. 3 Op. citat., p. 207. TREATMENT. 99 inflammations cold is often more beneficial than heat, especially if the mere outward surface is inflamed ; but if deeper structures be involved, the ap- plication of heat is more useful. Even here there are contradictions I have never seen explained. For instance, if the penis be exposed to cold air during the acute stage of gonorrhoea, an exacerbation is apt to follow, but if the organ be kept cool and moist, the very opposite result ensues ; again, if it be kept too warm, an aggravation of all the symptoms, especially of the chordee, sets in, while the free use of scalding hot water materially re- lieves all this, and is invaluable in such complications as perineal abscess and sympathetic bubo. Prolonged application of cold water to the interior of the urethra has undoubtedly been of service in gonorrhoea. Evaporating lotions seem to have no effect on this disease, yet, in the wide field of in- flammations, I do not know of one that is affected by any remedy so quickly and certainly as orchitis is by these very compounds. In mammary abscess an increase of pain is often induced by exposure to cold, but if warmth and moisture be applied, relief of the most gratifying kind is experienced. Heat and moisture have the same soothing effect upon whitlow, and under their influence the skin becomes cooler and less uncomfortable. Dry heat, such as that of a hot sun, especially if accompanied by much light, will often rapidly aggravate eczema ; the heat of a furnace is frequently far less inju- rious in this disease than that of a cold wind, and sometimes appears rather beneficial. Some persons, suffering from eczema of the backs of the hands and wrists find that holding them before a bright fire till the skin is almost scorched gives great relief. Bathing an eczematous or erysipelatous surface with hot water seems to me useless or injurious, whereas this applica- tion, properly carried out, is of much service in many forms of inflamma- tion, such as croup, peritonitis, suppurative inflammation of the cellular tissue, etc. Are we to conclude that in some men the urethra, rectum, and adjacent parts are acted on in the same way by cold as they are in others by heat ; or must we believe that, in certain circumstances, any great departure in either direction from the' natural heat of the body is attended with precisely the same effect ? It seems to me that some of the facts bearing upon the influence of great change of temperature on the urethra must demand one of these two solutions. Thus, Sir Benjamin Brodie says, 1 that a gentleman of his acquaintance, who was subject to attacks of retention from stricture, almost always began to pass urine after a pint of warm water had been thrown up as a clyster. I do not cite the effect of the hot bath on the same state, because its power has been disputed by very good observers ; but I have seen the urethra yield to a sudden application of almost boiling water to the penis, after holding an instrument with such firmness that I could not withdraw it till the water was used, when it relaxed directly. I should 1 Works, vol. ii., p. 417. 1865. 100 ON GONOERHCEA. have thought that such facts as these, which any man of great experience could verify for himself, proved that heat does exert a relaxing influence over spasmodic tightening of the urethra. Yet Mr Teevan, in a paper read before the Harveian Society, recommended, in spasmodic retention of the urine, that the rectum should be plugged with ice, as a potent means of overcoming the spasm ; and Sir Thomas Watson says' that "in cases of ex- ternal inflammation, sometimes cold applications are found to be of use, and sometimes warm." C. DIRECT APPLICATIONS. 1. Injections. Variety of Substances Used. A list of the substances recommended for injections within the last few years would perhaps show, more strongly than anything I could say, the discrepancy of opinion that prevails as to which is the best. I therefore give a selection : chloride, tannate, and acetate of zinc, carbolate of zinc, sulphocarbolate of zinc, sulphate of zinc, curing as a rule on the third or fourth day, or even sooner ; nitrate of silver ; acetate of lead ; sulphate and chloride of copper ; the four sulphates (a combination of alum, zinc, iron, and copper) ; iodide and potassio-tartrate of iron, iodide of iron in combi- nation with iron filings, tincture of sesquichloride of iron, solution of per- chloride of iron, solution of persulphate of iron ; oxychloride of tin com- bined with phosphate and tannate of tin : trisnitrate of bismuth ; perni- trate of mercury, perchloride of mercury ; chloride of soda ; chlorate of potass, carbolate of potass, carbolic acid and potass, permanganate of potass, which was said to cure recent attacks of the disease in from one to two days, and only failed twice in 64 cases, being just one day less than was requisite to effect a cure with the chlorate of potass, a period subse- quently extended to twelve days for recent cases alone ; Condy's fluid ; alum, tannate of alumina, succeeding, according to one author, where all the usual injections had failed, and described by another as not more effi- cacious than other kinds of injections ; lime-water, chloride of lime, bisul- phite of lime ; sulphate of cadmium, recommended as calming very rapidly the acute period of blennorrhagia ; tincture of iodine, recommended as having never failed during a ten years' trial ; nitric acid combined with strychnia ; sulphurous acid, curing " in an average of six days ; " tannin, glycerine of tannin, singly and combined with olive-oil and mucilage ; gly- cerine, combined with carbolic acid and tannin ; glycerine and starch ; quinine and glycerine ; matico, subsequently denounced as the last med- icament of the kind we should have recourse to ; eucalyptus emulsion, used, along with boracic acid, to supplement soluble bougies ; starch ; tincture of catechu, solution of catechu in syrup of tolu ; tincture of rha- tany, extract of rhatany ; vinum opii, tincture of opium, watery extract of opium, opium and glycerine ; decoction of poppies ; acetate of morphia ; belladonna ; infusion of Unseed ; chloroform ; hydrate of chloral, intro- 1 Principles and Practice of Physic, vol. i., p. 250. 1857. TREATMENT. 101 duced at least two or three times ; tincture of aloes ; hydrastin ; leptan- drin ; red wine ; copaiba, volatile oil of copaiba, repeatedly tried in vain at the recommendation of previous observers, copaiba water, far more effica- cious than the drug taken internally ; honey ; green tea ; wine ; ice-cold water, lukewarm water, not known to have failed " where the system was adopted at the commencement of the disease and followed throughout," warm water, recommended as curing in from seven to nine days ; earth and water, often curing in two or three days ; kaolin and water ; and retention of the urine by means of a kind of forceps (pince). Though the last can scarcely be considered as an injection it is intended to act in the same way. The reader will be interested to observe that substances of the most opposite nature are equally efficacious in effecting the desired purpose ; curing the case with fabulous rapidity, never failing, and entailing no disa- greeable results whatever. I do not know what he thinks of all thi^^>ut to me it is unsatisfactory in the highest degree. A series of careful experiments, prolonged for at least sixty or seventy years, would be required to examine with anything like accuracy the comparative value of the different substances here recom- mended. I say this quite deliberately, for it took me more than two years, at a time when I was not overburdened with private practice, to satisfy myself, even imperfectly, as to the relative power of three drugs only, namely, the sulphate of zinc, acetate of zinc, and the nitrate of silver. It is certain that there must, only too often, have been a serious mis- take as to the real facts of the case, and that the substances so highly rec- ommended do not possess the virtues ascribed to them. How otherwise did it happen that very competent observers entirely failed to achieve any such success, and that we find such an ominous silence about drugs once vaunted as specifics ? Take the history of permanganate of potass, for ex- ample. Is has been recommended by at least five^ or six writers, some of them quite in position to judge of its value Dr. Rich, of Canada ; ' Dr. Warden, of Haulbowline Hospital ; Dr. Van Versen, of the United States Army ; Mr. Macfie Campbell, of the Dreadnought Hospital, etc. It has been extolled by one author as curing in from one to two days, by another as curing even old cases of forty-five days' average duration in two to ten days, 2 while the failures, taking all the cases together, do not amount to more than one in forty. It is equally adapted to all cases, old or recent, and possesses, in addition, the valuable property of being painless in its operation, or only occasioning very slight inconvenience even in pretty strong solution. Such being the case, the permanganate ought to take rank as the para- gon of remedies for gonorrhoea. Nothing that I have experimented with 1 Edinburgh Medical Journal, September, 1864. 3 Lancet, vol. i., p. 73. 1871. 102 ON GONORRH(EA. approaches it in point of efficacy, and the mystery is that a substance of such power has not come into universal favor, and indeed banished at once every other drug, seeing it would be little less than criminal to go on ordering antiphlogistics and specifics, when we possess a simple and painless remedy, which puts an end to the complaint in six and thirty hours. But now let us hear the other side of the question. According to the evidence here the permanganate, so far from being either a pain- less remedy or a specific, is quite the contrary. Gentlemen worthy of credit distinctly state that its action on the urethra is so strong as to en- tirely deter patients from continuing it. Used in solution a little more than a fourth of the strength recommended as painless, it has been found to give so much pain as to necessitate its abandonment. Mr. Berkeley Hill reports ' that it has been tried rather extensively at the Lock Hospital, and that very few patients have derived benefit from it, a statement cor- roborated, as far as one casein go, by another contributor to the same journal ; * while Dr. Fessenden Otis says 3 he has used this salt in perhaps twenty cases, with the apparent effect of arresting the discharge for a short time, but that he has " invariably been obliged to resort to other means to complete the cure." We hear a great deal about medicine* being an inductive science, but in so far as the therapeutics of gonorrhoea are concerned, the state of mat- ters which has just been laid before the reader is, in some particulars, much more on a level with fortune-telling, or the prophecies in Moore's Almanack, than with science in the proper sense of the word. The reader may think this is going too far ; perhaps it is, but the real authors of this confusion, the medical men who ushered so many useless things into public notice on such insufficient grounds, first of all went a great deal too far in the opposite direction ; and to recommend, in a disease like gonor- rhoea, which will often disappear under a few cold water injections, a remedy on the strength of its having been successful in some few cases, as has repeatedly been done, looks to me quite as haphazard as palmistry or weather-wisdom. I do not wish to convey the impression that it is always so. On the contrary, I am anxious to bear testimony to the value of many contribu- tions on this subject, and in particular to the labors of Mr. de Meric, who examined the action of a remedy in 140 cases before bringing the subject under public notice. 4 The substance experimented with was the trisni- trate of bismuth. A special register was kept of all cases, but owing to the neglect shown by the patients themselves, Mr. de Meric was only able to obtain an account of the results in 52 instances. Out of the 52 there were 'Lancet, vol. i., p. 570. 1871. 5 Ibid., p. 35. 3 Jsew York Journal of Medicine, vol. i., p. 359. 1870. 4 Lancet, vol. i., p. 468. 1860. TREATMENT. 103 36 cured, 5 much better, and 11 not improved at all. Even in those cases which were cured, the patients remained on an average two-and-twenty days under treatment, and this, so far as the injections were concerned, did not begin till the inflammatory stage had subsided. But though the result of the trials was not satisfactory, the author deserves our praise for the candor with which he states this, and the pains he bestowed on the subject ; his paper is of infinitely more value than the vague generalities we often meet with in books, or hasty encomiums which crumble into nothing at the first touch of experiment. I think I am not going too far when I say that the introduction of some of these substances, such as honey, chloroform, quinine, tincture of aloes, creasote, et similia, must be ascribed to some defect in the reasoning powers of the persons who first recommended them, and that any one who could expect to derive benefit from the use of these remedies must be in- capable of forming a sound view of therapeutics ; for what property is there in any one of them which would lead us to infer that it could possess the least power of controlling such a disease as gonorrhoea, or even modi- fying purulent inflammation of any kind ? Only practical experience could of course prove they were worthless ; as might have been expected it did so whenever these wretched tricks were put to the test, but it proved at the same time that they were often most injurious. Some of the persons injected with chloroform suffered severe pain, amounting, it was said, even to agony, for hours, followed by copious discharges of blood from the urethra, and any person who has suffered from the contact of chloroform with his lips knows how severe the pain is which it occasions, and will appreciate the torment these unfortunate patients must have gone through. The pro- fession ought, in my opinion, to have visited with equal 1'eprobation those who perpetrated such shameful experiments, and the journals which lent them the sanction of their columns. I beg to record this as my deliberate opinion. To give, as a mere experiment, an injection producing frightful pain for hours, and copious discharge of blood, is in my judgment a most scandalous act, and if the reader will kindly hold a teaspoonful of one of these chloroform injections in his mouth for a few minutes he will, I think, be of my opinion. I dare say these abominable tricks now and then ef- fected a cure, and so would, perhaps, an injection of pure sulphuric acid, or a red-hot wire, with the additional advantage of preventing any new in- fection by closing up the urethra. Seeing that I never heard an opinion on the subject expressed by any one, I am ignorant whether people think the evil of this dissonance of opinion is past cure, or is so slight a matter as not to require anything be- ing done for it. To me it seems that the introduction of such a host of new remedies, and the irreconcilable difference of opinion as to their value, are proof enough that there is some vital defect in our present method of trying to get at the truth. The basis on which our principles of treatment 104 ON GONORRH(EA. rest must be, indeed, ready at any instant to crumble under our feet, if all the teachings of authority and experience are liable to be overturned, at once, in favor of some new remedy which has not been tested in more than three or four instances. In some cases in the literature of gonorrhrea, there was scarcely even this ground for recommendation, as even a most cursory examination left it very doubtful if the substance in question had exerted any influence whatever ; e.g., the evidence about honey and chloro- form was of this class ; but if we are ever to attain anything like accuracy in medicine, it will be absolutely necessary to have a better system of re- cording cases, the best that I can suggest being what I first suggested quite thirty years ago, a school of experimental medicine, with a system of regis- tration for correcting errors of observation. The disagreement as to the comparative value of different substances for injection has, perhaps naturally enough, extended itself to the strength in which they are to be employed, especially with regard to the nitrate of silver, the recommendations about which exhibit such a variety of opinions, that it is quite impossible to understand how men can have arrived at con- clusions so diametrically opposed. Thus, for instance, while some surgeons find an eighth, a quarter, or half a grain of nitrate of silver to the ounce quite strong enough, others have not hesitated to use solutions of a scru- ple, 1 or even half a drachm, 2 in the same amount of fluid ; and it has been recommended 3 to inject a solution of twenty grains to the ounce not merely once, but as much as twice or even thrice in the twenty-four hours. Even this heroic treatment was not active enough for those surgeons who advise that the solid nitrate should be employed. Cold Water Injections. But whatever the merits or demerits of the nu- merous substances and systems just passed in review, they ought now to become things of the past, the progress of that oblivion, which sooner or later conducts most of them to one common tomb, having been not only accelerated in its speed but extended in its sphere of operation by a dis- covery which threatens to supersede all former treatment and to extin- guish all interest in the pathology of gonorrhoea ; for who would waste his time in studying a disease which is almost always cured at a single sitting, and never lasts more than a few days ? For such are the results obtained by Dr. Morris, of Kentucky. 4 He introduces a catheter with a large olive- shaped bulb, the latter being pierced at the shoulders and closed at the point, so that the fluid injected flows outward and backward, not into the bladder. The catheter being introduced, a pump-syringe is connected with it, and about a gallon of water is pumped into the urethra ; after this a solution of sulphate of zinc is injected by means of a "penis syringe." 1 Judd : Op. citat. , p. 6. 8 Outlines of Military Surgery. By Sir George Ballingall ; p. 513. 1855. 3 Berkeley Hill : Op. citat. , p. 387. 4 Southern Medical Record. Quoted in British Medical Journal, vol. i , p. 194. 1882. TREATMENT. 105 The results are miraculous. Out of twenty-five cases twenty-two were cured in twenty-four hours ; one in three days, and another in seven ; while that of a drinker, who continued his evil courses when under treatment, resisted the magical power of the remedies for fourteen days. I at once admit that I never heard of any success comparable to this ; the achievements of the injections which cure in two or three days fade into insignificance before such results ; and gonorrhoea may now be struck out from the list of troublesome disorders. When I was studying this dis- ease in the hospitals, and through the kindness of some Mends had access to a practically unlimited number of out-patients, I never once saw two successive cases cured in the same space of time ; and never saw many cases of recent infection in succession without meeting with one, where the urethra was so inflamed and tender, that the most gentle introduction of the silver tubed syringe was followed by great pain and faintness, neither of which seem to have occurred in Dr. Morris's practice. The method was, however, tried long since, Mr. Windsor tells us, 1 first apparently by M. Reliquet, who as far back as 1866 recommended continu- ous irrigation by means of a small catheter, kept up for half an hour to two hours ; then three years later by Dr. Hewsou, who employed a double catheter; in 1870 by Mi-. Durham, and again in 1871 by Mr. Windsor," who used an enema ball and tube, the ivory end being replaced by a glass cylinder, by means of which he irrigated the first three or four inches of the urethra with cold water or weak solution of permanganate of potass, the results being highly satisfactory. Can Injections bring on Stricture and Orchitis ? To this pertinent in- quiry the most unhesitating denial may be given, provided the injections be suitably used. Stricture occurs by far the most frequently among those who have been treated only with medicines, or with medicines and injec- tions given in a very inefficient manner, and is so rare among those treated with injections properly given, that in the course of many years I have never been able to trace a single case to this source. Mr. Phillips found 3 that, while out of 119 cases 117 had been preceded by urethra! discharge, astrin- gent injections had only been used in 49 out of the latter set of cases. One would suppose that those surgeons who object to their use on this ground would have adduced some facts in proof. All these disorders are so common that, with ordinary industry, any writer might have accumula- ted materials enough to support his views. But, instead of doing this, they content themselves with detailing their fears of what ought to follow ; they never appear to dream of relying solely upon a critical analysis of what has followed the use of such means, and seem entirely to have lost sight of the fact that the evidence of some of our best observers, of men like Hunter, 1 The Liverpool and Manchester Medical and Surgical Reports, p. 16. 1873. 8 The Manchester Medical and Surgical Reports, p. 52. 1871. 3 Op. citat, p. 226. 106 ON GONORRHCEA. Whateley, Babington, and Ricord, is to the effect that contraction of the canal does not result from their employment. One source of error often meets us here. A patient contracts a gonor- rhoea and uses injections for it, perhaps also takes copaiba, cubebs, or some- thing of that kind. After a time the disease gets well. By-and-by the patient contracts another infection, and this, or perhaps a third, fourth, or a fifth proves obstinate ; the surgeon passes down a bougie and finds a stiicture. Now any one who sees many of these cases is apt, however im- partial, to think that, after all, there may be some truth in the patient's opinion that the narrowing was brought about by the injections. And this much must be conceded. In very irritable systems over injecting with quite a short syringe may stimulate distant portions of the urethra, and possibly lay the foundation of stricture, even though not a drop of the fluid ever goes near the site where this afterward springs up. Thus I was con- sulted by a gentleman who had been under the care of a well-known sur- geon. The surgeon had ordered him a very mild injection of nitrate of silver, which the patient had, on his own responsibility, made much milder, reducing it to about one-eighth of a grain to the ounce. This he threw up several times daily, and then, as the disease did not get better, came to me. The symptoms did not seem to have ever been severe, and there was clearly not much the matter with him. I therefore wanted to give him an injec- tion of a grain to an ounce, and to use it myself, so as to try if I could end the affair at once. He did not so much object to the strength of the solu- tion, as to the idea of any person but himself inserting an instrument into his urethra, and I had to content myself with letting him use the injection, which he assured me he could do perfectly well. I found, however, that he only allowed the point of the syringe to go about a third of an inch down the channel of the urethra, and that the whole of the fluid streamed out as fast as it was thrown in. I told him it was no use to inject in that way, but he was convinced that the method had so far worked well, and that it would suffice for what remained of the disease, so he continued it. A few days after I received a letter from him, saying he was suffering from great irritability of the bladder and difficulty in making water ; he therefore asked me to see him at once. After he had taken a hot bath I passed down a number eight gum elastic bougie. About four and a half inches down the instrument encountered a very tender spot, and there was some difficulty in getting farther. It was here, the patient said, that he found the obstacle to making water. After twice passing the bougie I detached, almost certainly from this spot, a clot of mucus as large as an extremely small nut. It was ragged in outline, grayish, and speckled with a darker color, much as we see in patches of mucus expelled from the trachea. The extrusion of this mucus was succeeded by speedy relief, and passing the bougie once or twice more, followed by a couple of injec- tions with a long syringe, completed the cure. TREATMENT. 107 Now I consider I am warranted in assuming that, in this case, the in- jection aggravated a slight, localized inflammation, already existing at the part of the urethra from which the mucus came away. The symptoms were more severe, and rose more rapidly to a height than happens in such cases when no injections have been used. But I think it is pretty clear that what mischief was done by the injecting must be put down to the irritation set up at the mouth of the urethra, and not to the action of the fluid, as none of it could have reached within four inches of the tender part. I think too, after weighing ah 1 the circumstances of the case, that it is very probable stricture might have sprung up at the spot from which the mucus came. Some amount of temporary narrowing had indeed al- ready begun. A gentleman, who had previously suffered severely from gonorrhoea, contracted a fresh discharge while travelling in Belgium. Desirous to cut it short as quickly as he could, he procured some "bru" and injected it several times a day with a short syringe. At the end of a few days he be- gan to suffer from extreme irritability of the bladder, difficulty in making water, bleeding after micturition, dull pain over the loins, languor and loss of appetite. In this state he returned to England, and almost directly after his arrival consulted me. I found him very low, with a weak quick pulse, a thickly coated tongue and almost total loss of appetite. A speci- men of urine, which he brought, was almost chocolate colored from hema- turia, and this state of the fluid continued for nearly a fortnight. A num- ber six bougie passed with great difficulty. Two or three years previously I had several times passed a large sized instrument with ease. I could add more cases, of which I have seen several, but I pass on to the consideration of another fact of which I have also seen several instances, which is that over-injecting with a short syringe will sometimes bring on spasmodic stricture, great irritability of the posterior part of the urethra, and a good deal of constitutional disturbance, even when there is not and has never been any gonorrhoea. Thus a gentleman was recommended to inject himself, for spermatorrhoea, with the long urethra! syringe ; but not feeling at all assured as to the possible results, he left out the detached tube and injected with the syringe only. He had only done this " once or twice," according to his account, " at an interval of a day or two," when he was attacked with pain about the prostate, considerable difficulty in making water, great disturbance of general health, loss of appetite, head- ache, and vomiting. Of course there are many cases to which such an explanation as that given of the first case would not apply ; those for instance where the nitrate solu- tion is applied all over the urethra. Here I believe the explanation of the problem is to be found in the inability of nitrate of silver to cure gonorrhoea without the aid of other means. My conclusion would be, that the con- traction is not caused by the employment of the nitrate, but that it invari- 108 ON GONORRH 5 I Jan. 10 ...- 8 I - 8 46*0 347 S.W. 0'12 9 2 10 2 ' 12 2 I > Jan. 17 ... 13 14 I 2 I - 8 Sr8 4r5 s.w. I- 7 6 15 I Jan. 24 ... 21 | ... i 45' 2 35'9 S.W. '44 26 I Jan. '31 ... 27 28 I I I ... - 5 49-0 36-1 S.W. 0'54 31 I ... 2 2 Feb. 7 ... 3 5 I I - 5 53-2 41-9 W.S.W. 0-32 7 I 9 3 1 Feb. 14... 10 12 2 2 I 10 46-4 33'3 N. and S., S.E. O'22 13 I Feb. 3i ... 16 19 I I 2 4 46-1, 33-8 W. and N. 0-03 Feb. 28... 23 26 2 2 I 5 45-i 327 N.E. O'i6 i I March 6...- 3 I .., - 3 45-6 283 N, and E. 0'02 6 I 8 I March 13 - 10 12 2 I I I 9 49'9 32-3 N.E. O'OO 13 I I I 16 I March 20 - 17 18 3 4 487 33*2 N.E. O'OO 20 . . . ,., 22 i 2 3 I March 27 - 2 4 i I .. 6 $6-4 32-4 S.E. and N.E. O'OO 2 S i - 26 i .,. 176 ON GONORRHOEA. Week ending V St, Bartholomew's Hospital. St. Thomas's Hos- pital. 1i V V S Total Number. Mean highest Temperature in the Week. Mean lowest Temperature ia the Week. General Direction of Wind. Sum of Rainfall in inches. April'3 ... j I 2 ... 3 i ... 4 527 34-5 E, N., E. 0*12 April 10... 8 2 .. 2 56-3 33'3 E. and N.E. O'OO April 17... j 12 14 3 ... 1 I 5 60-0 33'4 E. and N.E. O'OO April 24... -j 19 21 23 3 i I > > 57*9 34'9 N.E. and E. O'OO May i ... 26 29 2 I ... 3 60-8 38-0 (i) 0*52 May 8 ...J 4 6 8 2 I I "* 60- 1 35' N.E. and S.W. croo May 15 ... j II 13 ... I I ' i 63-6 457 S.W. 0-30 16 ... I ... May 22 ... 17 19 I I I . I 7 66-3 47*3 (3) 0-84 21 ... 2 24 ... I I May 29 ... 25 28 2 I I 8 587 46-3 N. 0-87 29 2 ... ... 31 I ... ... June S .. - I 2 ... ... 5 637 43'4 S.W. and S. O'20 S I ... I June 12... 7 I ...- ... i 62-8 49-6 S.E. and S.W. 2'63 14 I June 19...- 15. 17 ; I I ' 66-4 49*0 S.W. and S.S.E. 1-09 . 19 I ... ... 21 I I 4.. June 26...- 22 I ... 4 69-5 50-4 S. and S.W. '54 \ 24 28 30 I I I ... 2 (3) 107 52-0 S.W. 0*09 July 10 ... 5 I ... ... I 86-2 57'3 S.E. O'OO July 19 ...J 12 13 15 4 I I ... ... }' 81-9 57'3 N.E. 0-27, ( I ) Generally calm ; most prevalent direction E. and N. ( 2 ) E. and N. prevailing. ( 3 ) The correctness of these entries is doubtful. TREATMENT. 177 . .5 *> o U 4J .5 c V K h. . t! u . v w _ 3 Jl ." . c~a J "Ss"" o H .5 A 1852. Week ending I! is'P 1 E rt O. u Is General Direction of Wind. &\ J3 V N H "3 s S ** S S" - el o o H H 3 Q tn w * H OT July 24 ... 19 22 I I i * 79*3 547 (0 O'OI July 31 -I 26 27 2 9 3 2 .-. j f 78-5 55-6 N.E. and N. 2-04 ( 31 I ... 3 5 August 7 4 i I - 8 74'4 53'4 S. I '01 5 i 9 i August 14 - 10 i 4 70*2 _7 S.W. 4-48 ii i I 16 2 August 21 18 I - 5 70-9 56-6 (2) rqi 19 I I August 28 27 28 I I 2 75'3 57T N., N.E.,andS.W. QUO i 30 I Sept. 4 ...-I 2 I I ... - 6 73'9 Si-9 S.W. and S.E. O'OO I 3 2 I 6 I 8 2 I 9 I 9 69-2 55'9 N. i '40 10 2 ii 2 14 I I 3 64*5 45-8 (3) 0-85 16 I 20 I 23 I I - 4 64-0 46-5 S.W. o-oo 24 I ... f 27 2 I 29 I Oct. 2 ...\ 30 3 ... ('i') 13 6r8 43'4 N.E. and S.W. i'3> 1 i ... ( 2 4 I . &. 7 I \ 5 ? 2 r 8 53'4 41-3 S.W. and N.W. rog 6 2 J ( i ) Variable ; S. and W. prevailing. ( 2 ) Variable ; much calm ; N. and W. prevailing. ( 3 ) Calm ; W. prevailing. ( 4 ) One of these is said to have occurred from stricture. 12 178 ON GONOKRHCEA. 1852. Week ending 1 St. Bartholomew's Hospital. ' St Thomas's Hos- pital. S .3 '3. s Total Number. Mean highest Temperature In the Week. Mean lowest Temperature in. the Week. General Direction of Wind. Sum of Rainfall in inches. | II I ... ... ^ Oct. 16 ... 12 15 I V ... 4 557 41-2 N.E. 0*03 16 I ... ... J 18 2 ... 19 I ... ... Oct. '23 ... 20 21 I 4 ... ... 12 59-6 39'9 N.E. and S.W. 0-42 22 2 ... i , 23 I ... ... . ' 25 3 ... ... 11 26 2 ... i Oct. 30 ...- 28 3 ... ... ' 13 52-0 40-5 S.W. and N.W. 2'OI 29 2 I ... . 3 I ... . i 2 ... ... 2 2 2 Nov. 6 ... 3 4 1 I ... 10? 607 48-0 S.W. 0-84 5 I V (O ... 6 I J 8 I i > 10 2 ... ... Nov. 13... ii 3 ... 9 49-2 43' S.W. and N.E. 1-30 12 i ... 13 i ... ... j 15 2 ... ... } Nov. 20...* 10 17 2 3 i 9 SS-o 45-i S.W. 177 19 i ) 21 2 ... i.. ~\ 22 I ... I Nov. 27...- 24 2 ... 8 51-0 40-6 N. and S.W. 1-46 25 I ... ... 27 I ... ... J f .29 I "... I 1 3 i Dec. 4 ...^ i I 2 ... r IS 47 -o 37'5 S.W. 0-33 3 2 I I I 4 3 2 j ( i ) These entries are uncertain ; the MS. by my amanuensis not being very reliable in this part. TREATMENT. 179 1852. Week ending *j Bartholomew's Hospital. Thomas's Hos- pital. tropolitan Free Hospital. :al Number. Vlean highest emperature in the Week. Mean lowest 'emperature in the Week. General Direction of Wind. a of Rainfall in inches. 5 ^ V o "H H A oi to 2 H CO 5 6 6 ... I Dec, -i i...- 7 2 ... I 17 S3'i 46^ s.w. o'6i 8 3 ... ii 3 I ... 14 3 I ... 1 15 I Dec. 18...- 16 I ... - 8 53'i 43'8 S. and S.W. 0'59 17 I 18 i ... j (i) Dec. 25 ... 20 21 i I 2 Si'9 40*5 (2) o'os 1853- 27 I >! 28 2 ... Jan. i ...- 29 30 2 I 8 517 41-8 S.W. 0'43 31 I ... I I ... ... . ' 2 I ... 3 3 JanS *.. 4 3 3 I I J4 51-2 39'i S,W, 071 6 ,.. I k . 7 i ... . ' 10 i 12 i .1. I Jan. 15 ...- 13 I 2 13 50-5 39'S S.W. o'4S 14 ... I ... . 15 2 4 ... . 17 2 ... IS I i Jan. 22 ... 19 2 8 47-2 36-1 N.W.-andS.W o'59 20 I . 22 I . . . t 24 2 ... 25 i Jan. 29 ...- 26 27 2 i 8 47 34'6 N.E. 0-007 28 I 29 i ... ( I ) For these last five weeks, no electricity shown by any instruments. For the next three weeks no record given, the electrical apparatus having been injured by a gale, which I regret, as the sudden rise might have been compared with the results. ( 2 ) Much calm ; S. and W. prevailing. 180 ON GONOKEHCEA. 1853. Weekending 1 St. Bartholomew's Hospital. St. Thomas's Hos- pital. E 1 V S Total Number. Mean highest Temperature in the Week. Mean lowest Temperature in the Week. General Direction of Wind. Sum of Rainfall in inches. Feb. 5 ...- 2 4 2 I I I ... , -12-3 32-0 (I) O'2O 5 I I 7 I ' 8 2 ... ... Feb. 12 j9 3 ... ... 9 39'5 3 r S S.E. and N.N.E. O'O6 ii i I 12 i 14 2 I IS 2 I I Feb. 19... 16 2 ... J 3S'S 26-1 N. 0'33 18 I 2 ... 19 I ... 21 I I 2 22 2 ... Feb. 26...- 23 24 I I I 17 39*8 28-0 N. 0-39 25 3 4 ... 26 I ... 28 2 ... ... I I I ... March 5...- 2 3 I I I 2 ii 42-8 297 (2) 0-68 4 I ... .... (3) 5 I ... ... 8 2 ^. ... ' March 12 - 9 ... ... 1 4 53-8 37'i (4) 0-17 10 ... I ..-. 13 2 M .-. * 14 ... I ... March 19 IS 17 3 I ... 9 447 3ix> NE. 0-51 18 I ... 19 i ... ... , 21 I ' March 26 22 i I I 6 417 26*0 N.E. O'lO 26 '" 2 ... ( I ) Much calm : N. and E. prevailing ( 2 ) Variable ; from all points of the compass. { 3 ) Electricity was only shown once this week and once the week before, jreek before that there was none. ( 4 ) Almost always calm. The TREATMENT. 181 ji> . ( V .S 1 m 4~l ^* e i E . ij s ' - " . "3 E o 5 i? 1 . a S tc ^ & 3 "c * fH&3- Week ending V 1'S. t a 03 S"5 j-s. H -'5. F e 3 K 1 ! " c u- 5 I II General Direction* of Wind. II u. n o 1 " g I ^ -.S -' 5 . tn ii li-^ J! .x 3 a j. 1853- . Week ending "o'S. .e g f! ^'s* | a V ^ rt O- u 8 " c Jj? General Direction of.WindJ a-s <~.s ; H H gW a w g^ SS^ "* rt V o E~t H H Q n s H W f 25 i i July 30 ...j 27 29 2 2 i I 9 70-2 S4'8 S.W. r39 I 30 i ~.. f I I 2 2 2 2 August 6 < 4 I ii 73'3 52-3 S.W. and calm O'OI 5 I / \ I 6 2 ' ' 8 2 I > 9 I August 13 10 ii I I 8 73'5 Si'4 ('2) O'OO 12 I ,, 13 I .... . 15 I ' Augusi 20 - 16 17 20 I 2 I I 6 < 70*4 53-8 N. and S.W. 0-59 / 21 I August 27 -! 22 23 I 3 6 67-8 SI'S SiW. and N. 1-50 I 27 ..-. i , ( 3 ) Sept. 3 - j 29 3 2 2(4) * .... 4 V %/ / 65-6 48-4 S.W. 1-03 [ 5 6 I 2 i (5) Sept. 10... 4 7 I I f 5 65-9 49-6, N. 0'22 9 4 I i I 10 3 . 12 2 ... 1 13 I 14 15 I I I ... 9 677 487 (6) 0'57 16 I i 17 I .. . J ( I ) Electricity mostly positive } and tension weak or moderate. ( 2 ) Principally E. ( 3 ) Both this week and last the electricity was much more active, both positive and negative. Tension strong or moderate. ( 4 ) These are called " swelled testicle " in the book. ) Electricity always positive ; tension mostly moderate, sometimes very strong. ) Much calm ; E. rather prevailing. 184 ON GONOKRHCEA. ..1853. \7sek ending V St. Bartholomew's 1 Hospital. St. Thomas's Hos- pital. 1 sHi F Total Number. Mean highest Temperature in the Week. Mean lowest Temperature in the Week. General Direction of Wind. Sum of Rainfall in inches. r 19 I I > 20 I ... '.. Sept. 24... 21 22 ... I I 8 65-9 44*9 W. 0-19 23 i I 24 I i j 26 3 I ... i 27 2 Oct. i .... 28 I i II 62'I 44' * s.w. O'6o 29 I , . , I 2 ^ ' 3 2 2 4 I i Oct. 8 ...- 5 I ... 10 56-3 4^3 Calm 1-03 7 I . . . 8 I I ... r 10 I 3 (_ \ 2 1 ii I 2 * / Oct. 15 ...4 13 I ... 13 60-9 45'2 Calm and N.E. 0-94 14 2 i I I 5 I 17 I I 18 2 Oct. 22 ...- 19 I ... 8 57'3 417 S.W. no 20 I 22 I I ... r 24 3 25 i ... ... Oct. 29 ...^ 27 i I 10 62 4 9 49'4 ... ... 1*46 28 ... ... I I 29 2 I ... ' 31 I ... ... I 2 2 ... Nov. 5 ...- 2 3 2 4 I ... 17 56-1 42-8 S.E. 0-03 4 2 ... ... (3) * 5 I 2 ... ( I ) With the exception of a small amount of positive electricity at 3 a,m. on Saturday, none was shown throughout the week. ( 2 ) No electricity was shown during the preceding week, or during the first days of this week, after which the apparatus is again reported " under repair." ( 3 ) During four days of this week, and three days of the week preceding, the electrical apparatus was out of repair. On every other day, and during the whole of the week ending November 12, it showed positive electricity, the tension being strong towards the close of this time. TKEATMENT. 185 , V ,e '$ Jj M M -S "* V K h *" "rt Is ~ 1 "S = 8 % 3^ *853- "Week ending 11 1-1 ft 8 53 2 2 g &0 ii* S a S General Direction of Wind. .1 V a K H "3 o $ |l S^ u c-S *l o' I o (55 w S H M / 7 2 i V NOT. 12...- 10 II 3 3 2 I 1 ^ 527 39-2 Calm o'o6 12 i 2 ) ' 13 i " 14 2 Nov. 19... 15 16 I I i i IO 48-8 SI'S Calm and variable 0*00 17 I I ... 18 I .., . 22 2 ... ' 23 I I ... Nov. 26 ... 24 ... I ... 7 43'9 30-8 Calm 1-25 25 ... I ... . 26 ... I ... _ 28 ... 2 ' 29 ... I Dec. 3 ...- 3 I I I I i 10 457 347 <> 1-05 2 I ... 3 I I ... ^ ^ 5 I I ... ' (2) Dec. 10...- 6 7 I 3 I 2 i - 12 35'9 ..f O'lJ 9 i i ii i ' (3) 12 2 I i Dec. 17 ... 13 I 8 37-8 27-6 N.E. 0-12 14 I 16 I 18 I - 19 I I Dec. 24...- 20 21 ... 2 I i 10 35'9 29-8 N.E. O'lO 22 ... I 24 2 . 26 I < 27 ... 2 i Dec. 31...- 28 29 I I c.. 10 35-J 23-6 O'i6 30 I 2 31 ... I ( I ) Much calm ; E. prevailing. ( 2 ) Positive and tension very strong during last three weeks; declines this week. ( 3 ) Electricity positive and strong. 186 ON GONOREHCEA. The entire number of cases then, obtained in 1852 was 309 ; and for 1853, 535. On consulting the table for 1852, it will be found that there was a slight but steady rise up to the end of the third quarter of the year, when the proportion increased so rapidly that in October there were nearly twice as many cases as in the highest of the preceding months. The greatest number in any one week occurred in the second week of Decem- ber, and the next greatest number in the first week of the same month. The minimum of cases ensued in June, April, July, and August. In 1853 the maximum was attained in July which, it will be seen, yields 70 cases ; next to this stand October, giving 52, and January, which gives 51. The lowest number is met with in March, August, May, September, and June, which possess an average of less than 34 ; while January, April, and November show about one-third as much again. Along with this table the reader will find one of the weather for those two years, and will thus have an opportunity of forming his opinion from facts. Whether changes in the electric state of the air have anything to do with the presence of orchitis, is more than I know. . I certainly suspect they have, far more so at any rate than heat or cold, the influence of which in producing disorders is, to my thinking, quite overrated. In the present instance it will be seen that, during the greater part of the first eight months of 1852, the number of cases is exceedingly small. Now during far the greater part of this time, week after week, the electricity is reported as positive with moderate tension, the number of days on which negative electricity was shown being very few indeed. In the second week of Sep- tember, the number of cases is greater than had been noted for a long time, and the electricity is reported negative and very active. Immediately after this there is a fall in the number, and the electricity is again marked positive and active. Then, after a slight wavering, a great increase in the number of cases will be found for many weeks after, and from this time till Christmas the reports give "no electricity at all." But here, unfor- tunately, the clue of the investigation is lost, for the electrical apparatus was so damaged by a gale of wind that a long time elapsed before it could be set to work again. An opinion that gonorrhoea is more liable to relapse at certain times of the year than at others, has been advanced by some authors ; M. Robert says that the spring seems greatly to favor relapses, and I have fancied I detected something of the tendency myself during the prevalence of cold, dry, east winds. The question, however, is difficult to settle till we have much better data. If the mere revolution of seasons influenced the num- ber of cases, we might expect a regularly recurring increase in spring, and of this I have not as yet seen any proof worth notice. We do not possess such full information as might be wished with respect to the proportion of gonorrhoea patients attacked by orchitis. M. Le Fort gives it at 129 to 914, the latter being all cases of first infections, but this TREATMENT. 187 is very much higher than anything I have seen. Castelnau found 1 the proportion to be as high as 1 in 4, or 265 in 1,172, while Gaussail computed the relative numbers at 1 to 10, and Fournier at 1 to 8 or 9 ; figures much more in accordance with my own observations than those of the two first authors. From a table by M. Castelnau 2 of 239 cases, we learn that the affection appeared in the 1st week of the gonorrhcea 16 times, in the 2d 34, in the 3d 24, in the 4th 39, in the 5th 54, in the 6th and later 72 ; whereas Fournier in 206 cases found none in the 1st week and only two on the 8th and 9th day. M. Despres holds 3 that relapsing orchitis is due to retention of the semen in the testicles. The cause of this does not always exist at the same point, but it is more than probable that swelling of the mucous mem- brane of the ejaculatory duct or of the vas deferens, or even peripheral swelling of the prostate or of the mucous membrane of the urethra, may induce the retention of the seminal fluid. As suppuration is so rare in orchitis, the affection might very well be called spermatic engorgement of the testicle, just as retention of the milk in the mamma is called lacteal engorgement, a suggestion of doubtful utility till we feel quite assured that we have mastered the pathology of the disease. Orchitis of this kind ensues after cutting for the stone. With proper deference to M. Despres, it seems to me that the action is purely reflex ; but I agree with him in this much, that I think a great deal of the morbid action we are called upon to meet begins with spasm, a doctrine long ago laid down by myself in earlier editions of this work. Prognosis. Always favorable when the affection is taken in time and the patient endowed with reasonable prudence and perseverance ; qualities, however, not unfrequently wanting. Extensive effusion into the vaginal sac and hardening of the cauda epididymis may prove very obstinate, especially if not duly attended to, but all their more serious results can always be removed. Results. Among these are enumerated death, neuralgia of the organ as also of the pudenda! plexus, 4 intense tenderness, setting up a fixed desire to have the gland removed, 5 tuberculous deposit, cancer, 6 abscess, effusion more or less extensive into the vaginal sac, suppuration in this cavity, 7 sphacelus of the testicle from inflammation attacking essentially the body of this organ/ destruction of the seminiferous tubes, 9 wasting of 1 Op. citat. p. 197. 2 Ibid., p. 199, 3 Gazette des Hopitaux, p. 965. 1878. 4 Zeissl : Wiener medizinische Zeitung-, 1870. Quoted in the Archiv fur Derma- tologie, B. iii., S. 413. 5 Lectures of Sir Astley Cooper, vol. ii., p. 155. 1825. "Robert: Op. citat., p. 221; Phillips: Op. citat, p. 120. 1 Johnson: Op. citat., p. 193. "Nouveau Dictioiinaire de Medecine, tome v., p. 222. 1866. 9 The Structure and Diseases of the Testis, part ii. , p. 23. By Sir Astley Cooper. 188 ON GONORRHCEA. the testis, and impotence. Only two authors, I think, mention death as a consequence, so that it must be very rare. I quite concur in what Roki- tansky says as to neuralgia being a rare result. I have often seen a good deal of weary aching and pain in the testicles follow gonorrhoea, and still more frequently if complicated by a sudden outbreak of spermatorrhoea, but I never saw orchitis end in what I should call genuine neuralgia of the testis. The connection of the two is, indeed, in no way established : and as to carcinoma, we may almost class it with the prejudices of a bygone age. If such an occurrence had been at all common, we ought to have had some proofs of it before now. The absorbent vessels of the penis and scrotum, we are told, may become inflamed on such occasions ; I have not seen this. Of sphacelus of the testicle I can say nothing from personal experience, having never seen such a termination of the disorder, though, like others, I have had to treat the latter. According to M. Fournier, who gives a very clear account of it, the unfortunate issue of the case is marked by sudden cessation of the " atrocious " pain which accompanies its earlier stages. M. Mauriac, in a series of exhaustive papers, 1 gives a very full account of the nervous pains set up by orchitis in the hypogastrium, groin, posterior crural region, waist, lower and front part of belly, sacro-iliac articulations, thighs, loins, etc. ; more perhaps to be considered as compli- cations than results. The real results to dread are obliteration of larger or smaller portions of the seminal tubes, owing to deposit of fibrine ; effusion of serum ; hardening of the epipidymis, generally seated in the cauda, where it forms a small knot ; wasting of the testicle, and suppuration in it or the scro- tum. That hardening of the epididymis, especially if it affect both sides, may lead to impotence, is a general and well-founded opinion. Mr. Curling mentions 2 several cases of absence of semen after orchitis of both testicles, and I have seen the same thing. Suppuration of the testicle and deposit of fibrine among the convolutions of the epididymis may go on to a con- siderable extent without interfering with the functions of the gland. There can be little doubt that authors are right in assuming that im- potence does not follow so long as the disease is only confined to one gland or limited to mere hardening. But this hardening is also apt to be accompanied or followed by contraction of the sole channel for the expul- sion of the semen. Mr. Holmes Coote told me that he had often found induration accompanied by obstruction of the epididymis. M. Gosselin's observations, and those of M Marce and M. Charles Robin, confirm this view, and my own are quite in accordance with it. Indeed when a delicate mucous membrane is converted into a rigid contracted tube, we can hardly expect that it will execute its normal functions. M. Robert, however, has 1 Gazette M6dicale, p. 381, etc. 1869. 9 On the Diseases of the Testis, p. 439. 1866. TKEATMENT. 189 seen, 1 at the expiration of five or six months, a return of the animalculse after double epididymitis, at first in small numbers, but subsequently as numerous as if there had never been a pathological change in the organs. Treatment usually Adopted. We are generally recommended to treat this affection by antiphlogistics. The plan of combating it by emetics, so greatly patronized by many of the older writers, has, generally speaking, died a natural death, though here and there, evidently enough, its ghost still lingers ; a relic of faith in this treatment may also be traced in the nauseating doses of antimony prescribed by some writers. The recom- mendation to use antiphlogistic means is only consistent with the theory of those who consider that inflammation is not to be exercised but by measures which reduce the patient's health ; they who hold such a view ought to stand by the axiom that we can only banish the intrusive demon secundum artem. But I am inclined to suspect that the system now lives only by sufferance, and that no one of its supporters, if put to the test, could prove it to be called for. Bleeding, considered by M. Eobert indis- pensable when the body of the testicle is affected, owes its tenure of existence, if indeed it exist at all, to a long and most respectable descent, to ancestral prestige in fact ; but I suppose we may look upon it as gone for good, whatever affection of the organ may seem to call for it. Leeches, calomel, antimony, salines, etc., often leave the pain unrelieved for eight or ten days, and so long as this lasts the inflammation is not subdued. Still less can we assume that it is even quelled by these means, seeing that if the patient remain in bed and restrict himself in respect to diet he will be cured just as quickly. Leeches indeed can only diminish to a fractional extent the quantity of blood driven toward any inflamed part, whereas the object of the surgeon should be, not to abstract blood, but to check the action which impels it in an abnormal direction. The congestion of this fluid offers a check to the process ; by relieving this arrest we set it going again plena rivo. Mr. Judd narrates 3 a case of orchitis in which twenty leeches were ap- plied to the testicle, with the effect of removing the pain. The day after this is stated, we find that the gland is larger, more tender and reinflaming, and the day after this again, we .are told that the patient is still suffering from a good deal of sweUing and pain in the part, " although the leech- bites bled until he fainted ! " Again, M. Salleron gives 3 one where the patient was bled freely, and where, two days after, the pain was worse than ever. Thirty leeches were then applied, and then thirty more, without any good being affected. Mr. Johnson, who used to lay the patient up, order leeches, and give calomel, opium, and antimony, occasionally adding salines and colchicum, says, " It is a very severe attack indeed which in less than a 1 Op. citat., p. 233. "Op. citat., p. 52. 8 Archives Generates de Medecine, tome ii., p. 165. 1870. 190 OX GONOKRHCEA. week of this treatment, has not lapsed into a milder form." And again : "I believe that the average duration of an acute attack, treated in the manner I have recommended, is between two and three weeks. "When relapses take place they may protract it to a month, or six weeks, or longer." As to the inconveniences said to result occasionally from the use of leeches, such as erysipelas, they would not deter me from employing a remedy from which I could expect aid. I believe them to be imaginary, and I am com- pelled to state that the diametrically opposite evidence on this point in England leads me, and indeed would lead any one else, to surmise that conjecture, respect for authority, and conviction have had more to do with the matter than observation and analysis. With regard to some other parts of the treatment, such as puncture of the scrota! veins, what little I can make out is that they are entirely use- less, although not harmless, as one patient died from a vein in the scrotum being opened ; a catastrophe which perhaps induced the surgeon to alter his views on the subject. 1 Puncturing the scrotum on M. Velpeau's method, whatever it may be, for he merely speaks " of it as "puncture of the tumor," seems to have been almost as unfortunate. M. Demarquay saw wasting of the testicle in three cases, and, including one of orchitis from stricture, four cases where it was trusted to, but in one of these if not in all, the tunica albuginea was opened ; and M. Montanier noticed serious bleeding after it, although the incisions were mere pricks (mouche- tures). 3 My experience of tartar emetic, calomel, and other items of anti- phlogistic treatment, is not more favorable, or, in plain terms, I believe them to be perfectly useless. Tartar emetic is a most potent remedy in controlling inflammation of the cellular tissue, but has little influence over those of mucous membranes, and in orchitis I have generally found that it produced no change whatever. It occasionally checks the formation of abscess in the scrotum, but I am not aware of any other good that results from using it. I suppose we or our descendants will some day be treated to a dissolv- ing view of those doctrines ; but in the meantime, as arguments will never work conviction, I will take the liberty of putting the rather awkward question whether any of those who recommend leeches, etc., have ever taken the pains to ascertain if there are justifiable grounds for putting pa- tients to such expense and weakening their health, for these are two almost unfailing results of antiphlogistic treatment. Except Mr. Curling, all those authors who fix a time at all, give a week as necessary to subdue the more severe symptoms of orchitis, and thirty or thirty-five days as the re- quisite period for a cure. Now as any case of orchitis will get well as fast as this if the patient only remain in bed, it becomes more than doubtful 1 Johnson : Op. citat. , p. 204. 2 Leqons orales de Clinique chirurgicale, tome Hi., p. 461. 1841. 3 Bulletin de Therapeutique, p. 550. 1858. TREATMENT. 191 whether the treatment recommended on such respectable authority really has the slightest influence over the complaint. Punctufc of the Tunica albuginea. Mr. Henry Smith ' incises the tunica albuginea in severe cases of orchitis, for which variety principally he re- serves the operation. He makes a deep and free incision through the tunic, with the effect of letting out several drachms of blood and serum. Nothing else is done beyond prescribing a little " white mixture" (a saline aperient, I presume, containing magnesia) and the ordinary lead lotion of the hospital. Mr. Smith describes the effect as highly satisfactory. The relief to the pain is so decided that the patient feels it has given way before he leaves the room, and the change for the better which takes place within the first forty-eight hours is so great as to attract general notice. This he justly attributes, not to the loss of blood, but to the removal of the constriction exerted by the fibrous envelope. He has never seen the operation followed by any disagreeable symptoms but twice. In one case, puncture of the testicle in a middle-aged man brought on rapid effusion of serum into the tunica vaginalis ; but this was speedily relieved. In the other case the incision was made much deeper than necessary, the point of the knife being carried nearly to the back of the organ. The only results, however, were a little faintness and the loss of about ten ounces of blood. The relief given in this case was more speedy and effectual than usual. The practice has been long in vogue in Paris ; it was recommended by Jean Louis Petit, was extensively adopted by the late M. Vidal de Cassis, who punctured to the extent of a centimetre and a half, and received the high sanction of M. Eicord ; Pirogoff, too, Mr. Smith tells us in a later communication, punctured as far back as 1852. He adds that in the prac- tice which comes under his cognizance swelled testicle is treated in the most heroic way, all the barbarities of the old school being combined with the worst features of modern treatment. Emetics, purgatives, leeches, strapping, are still in full play. Such, at any rate, is the picture drawn by one of the surgeons to the hospital where all this kind of thing was being daily enacted at the date of Mr. Smith's communication, and it must be admitted that it does not give us a very favorable idea of the practice at the sources from whence alone we ought to derive our inspirations. Mr. Smith's assertions were openly challenged by Mr. Holmes, and a squabble ensued not at all calculated to produce a favorable impression as to the mode in which scientific discussions are conducted in some of our English medical journals, startling assertions of success being met by something like flat denial ; the value of an operation contested, not so much on the evidence of trials and experiments as on that of authority and 1 Lancet, vol. ii., p. 149. 1864 192 ON GONORRHCEA. possibility ; and finally both disputants, though perhaps with their own convictions a Little modified, claiming a complete victory. Mr. Smith says that he has performed the operation about %, thousand times, reserving it for the more severe forms. Supposing the latter to amount to one in four of all the cases, this will give us about four thou- sand in eleven or twelve years. To those who remember that the entire number of orchitis cases in three of our hospitals, two of them among the largest in London, was, for two years, only eight hundred and forty-four, and that these have to be divided among ten assistant surgeons, the num- ber operated on by Mr. Smith seems enormous. This gentleman appeals, not only to the success of his own practice, but to that of others whose testimony he quotes. One of those, however, who are exhorted to bear evidence, gives it against the operation, but Mr. Smith disposes of his ob- jections by saying, substantially, that when he knows more he will know better. While according due weight to the opinion of the gentlemen whose authority Mr. Holmes quotes against the operation, and whose opinion I should be one of the last persons to contest, I yet quite agree with Mr. Smith, that the question is one to be decided, not by authority and conviction, but by trial of the method ; and I think that he has here the advantage over his opponent. Mr. Holmes says he cannot see how the operation is to do good, and speaks of it as splitting the tunica ; the im- mediate answer to which is that it has done good, and that the testicle is simply pierced by means of a bistoury, from one-eighth to a sixth of an inch broad, to a depth of half or three-quarters of an inch, immediately after which the blade is withdrawn, so that Mr. Smith has modified his earlier views. Mr. Holmes goes so far as to say, that a large proportion of those pa- tients cited as having been so promptly relieved by incision, are precisely those whose sufferings we need in no way particularly regret. Whether stu- dents or costermongers, they belong to a class whose absence, whe con- fined to their bed-rooms by orchitis, society is the least likely to lament. I trust my readers will agree with me in thinking, that it is not desirable to follow Mr. Holmes into this part of the argument, which may be strictly correct, looked at from a social point of view ; but which seems to me a mistake in a medical paper, and one the more to be regretted, because his deserved eminence placed him above the necessity for going out of his way. It is just possible that in some few cases incision may be a good, or even the best, remedy. Thus, for instance, Mr. Nunn had under him ' a case of swelled testicle, where suppuration from the same complaint in the fellow-gland had previously given a great deal of trouble. In the attack 1 Lancet, vol. i., p. 158. 1870.. TKEATMENT. 193 for which the patient was admitted under Mr. Nunn, a third of a grain of morphia three times a day had, at the end of four days, effected no im- provement, yet the operation proved quite successful. In undescended testicle, too, when affected by orchitis, it may turn out to be useful, hav- ing been successfully employed here by Mr. Johnson Smith, 1 who punct- ured, with " a deep stab," a testicle thus affected, and lying between the external and internal ring of the left side. But I believe that, as a general rule of treatment, it will not hold its ground. There seems no doubt that in some cases it did not afford the relief expected from it. The operation has been given up by some of those who saw it fairly tried and tried it fairly themselves. Taking the average results on Mr. Smith's own showing, they are not more satisfactory than those of Mi\ Gay's cases, or of my own practice. M Aubry, who seems to have honestly studied the matter, did not find that puncture materially shortened the duration of the complaint. 2 The bulk of patients will always shrink from operations of such a nature, and will rather risk mischief than face the remedy. There seems little doubt that harm has resulted in some cases from the practice, and we know that an operation, however safe when skilfully performed, will find bungling imitators and will then do mischief. Mr. Spencer Watson, in a communication to be presently noticed, said that he had heard of one case, though he had not seen it, where atrophy followed incision into the testis, but he hesitates about ascribing this re- sult to the operation ; I think, however, there can be little doubt that it was the cause of atrophy in two cases where M. Salleron tried it, 3 as also in two mentioned by M. Diday. 4 In the Giornale italiano for 1871 6 there is a very short account, taken from the Lyon medical, of a case in which the operation was followed by abscess, gangrene, and hernia of the gland ; and in the following case it was, whether skilfully performed or not, at- tended by consequences to all appearance of a most lamentable nature. In the summer of 1873 a gentleman consulted me for what he caUed spermatorrhoea, of which he gave the following account. More than two years previously he had contracted gonorrhoea while at college. He could not tell me much about the treatment, which seemed to have consisted chiefly of specifics. Before he had quite recovered, he was prevailed on by some friends to run a foot-race ; almost directly after he had done so the right testicle swelled badly, for which the surgeon who attended him made a free incision. This gave relief, a quantity of blood was lost and the swelling slowly subsided. Some time afterward, with gonorrhoea still 'Ibid., vol. i., p. 468. 1872. 2 Annales des Maladies de la Peau, p. 299. 1844. 3 Archives Generates de Medecine, tome i., p. 163. 1870. 4 Annales de Dermatologie, p. 23. 1869. 6 An., vi., p. 240. 13 194 ON GONORRHOEA. uncured, lie was foolish enough to indulge in some very hard rowing, whereupon the other testicle swelled and was similarly treated by the sur- geon. This time, however, the patient suffered a good deal from pain in the loins, followed, at a later date, by obstinate and serious abscess near the right tuber ischii. At the time when the patient called on me, he complained of great and increasing decline in sexual desire, though he was quite a young man. I endeavored to get some of the semen for examination, but he said that he scarcely thought now of attempting connection, though previously his passions had been very strong ; and that he never had any emissions, so that no supply could be obtained. I could not discover with certainty in what direction the incisions had taken effect ; the traces of them were faint and the patient did not seem to have noticed much about the matter ; but, as well as I could make out, there had been in each case a long cut, divid- ing great part of the lower end of the testicle, and possibly part of the cauda epididymis. Puncture of the Tunica vaginalis. This operation has been recommended as superior to the other by Mr. Spencer Watson. In a careful report ' of his practice we learn that, after an experience of about twenty cases, he finds it well adapted to instances marked by effusion into the cavity, but not to those where the epididymis is alone or principally affected. Mr. Richmond, however, in a paper read before the King's College Medical Society, 2 had previously borne testimony to the relief afforded by punctur- ing this membrane being quite as great as when the testicle is cut into. But the results do not tally with those of Messrs. Ragazzoni and Appiani, who found 3 that, in twelve cases of orchitis, puncture of the tunic put an end to the affection, but that it required twelve days to do it in, and my experience is that mere rest would have effected as much good. The strongest condemnation, however, passed upon it is by Mr. Watson himself, who has abandoned the operation, except when there is much effusion into the tunica vaginalis, being " inclined to think " that opium and antimony give relief as quickly. I need scarcely say that this looks very much like giving the method up altogether. At a somewhat later date Mr. Macna- mara, of Westminster Hospital, was in the habit of puncturing the testicle with a grooved needle, with excellent results. 4 As to the treatment of orchitis by means of tartar emetic in friction, I can only say, from what I have read, that it appears to unite in itself all the disadvantages which can possibly attend any method. One of the medi- cal men who writes in praise of it, warns his reader, that they should guard against the pustules coming out too thickly, as this state may be f ol- 1 Medical Times and Gazette, vol. i., p. 520, 1866 ; and vol. i., p. 390. 1867. 8 Ibid., vol. ii., p. 479. 1864. 3 Giornale italiano, 1870. Quoted in Archiv fur Dermatologie, B. III., S. 57. 4 Lancet, vol. i., p. 50. 1877. TREATMENT. 195 lowed by " vicious " cicatrices and gangrene of the tissues ! Seeing that these undesirable results only accompany a very moderate success in the way of.cure, it is difficult to make out what possible reason there can be for giving the method a trial. Strapping the Testicle is now, I fancy, rather a matter of tradition than of actual practice, and any notice of it, therefore, more the offspring of a desire to make the author's work complete, than a practical exposition of the benefits observed to flow from the operation. I certainly think sur- gery will not suffer much from its falling into desuetude. It is dirty, painful, and, generally speaking, uncalled for ; and as gangrene has been known, ' though I admit very rarely, to follow the employment of it, the in- conveniences of the practice must, in my judgment, be held to outweigh the .advantages. Among many other methods commended to our notice are 1. Continu- ous application of ice, long ago employed by a most careful surgeon, Mr. Curling, 2 with marked success, the pain in the first case recorded being materially relieved in a day. Enthusiastically recommended by M. Diday as infallible and relieving the pain within an hour, though requiring to be continued eighteen to forty-eight hours, and even four or five days ; now apparently abandoned by him in favor of M. Langlebert's method, which is opposed as any process can well be. 2. Freezing the testis, the same process presumably under another name ; seemingly dead, and cer- tainly long disused at one hospital where it was formerly much in favor. 3. The method recommended by Dr. Waterman, 3 acetate of morphia and acetate of potass internally, tincture of iodine and ammonia being applied topically. 4. That of Dr. Grammer, 4 bromide of potassium, five grains three times a day. 5. The method of Dr. Julian Alvarez, 5 which consists in the application of iodoform ointment, a plan recommended also in the Union Medicale." 6. That of Mr. Payne, of Wallingford, 7 painting the scrotum with solution of iodine, a drachm to three ounces of spirit, or with strong tincture of iodine every second day ; the cure in one instance being so rapid that by the fifth day the patient was able to resume his employment. 7. That of Dr. Assadorian, 8 constant application of sulphuric ether, a method in the efficacy of which I have great faith. 8. Painting with strong solution of nitrate of silver, as recommended 9 by Mr. Furneaux 1 Medical Gazette, vol. xli., p. 976. 2 Medical Times and Gazette, vol. i. , pp. 210, 233. 1855. 3 Practitioner, vol. ii., p. 334. 1876. 4 Virginia Medical Monthly. Quoted in Louisville Medical News, vol. ii., p. 276. 1881. B La Independencia Medica, June 1, 1877. Quoted in Lancet, vol. ii., p. 898. 1877. 8 P. 1088. 1881. 7 Lancet, vol. L, p. 131. 1863. 8 American Journal of Syphilography, etc. , vol. i. , p. 216. 9 British Medical Journal, vol. ii., p. 202. 1868. 196 ON GONORRH(EA. Jordan, which he tells us will remove the pain, swelling, and tenderness in. twelve hours. 9. M. Bonnafont's plan of applying collodion. 10. Com- pression in various ways intended to be improvements upon strapping. 1 11. M. Tachard's system, pressure and subcutaneous injections of chlor- hydrate of morphia. 2 12. M. Langlebert's method. 13. Absolute rest alone, fairly tried in the Ospedale maggiore at Lodi, to my thinking, with most indifferent success, but spoken of in the report as the most speedy method. Thus, without noticing minor points but including Mr. Gay's, we have nineteen distinct systems of treatment. Most of these plans are recommended as unfailing or nearly so, yet with the possible exceptions of Assadorian's and Langlebert's methods, I question if a surgeon, unfortu- nate enough to have contracted gonorrhceal orchitis, who had the full facts of the case put before him, would prefer any one of them to that of Mr. Gay, which was not ushered into notice as infallible at all, but as an honest record of facts. One great question is whether experience justifies us in the hope that any system of treatment, however thoroughly its success may have been demonstrated, stands a fair chance of being generally adopted ; and whether medicine is not, in many of its branches, so purely a game of hazard, that while a lecture on physiology at a college, or the introduction of a new remedy, will, as surely as the summer sun calls certain forms of being into life, generate a host of scientific experiments, only too many of them aimless and barren ; of theories and systems ; we cannot feel the slightest confidence that a mode of treatment, be it ever so superior to its predecessors, will even command a hearing. Thus, so far back as 1844, Mr. Gay showed 3 that orchitis could be cured in half the usual time by large doses of hyoscyamus, a sharp purga- tive, and suspension of the testicle. On an average the pain was relieved in less than five days, while the patients were discharged cured in from three to seventeen days or an average of seven days and a half. 4 Now with the exception of a note in Mr. Acton's work, recording an unfavorable ex- perience of the method, I believe almost the only notice taken of it was in former editions of the treatise now before the reader. Mr. Pitt, in a com- munication to the Lancet 6 on this very method of treating orchitis, does not mention Mr. Gay's name ; in the section on this affection in " Holmes's System of Surgery," it is likewise ignored ; and Mr. James Rouse, in his account 6 of the treatment of orchitis with opium, seems not to have had 1 Lancet, vol. ii., p. 556. 1863. Archives medicates beiges. Quoted in the Gazette des Hopitaux, p. 230. 1873. Medical Record U. S. , January 29, 1880. Australian Medical Journal, April, 1880. 5 Rev. m<^d. de Toulouse. Quoted in Gazette des Hopitaux, p. 211. 1874. 3 Lancet, vol. i., p. 602. 1844. 6 Ibid., vol. ii., p. 338. 1848. 4 Vol. i., p. 429. 1870. St. George's Hospital Reports, p. 251. 1869. TKEATMENT. 197 any idea that Mr. Gay and myself had recommended much the same plan years before. The originality of the mode has been contested, but the merit of the discovery belongs to Mr. Gay, and to him alone. None of the old authors, who have been spoken of as preceding him in this path, ever had the most remote idea of mastering the disorder by means of sedatives only, although even as far back as the time of Astruc their value as adjuncts was known. Swediaur indeed seems ' to have relied on opium as a medicine, but his great object was to bring back the " retropulsed " discharge, retropulsion being in his day something like what blood-poisoning or suppressed gout is in ours ; an ever busy demon which required all the physician's skill and watchfulness to keep it in subjection ; a skeleton which not only en- joyed a vested right to a seat in his consulting-room, but rode with him in his carriage, and stood with him at the patient's bedside. To revert, how- ever, to the subject more immediately in hand, two of the many systems just noticed, the examination of which was interrupted by this digression, had better be taken here. They are Bonnafont's and Langlebert's. M. Bonnafont treated successfully fifty-six cases with application of collodion, 2 the inflammatory symptoms sometimes disappearing in half an hour, and the cure being complete in two to three days ; and all this without having in one instance seen anything which contra-indicated its employ- ment, or diminished his confidence in its powers. The pain from it never lasted more than two minutes. M. Costes gave 3 almost as glowing an ac- count. But M. Velpeau found 4 that it required on an average twenty days and a half to cure patients in this way. M. Kichet saw 5 frightful pain and great excoriation in a case where M. Bonnafont himself applied the collo- dion in M. Richet's presence ; and M. Venot found the pain set up by collodion intolerable, while the cure was so slow that he abandoned the method as useless. 6 Lastly, M. Kicord reported 7 that the pain, though not of any great duration, was generally severe, that he never witnessed the rapid diminution in the volume of the gland spoken of by-M. Bonna- font, and that the results obtained were not of a nature to warrant any recommendation of the method. M. Langlebert's method consists in applying over the swollen gland a layer of carded cotton, and over this again a piece of caoutchouc cloth. The latter is put on with the glazed side toward the cotton, and over it is drawn a triangular concave suspensory bandage, with a long strap at each corner to tie round the waist. M. Horand reported 8 most favorably to the 1 Op. citat., p. 80. s Union Medicale, tome viii., p. 222. Ibid., p. 242. 4 Archives Generates de Mcdecine, tome ii., p. 613. 1854. 6 Union Medicale, tome viii., p. 249. 8 Ibid., p. 311. 'Ibid., p. 449. 8 Lyon Medical, April 14, 1878. Quoted in Medical Times and Gazette, vol. i. , p. 552. 1878. 198 ON GONORRHOEA. Medical Society of Lyons on this method. His conclusions were based on a large number of cases, and practically endorsed by M. Diday. Herr Zeissl also strongly approves of Langlebert's system, which at the date of his communication he had tried in fifty cases, and always with " most ex- cellent results." In one case which he was called to, the patient, who had passed five nights without sleep (!), was suffering fearful pain, every motion and the slightest contact with the testis causing him agony ; but so soon as the Langlebert bandage was applied he could get up and walk about the room (!). In most of the cases indeed the pain ceased directly the bandage was put on. M. Fournier's treatment of true orchitis, as he calls inflammation at- tacking essentially the testicle, is of the most heroic kind the freest pos- sible use of antiphlogistics from the very outset, abundant and repeated local bleeding, baths for a long time one after another, strong belladonna inunction, ice to the testicle, intestinal revulsives, meaning I suppose strong purgatives, and finally, at the first suspicion of strangulation, divi- sion of the tunica albuginea, which some persons will think might very well have preceded all this ; indeed, it is precisely for these cases that Castelnau would reserve puncture. 1 Proposed Plan of Treatment. The plan of treatment now to be de- scribed was worked out in the same manner as the other divisions of the subject ; that is, one remedy at a time was used till its value was ascer- tained. The surgeon's first object is to arrest the pain ; with this the inflammation stops. The assertion has been challenged, I must submit, on insufficient grounds. Nothing effects this purpose so rapidly and so well as sedatives, and it is surprising to me that they should be so little employed, when their value has been so long and so thoroughly established. Provided the dose is only large enough, the choice is not of so much moment. I prefer morphia myself, or Battley's liquor opii in the brandy mixture of the Phar- macopoeia, the latter being particularly useful when there is a disposition to nausea. The morphia may be given in doses of a fourth to half a grain two or three times a day ; in very severe cases three-fourths of a grain may be given once or twice in succession. To prescribe the twentieth of a grain is simply to trifle with the matter. Similarly, I should never think of giving less than fifteen to twenty minims of Battley's solution every three or four hours, and I should in no way hesitate to use much larger doses. If there be much prostration, ammonia may be added to either of these sedatives, and the solution of the acetate seems to suit very well with the morphia when there is any feverishness. In the way of external applications, I think that, if the reader will em- 1 Op. citat., p. 301. TREATMENT. 199 ploy the lotion given ! below, he will be as much pleased with its effects as I have been. One patient, who had been taking sedatives without much effect for two days, assured me that he felt decided relief in the first half- hour after using the lotion, and that he was, comparatively speaking, well the next day ; but at the end of four days I could still feel some enlarge- ment and considerable hardness, both of the testicle and epididymis. Similar testimony has been voluntarily rendered by many patients. The longest time I have known to elapse before relief was perceived was some- thing under three hours. But however beneficially the lotion may act, I would not advise entire abandonment of the sedative ; and whether this be given or not, the patient is always the better for a pretty free use of warm aperients, such as senna mixture with excess of tincture of cardamoms, in- fusion of rhubarb and coriander with sulphate of potass, and so on. A light warm diet is advisable, starvation being useless as well as hurtful ; and the patient should therefore be allowed to make himself comfortable on a good basin of mutton or chicken broth, and a little arrowroot with a glass of old port in it, and I have even known many patients to be all the better next morning for a glass of good whiskey and hot water over night. I therefore always suggest a fair amount of such stimulants for the first night or two. "When the patient has been using injections, it will be as well to sus- pend the employment of them, not for fear of making the swelled testicle worse, but because this disorder renders many persons languid, weary, and averse to anything which occasions the least trouble. Some people also still labor under the opinion that the injections bring on the swelling ; and as the loss of three or four days is not of much moment, while absolute rest is a great boon to such patients, it is best to indulge them in it. As to the monstrous proposal of attempting to remove orchitis by re- storing the discharge, I suppose it is now entirely given up and very justly so, being not merely useless in practice, but false even in theory ; for swelling of the testicle does not check the discharge indeed, the same agency which brings on the orchitis often increases the running, probably in much the same way as anything does which disturbs the health, such as a cold, or an attack of influenza ; cold, dry, dusty winds ; the over-free use of stimulants, etc. I can safely say that I never saw an unequivocal instance of gonorrhoea arrested by swelled testicle coming on. The patient often thinks so, but one glance is generally enough to show that it is present ; and when the two events really occur at the same time, they are simply a coincidence, not cause and result. In the worst case of orchitis I ever had under my care, first the right testicle swelled and then the left. I was not called in 1 3 . Liq. ammon. acetatis, 3!.; Spir. setheris, 3 iss. ; Mist, campk. , iiiss. M. ft. lotio. Signa. To be applied by means of a single fold of linen, which is continuously wetted with the fluid. 200 ON GONOKRHCEA. till the latter gland was affected, and then I found not only considerable tenderness, swelling, and hardness of the right testis still remaining, but very evident symptoms of what might fairly be called most severe inflam- mation in the other, accompanied by visible swelling over the lower part of the spermatic cord. The patient, a strong young fellow, complained of such excruciating pain, especially over the cord, that I could hardly help fancying he exaggerated ; but his mother and sisters assured me, that he had been delirious from the pain,- and that such a condition could not, in his case, be due, either to stimulants or medicines, for he had done nothing but apply hot linseed poultices, and was extremely temperate. Here I satisfied myself by examination that the discharge from the urethra was still profuse, and the patient said it had been so all through. The reader will find, further on, another case of double orchitis accompanied by discharge. If any of my readers appeal to authority, and say that in a simple matter of fact like this it is impossible so many excellent observers num- bering among them Brodie, Swediaur, Cooper, Larrey, Wallace, and many others 1 could have deceived themselves, I meet the objection, first, by asking them to use their own eyes and ears ; and secondly, by referring them to Curling, Fournier, and Bicord, who, basing their conclusions on an immense number of cases, have decided against the old doctrine. M. Ricord says 2 that if arrest of the gonorrhceal discharge take place, it is not above once in two hundred times ; M. Fournier observes that quite as often as not the discharge is in no way affected ; and Mr. Curling, 3 speak- ing of its suppression, or rather, strictly speaking, metastasis to the testi- cle, says, it is very questionable whether anything of the kind happens in genuine orchitis. M. Robert, in thirty-eight cases, found the discharge pretty abundant in twenty-six, while it could be detected in every one of the remaining twelve. It may, however, be, and often is, diminished, but that is a different question. It is almost superfluous to say that the patient requires a well-fitted suspensory bandage. Blistering the Scrotum. When the swelling and pain continue very ob- stinate, the surgeon may, at the end of a few days, blister the scrotum. Very alarming pictures of the results to be expected have been drawn ; but as I have never met with them, I object to giving up the teachings of experience for the sake of conforming to theoretical objections. I have seen a blister check or limit an abscess of the scrotum when it was almost point- ing, and hold such testimony of the action of cantharides to be better evi- dence than the fears of inexperience. Several years ago, one of the physicians at the Infirmary of Bishopwear- mouth ordered a blister to be applied to the epigastric region of a patient 1 Medical Times and Gazette, vol. ii., p. 271. 1871. 5 Trait'J Pratique, p. 754. 3 Op. citat., p. 243. TREATMENT. 201 suffering under great pain in that part of his animal economy. The pa- tient, being told to put the blister upon the epigastric region, and thinking this was only a jocular term for the organs of generation, actually cut a hole in the blister, pulled the penis through, and carefully fastened the vesicant on the scrotum. Two days afterward his landlady came to the infirmary to say that the man was dreadfully ill ; and, sure enough, when the surgeon went he was in woful plight, having kept the blister on ah 1 this time ; but the serious symptoms, which some authors profess to ex- pect from three or four hours' blistering, had not ensued at all ! Kegarding the treatment of the blistered surface, I must refer my reader to the section on blistering in the fourth chapter, where he will find full directions. I wish it to be understood that I do not recommend the above method either as infallible, or as possessed of any marvellous efficacy. So far, and especially as regards the use of ammonia and ether, it has not failed in my hands, and I consider experience warrants me in saying, that it has answered better than any method which I have seen tried, but I do not go beyond this. Subsequent Treatment. So soon as ever the symptoms of active in- flammation have subsided, iodide of potassium may be ordered, alone or in combination with liquor potassse, with the view of removing the hardness and swelling. A small quantity of mercury and chalk every second night will often assist the action of these remedies. 1 I suppose it would now be fighting with a shadow to attack the doctrine that the use of iodide of potassium may lead to wasting of the testis ; but it may be as weh 1 to ob- serve that the credulity with which this doctrine was at once received, and the ex cathedrd style in which it was taught for years vnthout one per- son being found to undertake the task of really looking into the subject, ought, if experience could ever do so, to make men more cautious about adopt- ing tenets on such evidence, or rather on no evidence at all. I need scarcely say that should effusion of serum take place into the vaginal sac, an accident which has never once occurred in a case where I had charge of the patient from the beginning, puncture must be resorted to. When the effusion is abundant a very fine trocar may be employed ; I use one only about twice the thickness of an insect needle. For slighter degrees I have found acupuncture sufficient. Most of the cases treated in this way have been thoroughly cured ; in- deed, so far as has been ascertained, success always followed a fair trial, and none of the patients suffered from a relapse most encouraging re- sults, when we consider how often authors have told us of the tendency 1 IJ. Potassii iodidi, 3]'.; potassse liquoris. 3iij.; syrupi flor. aurant., 3 iv. ; tinct. cinnam. co. ad iv. M. Capiat coch. , min. ij. ter quotidie ex aquae cyatho vin. 1J. Hydranryri cum creta, gr. xij.; pulv. cinnam. compos., gr. viij. M. et divide in pulv. vj. Sumat j. omni nocte. 202 ON GONORRHCEA. this disorder has to return under any form of treatment. 1 I do not, how- ever, say it is infallible ; I only say it has succeeded in my hands much better than any other. M. Castelnau gives a a very different account of how matters may go. According to him orchitis may become chronic. After doing well for a time, the improvement suddenly stops, and the testicle even augments in volume ; or the acute orchitis may subside and the patient suddenly find that it has returned. The same parts are affected as in the acute form, except that the spermatic cord is much more frequently implicated. The epididymis is more voluminous, hard, sometimes smooth, more often un- equal ; presenting knobs in which the induration is more marked than else- where. The testicle is by no means so much enlarged, and appears let into the antero-inferior part of the epididymis which is depressed to receive it. I never yet saw the progress toward cure interrupted by any such symptoms and must conclude that M. Castelnau has confounded syphilitic sarcocele with gonorrhoeal orchitis. Deferentitis. A case of this is mentioned 3 by M. Gosselin. It oc- curred on the left side, the swelling being below the external inguinal ring and almost on a level with the head of the epididymis. It was very hard, slightly painful to the touch, and about the size of a big hazel-nut. From it issued, below, a hard cord about the size of a quill, which stretched from it to the tail of the epididymis. From above, another cord, larger than the former, could be traced to the external inguinal ring, and from this to the upper opening of the inguinal canal. The tes- ticle and epididymis were quite distinct. The affection rapidly subsided under the influence of rest, purgatives, and mercurial inunction, and at the end of sixteen days only the slightest trace of it was found. Inflammation of the spermatic cord without affection of the correspond- ing testicle, as described by Bergh, 4 Wahrmann and Kohn, 5 I have not met with. In the case of double orchitis previously mentioned this symp- tom was evidently present in one cord, and, from the patient's account, had occurred in the other. He complained, however, so much of the ten- derness in the affected parts that I could not make a proper examination, and he was admitted as an in-patient into another hospital three or four days after my first seeing him. My experience, therefore, of the affection is valueless. I need scarcely remark that great pain near the external ring is in no way uncommon. The symptoms in the case described by Kohn were very severe. A case which seems identical with those just given is 'Johnson: On the Genito-Urinary Organs, p. 194. 2 Op. citat., p. 324. 3 Gazette des Hopitaux, p. 261. 1868. 4 Hospitals-Tidende, No. 49, December, 1848. Quoted in the Archiv fur Dermato- logie, B. I., S. 605. 6 Wiener medizinische Presse, p. 17. 1870. Quoted in the Archiv fur Dermatologie^ B. IH.,S. 58. TREATMENT. 20.'* mentioned by Hunter. ' M. Fournier, speaking of this and def erentitis, says 3 be has only seen two instances, but of which he does not precisely specify. At a later date he mentions 3 two instances in which the gonor- rhoea! inflammation was seated in the vas deferens without the epididymis being affected. 6 7. PHIMOSIS AND PAKAPHmosis. 4 The treatment of these complications may be summed up in a very few words. Phimosis seldom calls for more than suspension of the penis, which may be easily effected by any person possessed of the most ordinary mechanical skill. In the more severe cases, such as are occasionally seen when ineffective attempts have been made to check the disorder with specific medicines, and which never ensue when injections are properly employed, evaporating lotions containing ether and acetate of ammonia may be used ; I have never seen a recent case which required more than these. So soon as ever the prepuce can be drawn back far enough to admit the syringe, the treatment may be continued just the same as if there were no phimosis. It is quite a mis- take to imagine that this complication proves the presence of an amount of inflammation which would render the use of injections dangerous. In some long-standing cases it is necessary to act with decision, as I have seen nearly the whole prepuce ulcerated or adhering to the glans. The affair is, however, so simple as scarcely to require any rules at ah 1 , and I should not have done more than merely allude to it, had not such an un- necessary amount of words been expended on what every apprentice ought to be able to manage. "When division of the foreskin is necessary the director should be passed under it in the mesial line, and when the point will reach no farther, the skin is drawn well toward the root of the penis. The skin and mucous membrane are then cut clean through to the point. One necessary pre- caution is not to introduce the director into the urethra and slit up the glans. The reader may think this caution superfluous, but I have known a very good surgeon make the mistake. Mr. Johnson has also seen it happen. & Any warty growths found inside may be touched with a strong astringent, such as glacial acetic acid, etc. Dr. Durkee tells us that phimosis will sometimes yield to gradual dis- tention with a sponge-tent, and a very ingenious friend of mine invented an expanding ring which he assured me never failed to remove the con- striction. Mr. Travers also speaks of a dilating instrument invented by Trew. But I apprehend that such measures as these are, like circum- < 1 Op. citat., p. 54 s Nouveau Dintionnaire, tome v., p. 214. 3 Archives Generates de Medecine, tome ii., p. 390. 1877. 4 The modern spelling of these words seems to me a mistake, the Greek v having much more analogy with y than with i. However, as scholars like Hooper and Good, admit the innovation, anything beyond protest would be superfluous. 6 Op. citat., p. 136. 204 ON GOXORREKEA. cision, stilted more for cases in which there is no gonorrhoea to complicate them. There is one complication which I shall advert to presently, in which I think it highly advisable to divide the prepuce at the least. As to paraphimosis little need be said. The surgeon should carefully cleanse the penis, and then attempt the reduction of the strangulated part, in which with a little perseverance he will generally succeed. Some authors, Fricke among the number, profess to have never failed. I have not been so fortunate, and I have seen much better surgeons than myself make the attempt ineffectually. Rollet candidly admits * failure. This, however, is not of much importance, as in gonorrhoea, if properly treated, the strangulation, when not neglected, is never severe and rarely attains such severity as to require cutting of the constricting band. If it should, the evil is easily met. In the good old times of Musitanus, once a great authority in those matters, the doctors seem to have made sharp work with the swelling from paraphimosis. The plan was to " humble the crystalline [the swelling] with sublimate," and then touch the affected part with tinct- ure of tobacco, which was " to be done when the patient is lying, lest the Violence of the Pain, because of the violent operation of the Tincture, should make him drop down in convulsions ! " : Even much later it was quite a common thing to take off part of the organ in these cases. Dr. Mason Good tells us that in this " variety, amputation of a larger or smaller portion of the penis may be necessary." (!) 3 I must say this is a consolatory view to take of the matter, and the reader, if he ever suffer from paraphimosis, may thank Heaven that Dr. Good is not alive and likely to attend him. Why, in the very worst cases it would be far better not to meddle with the affair, as, when gangrene ensues the utmost that can happen is that the loose part of the prepuce is thrown off. Even this, I apprehend, must be extremely rare. Dr. Durkee 4 speaks of it as a fact " which the medical attendant sometimes witnesses." I have not myself seen it from gonorrhoea. 8. BALANITIS is one of the most easy complications to deal with, although some attempts have been made to bring it within the category of complaints requiring extraordinary means. M. Kicord advises cauterization, and if the patient be quite indifferent as to the amount of pain he may suffer, or perhaps rather prefer it, caustic will answer as well as mild lotions of sulphate of zinc in camphor mixture, four grains to an ounce ; or sulphate of copper in rose-water of the same strength, syringed under the foreskin two or three tunes daily, when this is tight, and applied, when the foreskin 1 Recherches Cliniques et Experimentales, p. 548. 1869. "Cockburn: Op. citat., p. 246. 3 When gonorrhoea was considered to be syphilis, the removal of the organ seems to have been a dernier re*s&rt. " Amputation of the penis," says Cockburn (p. 224), " has often been the last remedy for the sharp matter of the gonorrhrea." 4 Op. citat. , p. 78. TREATMENT. 205 can be drawn back, by means of a strip of thin linen soaked in the solution used and laid between the prepuce and glans ; but according to my expe- rience no better. Mr. Acton ' speaks of gangrene as though it was not an unfrequent re- sult of balanitis, and tells us that, though it generally attacks the prepuce, it may destroy the whole penis. M. Robert seems quite familiar with gangrene of the loose fold of the prepuce from this cause. Although for years I saw, quite twice weekly, specimens of the worst class of cases in the Metropolitan and Royal Free Hospitals, I never observed an instance of this. The occurrence seems to have been common enough when men did not discriminate carefully between syphilis and gonorrhoea/ but I should think it must be almost unknown now in good practice. It will, I trust, be unnecessary to say anything about the treatment of posthitis, the elevation of which into a separate subdivision seems to me rather a refinement. 9. INFLAMMATORY SWELLING OF THE PENIS. I should scarcely have been inclined to look upon osdematous swelling of the organ, even accompanied by balanitis, as a very serious affair, and have been disposed to think that rest in bed for a day or two, a sedative, and the free use of tincture of steel, with spirit lotions, were all that is requisite. Some of the French surgeons, however, evidently view it as a symptom of sufficient importance to require the most heroic treatment. The parts, says M. Melchior Robert, are to be enveloped in linen steeped in marsh-mallow water, elder-flower water, or any other emollient fluid. If there be no reaction, it is not necessary to do more than apply leeches to the groin or perineum, ; but if the system be seriously affected, blood is to be taken once or twice from the arm. Constipation is to be removed by purgative salines such as seidlitz powders, sulphate of soda, and citrate of magnesia. Along with these we may use warm baths, but not fomen- tations or cataplasms. The seat of the discharge is to be frequently cleansed with emollient lotions or injections, almost cold, to prevent pain- ful erections. Pills and enemata of camphor may be given, and conversa- tion or reading calculated to inspire lascivious ideas (!) is to be strictly excluded. In order to avert gangrene, solution of opium may be injected into the cavity between the glans and the prepuce. All this, however, and several other remedies to boot, such as decoction of mulberry-leaves, do not, it appears, always prevent part of the penis from being destroyed by mortification. I certainly should not think injecting opium was very likely to stay gangrene, but how this accident occurs af all is more than I can make out. I have seen and treated some rather bad cases of oedematous swelling of the penis, but I cannot call to mind such results as sphacelus, and should 'Op. citat., p. 71. 8 Swediaur : Op. citat. , p. 130. Surgical Essays. By Sir Astley Cooper and Mr. Benjamin Tr avers. Part i., p. 151. 1818. 206 ON GONORRHOEA. not feel very well satisfied if they occurred when under my care. Such a complication as erysipelas of the penis and scrotum, which must, I fancy, be very rare, should be met with large doses of tincture of the sesqui- chloride of iron every three hours, and the application of any innocuous fatty substance, such as benzoated zinc ointment applied, melted, all over the affected part. When it attacks the dartos, free incision is recom- mended by some authors. 1 t 10. INFLAMMATION OF THE SPONGY AND CAVERNOUS BODIES. The reader will find a very good, and rather amusing, account of these affections in Mr. Johnson's work on the genito-urinary organs. They are both intractable enough, but it can hardly be said that they interfere with the cure of gonorrhoea, as they rarely if ever show themselves except when the patient has thoroughly neglected his complaint, and indeed are rather results than complications. They are extremely uncommon, and inflammation of the cavernous bodies is perhaps the most rare of all the sequelae of gonorrhoea. One gentleman, who consulted Mr. Johnson for it, suffered lancinating pains on erection, and his penis twisted like " a pig's curly tail." It re- sisted the most energetic treatment, and when last heard of the patient was little if any better. In the fatal case of chordee, mentioned previously, which occurred hi the practice of M Villeneuve, these bodies were im- plicated. M. Robert, whose account of induration of the corpora caver- nosa * is very clear and concise, gives an unfavorable prognosis. I have only seen two cases, one of the posterior portion of the spongy body, one of the left cavernous body, both in only a slightly pronounced form. Neither of the patients could be induced to undergo any treatment for his complaint. 1 The merits of first noticing this affection, and suggesting incision for it, has been ascribed to Mr. Liston, but I believe it is due to Mr. Johnson. s Op. citat., p. 167. CHAPTER YI. TREATMENT (CONTINUED). COMPLICATIONS WHICH INTERFERE WITH THE CURE or GONORRHOEA. We now arrive at the consideration of those symptoms which are more calculated to fetter the surgeon's hands. From their importance I have been led to illustrate them by a few carefully selected cases, for which I solicit the reader's earnest attention. Under this head I propose to place all those affections which directly or indirectly interfere with the exhibition of proper remedies. They con- sist of 1. FAINTING FROM THE USE OF INJECTIONS. In speaking of a strong tendency to faint from the use of injections, I allude, not to the mere sense of faint- ness felt on passing the tube of the syringe down the urethra for the first time, as that is quite a common affair, but to that form where the disposi- tion is so strong and recurs so constantly as to constitute an idiosyncrasy. I have seen it in very strong men. An acrobat who had contracted a discharge came under my care. He was a healthy, temperate man, a solid mass of bone and muscle. His energetic method of gaining his livelihood was practised "sub Jove," and had developed his powerful frame to the highest pitch of health and strength it was capable of. Yet this man fainted so suddenly on my attempting to insert a short syringe into the urethra, that he fell like a stone. The in- sensibility was very prolonged, and he felt so ill after it that he refused to have any more injections. A gentleman consulted me for gonorrhoea. He was a remarkably strong man, exceedingly well made, and wore the appearance of being in very high health ; he was fifty years of age, and told me that he had never taken a dose of physic since he was a child, and never remembered having experi- enced the feeling of being out of health. He had never had a cold, he said, or a headache. The introduction, however, of only the tip of the syringe produced such an effect upon him that he begged of me to -with- draw it, as otherwise he should faint on the spot, and immediately after broke out into such a cold perspiration that I saw it would be useless to continue the attempt. A cavalry officer, a strongly built, hard-featured, resolute-looking man, 208 ON GONORRHOEA. consulted me for slight occasional discharge from the urethra, and great irritability of the passage for about half an inch down. I wished to give him two or three injections, and, according to my regular custom, asked him before using the first one if he thought it was at all likely that he would suffer in this way. He seemed quite satisfied that he should not do anything of the kind, but the. event showed he was widely mistaken, and that if I had been imprudent enough to repose faith in his assurances he might have been hurt ; for I had scarcely got the tip of the syringe into the urethra before he suddenly exclaimed that he was going to faint, and it was as much as I could do to save him from falling heavily. He remained perfectly blanched, sick and prostrate for a considerable time. I was beginning to inject a gentleman, a strong, finely grown, healthy- looking young fellow. Almost in an instant, as the instrument had en- tered the urethra, he turned pale and fell almost like a corpse ; but, as I have learned to expect this kind of thing, I was enabled to break his fall. The pulse at the radial artery stopped completely. On coming to himself he discharged the contents of his stomach almost at a single gush, and it was a long time before he so far recovered as to be able to leave the room. In my opinion the surgeon, unless he happen to know the constitution of his patient, should always be prepared for such a contingency ; and when he has satisfied himself that there is a disposition to syncope, or even has good reason to suspect it, then he had better give the injection with the patient in a sitting or lying posture. This will overcome the most ob- stinate disposition to fainting, as the following instance, among many others, may show. A very tall, delicate young gentleman applied to me with gonorrhoea. About eighteen months previously he had suffered from an attack, which, with all possible care, was not subdued with copaiba and salines in less than nine months ; ever since then the urethra had remained extremely tender, and whenever he had a cold, a drop of pus was seen at the meatus on rising. On inserting the syringe he immediately fainted, and as soon as ammonia was applied to his nostrils the contents of his stomach were thrown off ; but the impression made upon the disease was so evident that the patient willingly continued the injections, which were given sitting. At the end of eleven days the discharge was so far diminished that they were only given every second day, and then every third till the twenty- fifth, which was the last, no discharge having been seen for eight days. The faintness was present to the last. Some months later, during an excursion in Austria, he again contracted the disorder ; he was treated with specifics and derived almost as little benefit from them as before. Soon after his return to England he con- tracted a fresh infection, and six months subsequently he had another at- tack. On both these occasions the complaint was removed within a week by means of injections, but the tendency to faint was still as strong as TREATMENT, 209 ever when beginning with them. After the last gonorrhoea I recom- mended the use of a gum-elastic bougie twice a week. To the very last day of using it he always averted his sight from the instrument, feeling sure that he would swoon if he looked at it. This treatment, I may ob- serve, answered the end in view ; the patient, though he was soon as im- prudent as ever, contracted no more gonorrhoeas. 2. GREAT NATURAL OR INDUCED WEAKNESS. By this is meant, not so much great physical exhaustion, as a weak, irritable state of the system. The patient is gloomy and weary ; sometimes prostrated with sick headaches, at other times scarcely able to rise from mere lassitude. A cold confines him for a week, his bowels are costive, his tongue coated, his enjoyment of all comforts is lost, and he broods and frets over even a slight persist- ence of his malady. These cases are often exceedingly difficult to manage. Specifics and potass are sometimes badly borne, and the operation of such remedies as seem suited to the health is unsatisfactory as regards the gonorrhoea. Tonics can only be taken for a little time, as the discharge is apt to be- come exasperated when their action is kept up for long. Many patients of this class can hardly be induced to take aperients, though positively re- quired ; and they are so sensitive to pain, that they shrink from injections which are indispensable. It is impossible to lay down any rules for a sys- tem of treatment generally adapted to these cases, as so very much will depend on the complications that arise ; but I may briefly state, that the remedies which have succeeded best in my hands are gentle aperients con- tinuously used, tonics, the occasional resort to stimulants and sedatives when there is much prostration and pain, and the persevering employment of injections, which must often, at first, be extremely mild and be aided by blisters. Perhaps, however, the history of a case or two will exemplify the rules of treatment better than any description, and I therefore give two ; one in which the disposition to this state seemed to be constitu- tional, and another in which it appeared to have been chiefly induced by large doses of copaiba. F. H , Esq., a delicate-looking man about twenty-five years old, who had suffered a good deal from spermatorrho3a and nervousness, consulted me in the middle of August, 1872, for what he caUed a slight discharge, which, however, on examination, was evidently enough the beginning of a pretty severe gonorrhoea. His account was that he had had it some little time, but had found scarcely any inconvenience till a few days previously, when a hard pull on the Thames and some pale ale thoroughly developed the complaint. As he was of a highly excitable temperament, acutely sus- ceptible to pain, and already depressed by long-continued emissions and great irritability of the urethra, I restricted the treatment almost entirely to gentle aperients, moderate doses of the acetate of potass mixture and very mild injections. This treatment had nearly subdued the disease, 14 210 ON GONORKHCEA. when he imprudently went down to the sea-side, took a long walk, and in- dulged in other ways, the consequence of which was an immediate and severe relapse. As the gonorrhoea did not seem now to be influenced by the same remedies as before, I tried the santal-wood oil, in doses of thirty, gradually raised to forty-five and then sixty minims a day, which was as much as he could bear. At the end of three weeks he was no better as regards the discharge, while his health seemed to be decidedly worse, and he was much plagued with the emissions. Tincture of the sesquichloride of iron in full doses was ordered, the strength of the injections was some- what increased, and a longer syringe was used. The discharge very slowly diminished, and in order to remove it thoroughly, I applied the solid nitrate very gently to the back of the urethra and blistered the penis. These steps brought on a profuse discharge, and great irritability of the bladder ; but after a few days the symptoms declined, and there seemed a prospect of his getting quit of his tormenting complaint, when unfortunately, one evening early in December, on alighting from a railway carriage while the station was in almost total darkness, he slipped and violently strained the perineum. He immediately felt that he was badly hurt, and though he attempted for two or three days to continue his duties, he was obliged to take to his bed. I found him, December 14th, with an irregularly intermittent pulse, coated tongue, total loss of appetite, irritable bladder, profuse urethral discharge, and great swelling of the left testicle, which was also intensely painful and sensitive. His complexion was almost the color of a prim- rose, his whole frame was bedewed with perspiration, and he seemed extremely agitated ; he was also suffering greatly from indigestion and flatulence. He was put on a diet of slops, and ordered at least three glasses of port wine daily, with a glass of hollands at bedtime. Sedatives with stimulants were prescribed, to be accompanied occasionally by a gentle aperient ; but his stomach rejected every sedative that I tried, and I was compelled to give these remedies up. Under the influence, however, of the diet mentioned, rest, and carminatives, followed by nitric acid and bitters, his health improved ; mild injections were given occasionally almost from the first day, and apparently with benefit. The urine, which at first contained a surprising amount of urates, and a great deal of mucus, had returned to its normal state, the irritability of the bladder had sub- sided, and the testicle had lessened considerably. While he was thus progressing he decided to return to his work. I totally refused to sanction such a step, as the weather was raw and cold. In less than a week, January 26th, I was again called to him and found a complete relapse. The other testicle was swelled and very painful ; there was great pain in the perineum and bladder on making water ; the pulse was intermittent, the tongue coated, the stomach rejected food ; he was sleepless and excited, and suffered occasionally from headache, which was TREATMENT. 211 described as "frightful." Sedatives were again tried, bimeconate of morphia, hydrochlorate of morphia, solid opium, hyoscyamus and chloro- dyne being ordered in succession, but none of them agreed with him. The same treatment as before was therefore substituted and the injections were resumed, the fluid being carried to the neck of the bladder. The mem- branous part of the urethra was intensely sensitive ; otherwise he bore the injections very well. Having just then received a communication from a patient in India, stating that he had been cured of an obstinate gleet by painting the perineum with tincture of iodine, and taking small doses of iodide of potassium, I determined to try these remedies in the present case, though I had, years ago, used them several times without any benefit. Here, too, they failed to produce any impression on the discharge, and the patient begged me to desist from employing them, as it seemed to him sheer waste of time. The iodide was, however, continued, but in tolerably large doses and in conjunction with the liquid potassse and bitters, while the injections with the long syringe were kept up. He rapidly improved, and on March 8th he returned to work, having been for some days quite free from every symptom, except a slight hardening of each epididymis and the occasional appearance of small shreds in the urine, for which he was directed to pass a soft bougie twice a week. As the nocturnal emis- sions still plagued him occasionally, I prescribed the tincture of the ses- quichloride of iron. On March 20th he called to report that there had been no return of the discharge and that his health continued to improve. In another case the patient was a member of the medical profession, who placed himself under my care, after having made a most unsatisfac- tory attempt to treat his own complaint. I found him low, weak, and dejected ; he was suffering under enlarged prostate, with a painful bearing-down, as if the rectum were coming out, so that when walking he constantly felt an urgent desire to keep his hand pressed upon the anus. There was a moderate amount of discharge, with no great pain in making water or during erections. The tongue was brown, furred, tremulous, and indented by the teeth the breath was foul his face looked coarse and dusky he said he had lost all his color along with . his appetite and strength. Great part of his sufferings he attributed to the amount of copaiba he had taken ; and, as according to his own esti- mate, he had for some time past managed to get down five ounces a week, the supposition was very feasible. The use of these preposterous doses was always followed by nausea and loose stools. To complicate the case still further, it appeared very doubtful, from the patient's description, whether there was not some stricture to be apprehended, as six years pre- viously he had suffered under gonorrhoea, which, after having been duly treated with copaiba, slowly changed to a gleet, and this in its turn every now and then reappeared ; so often, indeed, that I doubted if it had ever been cured. Latterly, also, there had been a good deal of dribbling after 212 ON GONORRHOEA. making water, and, the patient thought, some slight nan-owing of the stream. Patient intensely irritable and gloomy. On examination by the rectum, the prostate was found greatly enlarged, and a blister was ordered to be applied to the perineum. A bougie was also passed, and a most irritable state of the urethra discovered ; no strict- ure, however, was encountered. "Within forty-eight hours after this operation the right testicle swelled in an extraordinary way. The patient could not allow me to touch it, and the attack was accompanied by such prostration that he was obliged to confine himself to his room. Morphia in large quantities was ordered, and relieved him so rapidly that he said, if he could hardly describe the comfort this dreamy, quiet state inspired, compared with his first night's suffering." Hot water to the scrotum so as almost to excoriate it, a well-fitted suspensory bandage, a brisk ape- rient, and a diet from which all cold, ascescent, heavy articles of food were rigidly excluded, soon relieved all the most severe symptoms. At the end of a week I examined the testicle ; and though this was one of the worst cases of orchitis I ever saw, I was not prepared to find such evidences of active disease. The epididymis was greatly enlarged and of almost cartilaginous hardness, as was also great part of the testicle ; and though all pain was gone, yet the patient still shrank instinctively from the slightest touch. I now asked him if he had ever strapped the testicle for orchitis, and if he would like to go through the process. He at once ad- mitted that he had performed the operation, but he entirely objected to having, it done on himself, and I very strongly suspect that many advo- cates for strapping might, under similar circumstances, give much the same reply. The discharge was now treated with mild injections of nitrate of silver, followed by the use of gum-elastic bougies every second day. Two blisters were applied to the perineum and two to the penis. Iodide of potassium was given in doses of ten grains twice a day ; calomel and black draught twice a week. A full meat diet was ordered, and a bottle of claret daily. The discharge soon ceased entirely. The urethra became so healthy that the bougie could be passed with scarcely any discomfort. After the first three weeks the prostate gave him no further annoyance ; and finally such a steady subsidence of the hardening of the testicle ensued, that when he paid me his last visit, about four months from the beginning, little more than a slight thickening remained to mark the seat of disease. His tongue became clear, moist, and firm his appetite returned, and he soon gained flesh and strength. From having been unable to walk a mile without fa- tigue, he was now almost as well as he ever had been, and in better health than he had enjoyed for years. Another case in which the weakness, partly natural and partly acquired, materially interfered with the treatment, will be found in the section on strong tendency to stricture. TREATMENT. 213 For the most part the weakness induced by long-continued use of co- paiba is easily remedied. The first step is, of course, to give up the use of the balsam itself ; after this almost any mild preparation of iron, such as the citrate, conjoined with some simple aperient, will soon remove the effects. 3. TENDENCY TO INFLAMMATION or THE LACUNAE OF THE UKETHRA. How- ever hazardous the statement may seem, that inflammation of the lacunae rarely perhaps never ensues under the use of the treatment recom- mended for simple gonorrhoea, provided this has had time to act before the lacunae are involved, I believe I am warranted in making it ; but whether it ensues or not, the treatment of the parent disorder, on the sys- tem mentioned in the foregoing section, may be safely pursued, even though the previous experience of the patient is that this complication will follow. A surgeon, at that time a student, placed himself under the care of Sir Astley Cooper for gonorrhoea. The great surgeon ordered him an injec- tion of nitrate of silver, five grains to an ounce. The inflammation and pain, however, became so unmanageable that he was soon laid up with or- chitis and abscess of the lacunae. The latter burst externally, leaving a fistulous opening, which healed in a few weeks, and a gleet which lasted ten months. Subsequently he had a second attack, which healed in four months by means of copaiba and injections ; this time also the follicles suppurated. He contracted a third gonorrhoea, and treated it himself with small doses of copaiba and cubebs, which purged and nauseated him so much that he was quite prostrated. Dyspepsia and total loss of appetite came on, making him so irritable and weak that he could not mount his horse or attend properly to business ; within a fortnight three of the la- cunae had run into suppuration and one had burst externally. He then consulted me. A mild saline aperient, with full doses of morphia at night, was ordered, along with sulphate of zinc injections ; subsequently quinine and purgatives were given, and blue ointment was directed to be rubbed over the follicles. He speedily improved, no more lacunae suppurated, the discharge rapidly subsided, and in a few weeks gave way entirely. But I have seen very troublesome results indeed where the case was treated differently, and I believe most of the cases recorded of suppurative inflammation in the cellular tissue of this part owe their origin to disease beginning in the lacunae. E. E , Esq., came under my care for gonorrhoea. He had been suf- fering under it for several weeks. A small abscess had formed on the right side of the penis, about two inches from the mouth of the urethra. The abscess was pointing, and burst within three days from my first seeing him. The urine began almost directly to pass through the opening, and continued to do so. It was difficult to imagine any reason why the patient should suffer in this way. He was a spare, strongly built man, of unusually 214 ON GONORRH(EA. active, temperate habits, and extremely healthy. He had used no injec- tions and seemed to have been treated principally with antiphlogistics and a few small doses of copaiba. While under my care injections of nitrate of silver, the solid nitrate of silver, blisters, etc., were all tried in vain. At last, by applying the actual cautery and the acid nitrate of mercury to the interior of the fistula, I succeeded in reducing it to a very narrow passage, and, that done, I speedily brought down the urethra! discharge to a mere gleet ; but I could not completely cure either, and while I was contem- plating further steps, the patient was compelled to leave for a journey into Russia. About a year after this, while still abroad, he again contracted a dis- charge, which seemed to have been treated in much the same way, except that copaiba was given more freely, and, along with it, cubebs. As the case grew much worse, he set out for England, but broke down before he got quite through Germany, and was laid up for a fortnight with great swell- ing of the penis, pain, and uneasiness of the organs generally. Directly he reached London he came to see me. The body of the penis was consider- ably swelled and persistently hard. In addition to the old sinus, through which the urine still passed, two new ones had formed at the junction of the lower surface of the penis and scrotum. From these radiated several passages backward under the scrotum, and forward under the skin of the penis, and though the probe could not be introduced into the urethra, the dribbling through these sinuses, every time the patient made water, showed that there was a communication between them and the canal For several weeks I tried everything I could think of to heal these fistu- lae. Dilatation of the openings, the application of the acid nitrate of mer- cury, of the actual cautery, and of a strong solution of canthao-adin in glacial acetic acid, were repeatedly used, but to no purpose ; while the gonoiThcea remained unaffected by blisters, injections, and the use of the solid nitrate to the interior of the canal. The thickening and induration of the penis and scrotum got worse, and the sinuses evidently increased in extent ; some of the skin, too, on the lower part of the penis was on the point of sloughing. At last, in a consultation with my friend, Mr. T. Carr Jackson, it was decided to put the patient under chloroform and lay open the si- nuses. This was done with the result of laying bare five fistulous openings into the urethra, and such a mesh of burrowing passages as has seldom, I fancy, been paralleled. Mr. Jackson said he had never seen anything like it I was compelled to remove some of the skin of the penis, its vitality being so compromised that there was no chance of saving it. Some weeks after the patient again left England, at which time not one of the openings into the urethra had healed. He subsequently wrote, however, from East India to say that he was a great deal better. ' 1 Mr. Johnson had also a patient tinder his care who had gonorrhoea several times, and on almost all occasions the lacunae suffered more or less. Op. citat., p. 183. TREATMENT. 215 Mr. Phillips seems to have been as fortunate here as in stricture. " I have," he says, 1 speaking of this complication, "adopted a treatment from which I have experienced the greatest success. I apply the lunar caustic to that portion of the urethra in which the interior orifice of the fistula is situated." The reader has just seen with what success I applied it, and I repeatedly touched not only the orifices, but also the sinuses themselves and adjoining parts of the urethra. Mr. Lee, as I understand him, thinks that these abscesses begin in the areolar tissue surrounding the urethra, and this view is supported by the observations of M. Lagneau, fils," who, speaking of three cases, in two of which the purulent collection was seated near the frsenum, and in one just before the scrotum, considers the peri-urethral tissue most likely to be their seat, because they did not impede the passage of the urine, projected outward, and opened exclusively on the outer surface ; grounds which do not seem to me conclusive, as closing of their urethra! orifices and disten- tion are not essential steps in the process. 4 MORBID SENSIBILITY OF THE URETHRA. In excessive natural tenderness of the urethra it is sometimes necessary to wait a day or two in order that the action of the potass 3 may be set up, and to give a sedative every night, before beginning with injections. The first two or three of these may con- sist of warm water ; the next of weak solution of nitrate of silver, begin- ning in some persons as low as one-tenth of a grain to an ounce ; after this no farther precaution is necessary. "Where this extreme sensibility seems dependent upon rheumatism or gout, a grain of the extract of colchicum every night may be serviceable. I speak doubtfully, however, and more out of deference to tradition than as the result of experience, for I myself never saw the least good from the practice. In most cases, after this difficulty is overcome, the injection may be in- creased in strength as with other patients ; but, on the other hand, there are many persons who can never bear injections stronger than a grain to the ounce without feeling severe pain. One gentleman, under my care, complained of much uneasiness, lasting for several hours, with heat and swelling of the penis, from a solution of two-thirds of a grain to the ounce, and noticed these symptoms very perceptibly when the strength was reduced to the eighth of a grain. Now it is never necessary to give severe pain. If the patient is only seen when the gonorrhoea itself is declining in violence, I would recommend free bathing of the penis with hot water two or three times a day ; the application of veratrin ointment, five grains to half an ounce, to the under surface of the urethra ; and the use of gum-elastic bougie. In some cases of acquired morbid sensibility of the urethra behind a stricture, both of them the sequelae of gonorrhoea, the nitrate gives ease 1 Op. citat., p. 289. s Gazette Hebdomadaire, p. 343. 1862. 3 See p. 124. 216 ON GONOEKHCEA. where the most delicate touch of the bougie is not borne. I had under my care a case thus originated, where I was for some time entirely foiled. The patient suffered little discomfort from the application of caustic to the stricture, and he scarcely complained at all when I expanded the contraction with a straight screw dilator which I use ; but, though a 'resolute man, he always shrank so from the contact of the point of the instrument, and even of the softest bougie, with the urethra behind the stricture, that I was obliged to desist. At last I passed the nitrate right through the stricture to this tender spot and used it pretty freely. The patient suffered little more than from the bougie, while the abnormal sensitiveness was so com- pletely removed that, though I employed both dilator and bougie on sev- eral subsequent occasions, he never complained. The instrument for ap- plying the nitrate in this way, as also that used for stricture, will be de- scribed in the next section. 5. STRONG TENDENCY TO STRICTURE that is, where the canal begins to contract within a very short time after the first appearance of gonorrhoea though not very uncommon when this disorder is neglected, has only oc- curred in my experience three times in cases treated properly with potass and injections. In two of them it yielded quickly enough to the solid nitrate applied by means of the sheath and stylet to be presently described. In the third case the patient, quite a lad, with a first and pretty sharp gonor- rhoea, was suddenly despatched on business which enabled him to indulge in the pleasures of the table to any extent he liked. Not having enjoyed such a privilege before, he made the best use of it now lived on game, salmon, champagne, punch, etc., and returned to London with the urethra closely strictured for about two inches a state of matters which required about eight months to set right again. A slighter degree of this disposition may, when accompanied by great con- stitutional weakness and impaired health, also give a great deal of trouble. C. F , Esq., a thin, extremely delicate-looking man about twenty- seven years old, consulted me March, 1874. His account was that he had inherited a very feeble and excitable constitution, with a morbid dread of pain, and that he had resided a considerable time in Jamaica, where he had contracted intermittent fever, from the effects of which he had never re- covered. Some considerable time before his visit to me he had been infected with gonorrhoea, which, though never severe, and treated by his medical attendant with great care and skill, had lasted six months. Al- though the discharge had ceased there was a sensation of tenderness and uneasiness in the posterior part of the urethra, which showed something was not quite right, and it was for this that he came to me. I advised him to pass a bougie once a week and to take a tonic, but he neglected to do either, and I saw no more of him till the beginning of June, when he came to be treated for a rather active gonorrhoea which he had caught quite recently. TREATMENT. 217 He was put on preparations of potass and gentle aperients, but, owing to his excessive dread of pain, I had great difficulty in gaining his assent to anything in the shape of injections. He was imbued with an utter horror of even the slightest operation. Vaccination, he said, had made him faint. However, after a little while I succeeded in carrying the point, with many stipulations on his part that the injections should be very mild, and that the point of the syringe should only just enter the urethra, the latter con- dition being one which I took the first opportunity of evading. The dis- charge was gradually brought down to a very slight affair, and then the im- provement came to a stand-still. I now tried thelsandal-wood oil, which the patient took with great regularity in quite half-drachm doses three times a day for some time. He was most anxious to get well, and I believe implic- itly followed out every direction given him. The oil seemed to produce some improvement, and then there was a relapse and another stand-still. As he was extremely low, with a weak, small pulse, I did not much like going on with the medicine and prescribed him quinine, followed by steel, with blistering. This, however, effected no particular good as regarded the discharge, which did not get quite well From the beginning I had warned the patient that the stricture, which I fancied was springing up in consequence of the first gonorrhoea, would be aggravated by the present attack, and when I saw that the means em- ployed were not bringing about 'a cure, I advised him not to waste any further time upon them, but to let me pass a bougie. Of this he would not hear unless he was put under chloroform, to which I most reluctantly consented, and he was accordingly chloroformed four times. He was how- ever so refractory, declaring he should die if his hands were held, and then, when they were set free, snatching the inhaler from his mouth, that three times no real insensibility was produced, and he foiled all attempts to explore the urethra. Once only he was fairly brought under the in- fluence of the anaesthetic, and then the insensibility became so great, that the surgeon who gave the chloroform grew alarmed, and I could do no more than satisfy myself that there was some contraction about five and a half inches down, a number, six passing with moderate ease. As chloroform was of no use, he was put under laughing-gas. I then passed down an armed number eight bougie, and as it would not go through the contraction just spoken of, pressed it sufficiently long against the narrowed spot to act thoroughly. The patient suffered very little after- pain, but the discharge remained as before. The sandal- wood oil was again tried, in as large doses as his stomach could bear, and again failed. He also took matico, in which he had great faith, with as little effect. 1 As he still shrank from the only step likely to be of service, the use of the bougie, except under chloroform, which I refused to employ, I advised him to blister 1 See page 83. 218 ON GONORRHOEA. again, and to accept an invitation sent him to spend a few weeks at the sea-side. He went down and, while there, blistered four or five times, he could not exactly recollect which. His health improved considerably from the change of air, and an impending attack of intermittent fever passed off ; but the discharge continued so entirely unaffected, that at last he made up his mind to have the bougie used, which, however, owing to my own ab- sence from town, could not be begun until near the end of October. Mean- while I directed him to give up the dilute phosphoric acid, which had been ordered for the symptoms of fever, and to take, instead of it, the tincture of sesquichloride of iron, ^hich he did, and reported, when I next saw him, that he had gained both flesh and strength from the use of the latter. On my return from London the employment of the bougie was com- menced, and with this began the first real improvement in the case. The stricture yielded slowly but steadily, and directly this change showed itself the discharge lessened. At first there was always some slight bleed- ing after even the most gentle passing of the instrument, but this was soon checked by the internal use of tannin. The patient had at one time suf- fered, though not very badly, from chordee, the annoyance being rather persistent than severe, and this the bougie only relieved slowly. By the end of the third week of December the discharge was practically extinct, and the urethra dilated to its natural size. During the first few days of the sudden thaw which took place in the beginning of January, there was an apparent relapse, possibly due to the patient having caught a bad cold, but the discharge was different from what I had ever seen it in him, being thin, not a$ all viscid, and of a pale, dirty yellow. I pronounced it not to be gonorrhoeal, and under the use of a drachm of tannin daily it went away almost as fast as it came. On the 25th of March he reported that, for thirty-seven days he had not perceived a speck of discharge in the urine, which he always scrupulously examined at least once daily. During the whole time the patient was under my care I believe he never omitted to take a single dose of the medicine ordered for him, nor had I ever reason to suspect that he transgressed against the suggestions made to him about remaining quiet and abstaining from stimulants ; yet the disease lasted nearly seven months. Possibly the stricture was the chief cause of this persistence, but his morbid dread of pain was the cause of the stricture remaining so long unrelieved, and his first attack, with which stricture had nothing to do, lasted six months. Caustic-holders. The instrument ' just spoken of and displayed in the engraving consists (1) of a platinum or silver canula, A, shaped like a No. 9 catheter with the blunt end cut off, and a pea-headed stylet, B. It ia passed down, with the stylet in, to any part of the urethra that seems very 1 The larger instrument is reduced almost one-half, the smaller one a fourth. The drawing of the ladle is of the actual size. The instruments are made by Messrs. Wal- ters & Co. , Moorgate Street. TREATMENT. 219 tender, and the stylet being withdrawn, a small flexible bougie, armed by dipping the tip into caustic fused in the ladle, Z>, is introduced through the canula and drawn lightly over the urethra for an inch or two. It is then drawn back within the stylet while the instrument is removed, so that only the part the surgeon wishes to cauterize is brought into contact with 220 ON GONORRH(EA. the nitrate. C represents a smaller instrument of the same kind sheathed, to be used when the seat of morbid action is nearer the mouth of the ure- thra. I have, however, after many failures, devised an instrument which I think I may safely speak of as superior to that just described, so far as re- gards applying the nitrate to the walls of the urethra in morbid sensibility of the passage, gleet, etc. It does not in any way supersede the sheath and stylet in stricture, and indeed aims at a different object. The instrument consists of a soft gum-elastic bougie, into which is in- serted, two inches from the tip, a platinum cage, soldered with gold so as to resist the action of the nitrate. This cage is an inch long, and some- what less in diameter than the part of the bougie into which it is inserted, an arrangement which affords greater protection to the nitrate, and the material in which it is imbedded, while the instrument is passing along the urethra, at the same time that it allows the salt to flow out when melted. It (the cage) consists simply of four slips of platinum let into a ring of the same metal at each end. Though the construction appears slight, it is really possessed of great strength, a wire being continued from the cage over the tip of the bougie. It is charged as follows. In summer a piece of white wax, as big as a small pea, is put into a Berlin crucible, and melted with a gentle heat over a spirit lamp. To this, when melted, is added twice the bulk of cacao butter, which at once mixes with the wax. So soon as this has set, the surgeon takes a piece big enough to fill the space between the bars of the cage and squeezes it in. Then, with a penknife, he scoops out a groove in the wax and butter, more than large enough to hold the amount of nitrate he intends to use, which may be half a grain to a grain. This being placed in the groove, any space left is filled up with a little wax and "butter melted for the purpose, and any loose or projecting points left are scraped off with the penknife, or rubbed down with the fingers. In win- ter less wax must be used, and in very cold weather it may be dispensed with altogether. The surgeon, having first of all passed a gum-elastic bougie a size larger than the instrument I have been describing, with the idea of finding out whether the passage is clear up to the part where he intends to apply the caustic, as also whether there are any tender spots on the way, with- draws the bougie and introduces the caustic-holder, well oiled, sliding it along as quickly as he can, till the cage is brought opposite the irritable part. Having now introduced the instrument, the surgeon allows it to remain till the patient begins to complain of a burning sensation, when it may at once be withdrawn. With management there should not be any- thing like severe pain, but if by chance this be set up, the use of a hot bath at 98 or 100 Fahr. for two or three minutes, and a good sedative, such as a dose of Battley's solution in an ounce of the brandy mixture of TREATMENT. 221 the pharmacopoeia, will generally relieve it in a short time. Or, instead of a bath, the patient may bathe the perineum well with hot water, but this, if more convenient, is less efficacious. In my own practice I have rarely known either called for. Sometimes a little purulent discharge, or a slight degree of bleeding, follows even a very gentle application of the caustic, but the surgeon may quite safely leave this to itself, and repeat the appli- cation from two or three to several times, as the case is more or less severe. If there be no particular tenderness, the caustic may be applied to the prostatic portion of the urethra. The advantages offered by this instrument are, its small cost, which is not more than half that charged for other caustic-holders ; its simplicity, all screws, stylets, etc., being done away with ; its safety, the strength of the materials being so great that a strong man could not drag them asun- der, while they are not acted on by the nitrate as in Lallemand's instru- ment ; and finally, the ease with which it can, owing to its softness and elasticity, be introduced even into a very sensitive urethra. 6. RETENTION OF URINE. This complication may very well be taken here, though really its more natural place would be in the preceding chapter, as it belongs to those things 'which do not, materially at least, interfere with the treatment of the gonorrhoea. I have not often seen it except in the case of a patient who, with a previously existing stricture from gonorrhoea, had contracted a fresh attack of the latter disease ; in these instances, too, the immediate attack of spasmodic stricture has generally been traced to a debauch, though sometimes it arises from long exposure to cold and wet, one of the worst cases I ever saw following upon a walk of some hours through a snow storm. One patient, not suffering previously from stricture, brought on the contraction at the very outset of the gonorrhoea by passing a bougie four times in one day, setting up a degree of spasm which took four or five months to overcome. In addition to this M. Mauriac recognizes ' a progressive and incomplete retention, generally due to the inflammation having reached the membranous or prostatic urethra, seen usually in irritable subjects, persons suffering from catarrhal " urethrorrhcea," contracted by connection with the female just before or after the menstrual period, a complaint with which I am not familiar. Treatment. When such a thing can be procured the patient should at once take a hot bath, quite 100 higher if he can bear it. Very often this will suffice, and it almost always affords some help, but it should be accom- panied by a full dose of laudanum or Battley's sedative ; and unless this speedily overcomes the obstruction the catheter should at once be resorted to. On the whole no instrument has answered so well in my hands as a moderate-sized or small gum-elastic catheter, which I almost invariably 1 Progrs Medical. Quoted in London Medical Record, p. 335. 1880. 222 ON GONORRHOEA. use without a stylet. Mr. Savory strongly praises ' chloroform in spasmodic stricture ; he also remarks that the action of a brisk aperient will often cause a passage of urine. Sometimes a gonorrhcea supervenes upon an old stricture. The gonor- rhoea is cured or reduced to a slight gleet, but so soon as ever a bougie is passed to remove the stricture the discharge returns. I have tried pretty well every variety of treatment, and consider on the whole that embodied in the following paragraph as the most satisfactory. 7. BALANITIS OCCURRING ALONG WITH PHTMOSIS AND STRICTURE. If there be, along with the state of matters just described, balanitis and phimosis, the prepuce should forthwith be divided, unless the patient will permit of circumcision being performed, which is still more effectual. This step speedily disposes of both the latter complications, the balanitis requiring little, if any treatment after the operation has been performed. The next thing is to reduce the gonorrhcea to a minimum, for according to my expe- rience it is rarely cured at this stage, by means of very mild injections of nitrate of silver. So soon as ever this is done the solid nitrate should be applied to the stricture, and nothing further need be attempted till this is set right. With the removal of it, the gonorrhcea I believe invariably disappears of itself. The bougie may be tried instead of the nitrate, but my essays with it in such cases have been unsatisfactory, whereas it is scarcely exaggerating to say that the nitrate, though applied only to the contraction, acts with almost unfailing certainty on the whole seat of the running. 8. EXCESSIVE IRRITABILITY OF THE BLADDER. Sudden and almost irresist- ible irritability oceurs at times in very healthy persons, often when the gonorrhcea is yielding to the influence of medicines ; but there is also an extreme and rare form which is encountered in delicate persons, and appears to arise from the gonorrhea al inflammation extending back within the first few days of its existence to the bladder. It is sometimes accom- panied by a strong tendency to evacuate the bowels on administering a urethral injection. Notwithstanding all my attempts, I have failed to discover any remedy on which we can rely in this variety of irritable bladder, which, however, is not often met with. I have tried every means recommended in standard works for the form usually seen, along with most of our sedatives and antispasmodics, such as sumbul, chloroform, etc., with no good result. On the contrary, I found the ordinary remedies so injurious here that I soon abandoned them in favor of tonics (using mild sedatives merely as an aid), an antacid purgative, such as a dose of Henry's magnesia or the effervescing citrate, and the steady use of injections. The following his- tory will, I hope, exemplify this class of cases better than any formal description : 1 St. Bartholomew's Hospital Reports, p. 29. 1868. TREATMENT. 223 A gentleman engaged in speculations of a very hazardous nature, and subject in consequence to all the variations between the extremes of excite- ment and depression, consulted me respecting a gonorrhoea which he had just contracted. As he seemed very irritable and nervous I inquired into his history, and found that, after having been long in indifferent health, he had two years before been attacked with influenza, for which he placed himself under the care of a well-known physician. The disorder slowly gave way, but he had never regained his flesh and strength ; his digestion was impaired, his appetite capricious, bowels often costive, urine loaded with phosphates and mucus, tongue coated and marked by the teeth. He was haunted by a feeling that he was growing smaller, which, he said, in spite of its absurdity, he could not shake off. The dis- charge from the urethra was thin, yellow, and profuse, much like that occasionally seen without any manifest cause in elderly men. There was no particular uneasiness about the parts of generation ; no pain in making water, chordee, or swelling of the prepuce. The discharge had appeared only two days previously. A mild saline aperient was ordered, and, as the patient was very timid, only a weak injection was employed. In a few days the irritability of the bladder became so excessive that the injection was instantly thrown out again with a little urine, and the patient had to make water three times in the first half hour after. This state continued to a certain extent up to a late hour in the evening. He was ordered meat and a glass of port daily, quinine and sedatives were given', and as it was found that the occasional use of brisk cathartics induced much less irritability of the bladder and rectum than the mild aperients had done, they were substituted. Injec- tions of nitrate of silver, however, were principally relied on to remove the discharge. The first effect of these was to increase the irritability of the bladder for an hour or two after using them, when it quickly ceased and did not return till the injection was repeated the next day. Having syringed out the anterior part of the urethra, the tube of the long syringe was passed down, and when withdrawn pus was found adhering to its point. The long syringe was therefore substituted for the short one, and the injection was gradually raised to the strength of ten grains to an ounce ; an amount I have often found necessary whenever it was requisite to apply injections low down. This alteration had the desired effect ; the discharge dimin- ished steadily, though it did not entirely disappear for six weeks. The irritability of the bladder grew gradually less, but to the very last the pa- tient was always compelled to sit down immediately after an injection ; and hence as the remedy was continued occasionally for some weeks after, it may be assumed that the irritability endured, in all, full ten weeks in a rather severe form. There was no relapse, the patient gained flesh and strength under the use of quinine, and married soon after. 224 ON GONOERHCEA. 9. INFLAMMATION or THE BLADDER. This rare complication, when it does happen, generally attacks the neck of the viscus, but whatever be the part assailed, it should, I think, be treated in the same way. The prompt and liberal use of sedatives, hot bathing, the application for a short time of a hot turpentine stupe over the pubis, and a diet of slops, from which wine is not necessarily excluded, are the most suitable of the means with which I am acquainted. Any direct applications are, I think, even when the more formidable symptoms have abated and the affection seems enter- ing upon a chronic state, better suspended. As a rule, the symptoms al- most invariably, if not in every case, decline under the influence of these measures, and those recommended for irritability of the organ. The em- ployment, too, of some of the substances of which the injections, recom- mended by certain authors for this symptom, are composed, seems to me as much calculated to endanger the patient's life as to cut short the course of the disorder. M. Robert mentions ' most serious results as having arisen from an injection of cold tar- water. A case of acute cystitis from gonorrhoea, treated with "balsams" and Van Swieten's fluid, ending fa- tally, in the practice of M. Guilvac, is mentioned in the Giornale italiano? After death it was found that perforation of the bladder had taken place. Brodie says * that when, in acute inflammation of the bladder, the urine remains acid, and the sediment which it deposits is yellowish, having no adhesive property and being apparently purulent, the patient will often derive benefit from two grains of calomel and half a grain of opium two or three times a day ; when it is alkaline, he has known much good arise from the use of vinum colchici, fifteen to twenty minims three times daily, for three or four successive days. 10. EXCESSIVE IRRITABILITY OF THE RECTUM seems principally due to the sudden and irregular distention of the urethra by the injection. I in- jected a gentleman with solution of nitrate of silver for a gleet which had been treated with chloride of zinc injection and copaiba ; he was compelled to make a precipitate retreat to the water-closet. The next day I made the injection quite weak, although the first had occasioned no great pain ; the irritability of the rectum was still as great. I then used the caustic plug described at page 134; this did not induce any irritability of the rec- tum, and four applications removed the discharge. It came back a little, and he never summoned up resolution again, saying that " for a mere drop of discharge it was not worth the trouble." 11. PERINEAL ABSCESS. Of gonorrhoea accompanied by this complication I cannot give so favorable an account, not having found it so amenable to treatment as might have been expected. Fortunately enough, it is rather rare. 'Op. citat., p. 91. 9 An. viii., p 302. 1873. Quoted from the Bordeaux Medical. 1 Works, vol. ii., p. 463. TREATMENT. 225 It is laid down as a rule of treatment that leeches, antimony, calomel, and black draught should be exhibited for this affection. Those who have succeeded, with these remedies, in checking the progress of perineal ab- scess, have had better fortune than has fallen to my share, as they have never appeared to me to exert any material influence over its course. The only remedy from which I have ever found benefit arise is the po- tassio-tartrate of antimony in large doses, aided by the application of water at nearly scalding heat to the perineum, and sometimes the free applica- tion of the nitrate of silver to the surface. In six cases out of eight in which I collected the histories, and had an opportunity of tracing them to their close, a complete though slow cure of the abscess took place ; the gonorrhoea, however, proved more difficult to subdue than in most other cases. In the seventh the patient, just as the abscess was a little improved, gave up the medicine in disgust, and soon returned with a larger and more painful swelling. This was also subdued by the use pf antimony ; but though he attended regularly, the urethra long felt hard and tight at the seat of the abscess, and a gleety discharge remained which proved very intractable. On passing the bougie the canal did not appear much narrowed, but it was somewhat twisted and peculiarly hard and inelastic ; there was also considerable dribbling after making water. More than a year after this I met him, when he informed me that he had had no return of the gleet, but the uneasy feeling of hardness was still there. The eighth case was that of a gentleman in whom the abscess had been checked, eighteen months previously, by the heroic use of leeches, poul- tices, etc. ; since that time the discharge had never diminished, and was now thick and yellow. He had taken large quantities of medicine, principally copaiba and cubebs, but without any result, except that of increasing dis- gust for " all physicking." For three or four months he tried blisters, aperients, and short syringe injections with unwearied perseverance, but with no effect. I wanted to cauterize the urethra and use bougies, but he said he had suffered so much that he could not bear the idea of more in- struments. At last he permitted me to introduce a gum-elastic bougie ; on reaching the seat of the abscess, the urethra was found excessively ten- der and irregular. Three years subsequently he again consulted me for two confirmed and very tight strictures of the urethra, one of which was only an inch and a half from the orifice. He had for some time always carried a small bougie, which he occasionally passed a little way down. The discharge had never ceased ; his health seemed quite broken down, and he presented a melancholy picture of a constitution never very sound, now to all appearance ruined for want of resolution to undergo a mild op- eration. He still persisted in refusing to allow bougies to be used. Sub- sequently I attended him for complete retention of urine, and succeeded in passing a No. 2 catheter with the greatest difficulty, just as the symp- 15 226 ON GONORRHCEA. toms had become too serious to admit of further delay, and after I had re- solved, if this failed, to pierce the bladder from the rectum. Although he knew in what jeopardy his life had been placed, and though strangely enough his brother died about this time from stricture, he seemed after his recovery to grow more indifferent than ever. These cases, coupled with others which I could not watch so completely, quite impressed me with the conviction, not only that perineal abscesses should be attacked with the utmost vigor, but also that the treatment ought to be continued till the hardness has disappeared. Subsequent experience has enabled me to verify this opinion ; and of late years I have always, so soon as the antimony had checked the inflammation, used the iodide of potassium in combination with liquor potassae till some effect was produced. The perineum should be blistered as often as the patient will allow it, and during the intervals blue ointment combined with camphor may be rubbed in every night. The bougie is also to be passed twice a week, so soon as the state of the urethra will permit. If suppuration cannot be averted, the matter should be let out by a small puncture with an insect-needle. Mr. John Marshall has used, 1 with great success, solution of morphia in oleate of mercury as an outward application in threatening abscess of the peri- neum from inflammation of one of Cowper's glands, as also in epididymitis ; in one case where I tried it the result was decided failure. 12. INFLAMMATION OF THE PROSTATE. Pathology, Divisions. Three forms are distinguished. 1. Acute, marked by acute, often violent, burning pain in perineum, aggravated by walking or even moving, perineum sometimes becomes sensitive to every touch, feeling of a foreign body in rectum, great difficulty in evacuating bowels and making water, which may rise to tenesmus, strangury, and passing of water drop by drop, catheter sud- denly arrested at prostate. Sometimes hypogastric tension, great anxiety, and even fever of synochal type. After a day or two pulsating pain in region of prostate ; one or more lobes of the gland may be swollen, fluc- tuation usually in eight to twelve days, possibly marked by rigors. 2. Subacute or chronic (Congestion of the Prostate). Heavy dull feeling in the perineum, with stiffness and heat, particularly on standing or moving, pain and smarting in upper part of thighs, frequent desire to make water, pain after voiding it, possibly, though by no means frequently, some mixt- ure of blood in the last drops of the urine, often urine turbid, not unfre- quently hypersecretion of mucus in urine, or there may be small strips of mucus in it mixed with pus from the prostate. Gland not much en- larged ; painful on firm pressure. Affection seen chiefly in my experience when the patient has taken much copaiba and hard exercise. 3. Mucous, known also as catarrhal or canalicular. Affects principally the mucous membrane, from the ramifications of which in the gland drops of muco-pus 'Lancet, vol. i., p. 711. 1872. TREATMENT. 227 have been seen at an autopsy exuding on pressure, the stroma not being inflamed or even red ; but organ almost always tender. Prognosis. Favorable; I believe recovery to be, even in bad cases, almost entirely a question of attention and sound treatment. Results. The end of the first form may be that the gland becomes filled with matter, generally burst by passing the catheter, though it may open externally. Not unfrequently, according to Fournier, 1 the inter- minable suppuration from a prostatic cavity carries the patient off after a long period of suffering and cachexia. Mr. Phillips says a this form may end in gangrene. A case of death from abscess of the prostate, following upon this variety of the affection, occurred some years ago at St. George's Hospital, under the care of Dr. Pitman. 3 The patient was a man, aged five-and-twenty, and had only been suffering a fortnight when he was admitted, eight days after which he died. The abscess was not detected during life. The autopsy revealed nothing beyond extensive suppuration in the gland, and profuse purulent discharge from the urethra. Indeed, but a few years ago, when it was thought that the running in gonorrhoea is the natural cure of the disease, and the effort of nature to throw off the virus, death from disease of the prostate was not at all uncommon. 4 The subacute kind may, if neglected, end in very obstinate induration. The follicular order frequently degenerates into an obstinate gleet, and I shall have to say a few words about this in the next chapter. Treatment. In my opinion, when we have to deal with an acute case, the remedy before all others is tartar emetic as recommended for abscess of the perineum, and, if the patient object to this, small doses of calomel or hydrargyrum c. creta, a good sedative every night, rest in bed, and very light diet. Leeches are often useful, this being perhaps the only compli- cation of gonorrhoea in which they are called for, and patients often speak gratefully of the benefit derived from the employment of them ; but in point of potency they are far behind the antimony, the operation of which should be seconded by a resolute and persevering scalding of the perineum, with the exhibition of a full dose of some gentle aperient, such as syrup of senna, or castor-oil in hot milk in the morning. As to enemata and sup- positories, they have, the latter especially, always given more pain when I have seen them used than done good, and I quite concur with Dr. Erskine Mason 5 in objecting to their employment. So soon as the more acute symptoms have passed off, iodide of potassium should always be given. Brodie relates 6 a case, where the patient was suffering great distress from enlargement of the gland, which was two or three times its ordinary size. The patien tattributed the disease, and I think with justice, to an attack 1 Nouveau Dictionnaire, tome, v., p. 203. 2 Op. citat., p. 303. 3 Lancet, vol. i , p. 408. 1860. 4 Howard : Op. citat., vol. i., p. 218. * American Journal of Syphilography, etc., p. 289. 1870. 6 Works, vol. ii., p. 503. 228 ON GONORRH(EA. of gonorrhoea ten years previously. The affection had existed in its pres- ent form, and that a pretty severe one, for three or four years. Yet two grains of iodide of potassium, three times a day, in about seven weeks re- duced the prostate to its normal dimensions, and, judging from my experi- ence of such cases, would, if taken earlier, have saved the patient all these years of suffering. So soon as the prostatic affection is checked, the treat- ment of the gonorrhoea may be resumed. Brodie recommends J rest in bed in the horizontal position, blood to be taken from the loins or perineum by cupping, from the latter region, how- ever, only when the services of a dexterous cupper can be secured ; when this cannot be obtained, then leeches to be applied to the part. Active aperients are to be exhibited, followed by opiates in the form of an enema or suppository. After the bowels have been freely opened, calomel, in doses sufficient to bring on the mercurial action, is often useful, and if there be retention of urine, a small gum catheter is to be introduced, and the water drawn off when necessary. But, even with so great an authority against me I do not hesitate to say that the tartar emetic is more effica- cious. In bad cases Fournier applies twenty to thirty leeches two or three times in succession. When any part of the prostate remains tender and swollen, as also in indolent swelling after epididymitis, Dr. Schuster finds the Aix-la-Chapelle warm sulphur-baths very useful At the same time I must observe, that the recorded effects do not seem to exceed those follow- ing the plan recommended, which, thoroughly carried out, rarely, I believe, fails. For the second and third forms nitrate of potass in five to ten grain doses three times a day in infusion of cascarilla or snake-root, or bromide of potassium fifteen to twenty grains every four or five hours, with the mercury and sedative at night, can, I think be quite relied on. This treat- ment must be supplemented by hot bathing, blistering, rest, and iodide of potassium, just the same as the other. 13. INFLAMMATION OF THE SEMINAL VESICLES. I have no personal experi- ence of anything like active inflammation of these bodies being set up by gonorrhoea ; but it seems pretty certain that an action closely resembling irritability of the bladder is sometimes thus induced, for I have seen vesic- ular gleet developed by gonorrhoea and prove rather difficult to cure. M. Velpeau was in the habit of pointing out the rather frequent occurrence of a certain degree of inflammation in these bodies from gonorrhoea. In a few rare autopsies, according to Fournier, the appearances were general tumefaction with hardness, injection of the mucous membrane, the seminal fluid sometimes replaced by yellow muco-pus, in which the microscope showed pus-globules. Godard twice saw atrophy of these organs. Respect- ing the treatment of the inflammatory form I can say nothing worth the "' Works, vol. ii., p. 191. TREATMENT. 229 reader's attention ; that of the latter consists of tonics, with mild aperients to obviate the irritation set up by hard stools, blisters to the perineum, and, when the urethra remains irritable, weak injections of nitrate of silver with the long syringe described at page 172. It is perhaps scarcely neces- sary to caution the junior practitioner and student here as to the diagnosis, by digital examination, of an inflamed and projecting prostate, only about an inch from the entrance of the gut, and with no very marked parting between its lobes ; and of the vesicles, which can scarcely be reached with the finger and are widely separated. 14. GONORRHCEAL PERITONITIS. Although those authors who have touched upon the subject seem undecided whether this complication and phleg- monous inflammation of the cellular tissue outside the peritoneum are due to extension of the orchitic inflammation along the vas deferens to the cavity, or that of gonorrhoea from inflamed seminal vesicles, I am quite disposed to think that, as regards the phlegmonous inflammatiou at least, we must, supposing either can be looked upon as a profitable factor, lay the burden upon the vesicles. Were such a result due to propagation along the vas deferens, we should, judging from the frequency with which this occurs, see abdominal complications more often. Besides, it is at least as probable that a suppurative inflammation, such as is noticed in the ves- icles, would set up a similar form of action within the abdomen, as that this should result from the affection of the deferent canal, which I believe never ends in the formation of pus. For such reasons I have decided to take these complications here. Hunter, however, had a case of peritoneal inflammation, arising in his opinion from the vas deferens being affected by gonorrhoea " in its course through the belly and pelvis." According to Fournier ' Eicord has several times seen this complication, which, judging from the context, must be supposed to have arisen in the same way. Cases have also been recorded by Messrs. Gosselin and Godard. In the first case mentioned 2 by the former of these two authors, the inflammation seemed clearly to extend from the right testicle by the corresponding vas deferens and seminal vesicle, the latter being extremely tender on pressure, although the orchitis was not very marked. The attack was, however, very slight, the patient being much better the next day, though only the most simple means were used ; the disorder being apparently supplanted by a large swelling of the cauda and lower half of the body of the epididymis. So far back as 1856 M. Peter published a case of gonorrhoea! orchitis followed by inflammation of one of the seminal vesicles, and then of the peritoneum and pleura, ending fatally. The patient was a delicate lad, sixteen years old, admitted into the hospital for orchitis of the left side. Ten days after entering he was attacked with shiverings, feeling of illness, 1 Nouveau Dictionnaire, tome v., p. 214. s Gazette des Hopitaux, p. 434. 1873. 230 ON GONORRHOEA. nausea, vomiting, which became bilious and abundant, and pains in the abdomen, slight at first and then growing severe. There was no abdominal distention, but the patient rested fixedly on his back ; there was slight cough with dyspnoea ; no hiccough. The pulse was 105 and compressible ; there was great thirst, accompanied by repeated and abundant bilious vomiting. The orchitis does not seem to have been very severe, and the indurated epididymis was not very painful to the touch. The case was diagnosed as peritonitis, due to extension of the gonorrhoeal inflamma- tion through the medium of the vas deferens and seminal vesicle, and was treated with leeches, mercurial inunctions, cataplasms, and ice. Delirium came on, the left side of the chest became painful, and the patient died in a week from the beginning of these symptoms, and sixteen days after ad- mission. M. Peter expresses the opinion that, in this case there was in- flammation by contiguity as well as by continuity. At the autopsy a litre of purulent fluid was found in the pelvic basin, the intestines were covered with purulent and glutinous serum ; there was some amount of false membrane on the ascending colon and liver. The urethra was red at its anterior part ; the veru montanum of remarkable pale- ness ; both the ducts and stroma of the prostate were inflamed. In the right seminal vesicle was a small quantity of spermatic fluid which con- tained epithelial cells, molecular granules, and a few dead spermatozoa. ID the left vesicle was found a small quantity of purulent liquid, in which the microscope showed existence of pus-cells, mixed with epithelial cells, but no spermatozoa. This vesicle was larger than the other, owing to the surrounding cellular tissue being much injected and thickened ; the peri- toneum underlying it was more vascular than any other part even at the seats of inflammation. At the point where it turns round the left seminal vesicle the vas deferens was much injected, as was also the surrounding cellular tissue. There, as in its pelvic portion, this duct was swollen, hard, and firmly adherent to the peritoneum which covered it. The overlying cellular tissue was hardened ; the mucous membrane of the canal pale. The left epididymis larger than the right. Prognosis. Serious, three patients out of five attacked having died. Founder admits the possibility of this grave result. Of the treatment I cannot speak, having seen no cases myself, and having found no directions in any work or paper. 15. SUB-PERITONEAL INFLAMMATION. Some years later 1 M. Faucon ad- dressed a note to the Societe de Chirurgie on the subject of this complica- tion which he connects with the peritonitis of gonorrhoea, first mentioned by Hunter as due to the gonorrhceal inflammation having extended by the vas deferens, but no further investigation of the subject took place till the publication of his own excellent memoir 2 on the subject. 1 October 22, 1873. * Archives Generales de Medecine, tome ii, p. 385. 1877. TREATMENT. 231 In a case of this inflammation, following upon gonorrhoea! cystitis and orchitis of the right side, described ' by him, he says there was no swelling over the tract of the cord, but the patient pointed to the sub-inguinal and inguinal parts of this line as the chief focus of the pains which he felt in the whole of the hypogastric region, and which seemed to radiate, growing weaker from the inguinal region toward the surrounding parts. The pain was increased by pressure. Fever, which seems, though not expressly stated, to have accompanied the orchitis, reappeared, the patient felt very unwell, and during the following twelve days considerable tumefaction of the sub-peritoneal cellular tissue took place. At first there was a sort of puffiness, appreciable only to the touch, at the lower part of the internal iliac fossa. This puffiness extended rapidly to the inner inguinal ring. It was then found that the wall of the abdomen was not invaded, but at the end of a few days this in its turn was attacked, and became the seat of a dense induration like wood (ligneuse), quite separate from the skin, ex- tending to four fingers' breadth above the fold of the groin. At one time the swelling of the vas deferens was fused with the induration of the ab- dominal wall. The pain, which had at first been dull without throbbing, was speedily accompanied by nocturnal exacerbations which entirely (!) deprived the patient of sleep. The pain stretched along the iliac crest and in the direction of the navel, but never toward the thigh. The pain was increased by coughing, laughing, and speaking, and pressure even elicited a cry of pain. Movements of flexion and extension, though restricted, were practicable so long as the patient remained in bed, but became much more painful and difficult when he stood up for a few minutes. The inguinal and scrota! parts of the cord remained normal. The general health was bad, there being continual fever, with a pulse of 100 to 105, accompani d by low delirium at night even when the patient was wide awake. The tongue was thickly coated, and there was complete anorexia with thirst and obstinate constipation. The affection evidently lasted in a very severe form from August 3d to October 20th, and at one time as- sumed such a grave aspect that M. Faucon cut down more than an inch (4 centimetres) deep in search of pus, but found none. M. Faucon considers that both gonorrhoea! peritonitis and sub-perito- neal inflammation appear in the third to the fourth week of the discharge, a statement of great moment as respects the diagnosis, particularly when we are told " that in Velpeau's case the peritonitis remained undetected for four days. Prognosis. Serious here also, for though I do not anywhere find death mentioned as the result, it is clear that the course and symptoms were of a nature to awaken great anxiety. Treatment. M. Faucon recommends energetic use of antiphlogistic 1 Archives Generates de Modecine, tome ii., p. 394. 1877. 2 Ibid., p. 558. 232 ON GONORRHCEA. measures, prolonged employment of ice, and preventive division of any constriction in the affected parts. Along with this complication may, I think, very properly be placed that which follows. 16. GONORRHCEAI, PERiNEPHRiTic ABSCESS. A case of this, the predispos- ing cause being evidently gonorrhoea, is mentioned by M. Laforgue. 1 The patient, a young man, age not given, had used some quack injection to cure a gonorrhoea, which had the effect of arresting the discharge ; then, having indulged in a debauch, he was seized with retention of urine which re- quired the immediate use of the catheter and antiphlogistic treatment. The passing of the instrument was painful, and revealed a tender and swol- len state of the prostate, which had been the cause of the stoppage. The bladder became inflamed, and notwithstanding the most energetic emplo}'- ment of hip-baths, belladonna inunctions, and so on, very little relief was obtained. There was great f everishness with exacerbations at night. The pain and difficulty in making water slowly gave way, but the straining of the bladder caused persistent suffering, and the urine was fetid and charged with membranous debris. The patient felt ill, lost his appetite, and suffered from constant pain in the hypogastric region. After drag- ging on in this way for three weeks he was suddenly attacked with shiver- ing and intense abdominal pain, accompanied by tumefaction of the right lumbar region, which also extended to the right iliac region. The lumbar swelling was opened and gave issue to a large quantity of pus. The reason of the collection forming in this part is, according to M. Laforgue, that such abscesses have their seat behind the kidney which separates them from the peritoneum. The following case by Dr. Alexander 2 was evidently enough of much the same nature. The patient had been treated for gonorrhoea with aperi- ent salines and alkalies, under the influence of which, apparently, the dis- charge ceased. Soon after he began to feel unwell and lost his appetite ; pain came on in the left lumbar region. The skin became hot, thermome- ter in mouth 105. A diaphoretic with aconite reduced the temperature, but the tongue was furred and bilious vomiting set in, accompanied by " horrid " pain in left loin, which hot fomentations failed to relieve ; in- deed he continued to get worse, and at the end of eleven days complained that the pain was extending round the back to the right side. On examin- ing, a small immovable tumor, with a doughy feel, was found two inches to the left and on a level with the umbilicus. The patient was now moan- ing, restless, and bathed in perspiration, the tongue was hard and brown. Hypodermic injections were ordered to induce quiet, and castor-oil and croton-oil to clear the bowels well out. On the nineteenth day there was a distinct feeling of fluctuation in the tumor ; the next day a needle was in- 1 Revue medicale de Toulouse. Quoted in Gazette des Hopitaux, p. 316. 1877. Also in Archives Generates de Medicine, tome ii., p. 547. 1877. ''Lancet, vol. i., p. 538. 1881. TREATMENT. 233 serted into the most prominent part of it, in front and two inches to the left of the umbilicus. Seven ounces of healthy pus were drawn off, and two days later seven ounces more ; another day twenty ounces were taken, and again on another twenty-two, the patient finally recovering. The treatment after the aspiration was commenced is not stated. 17. GONORRH on specific virus of gonorrhoea, 15 Avicenna, evidence of, as to early exist- ence of gonorrhoea, 4, 6 BADER, MR. , his treatment of gouorrhoeal ophthalmia, 204 Balanitis as a cause of orchitis, 172 occurring along with phimosis and stricture, 222 treatment of, 222 Bantock, Dr., on Noeggerath's theory of gonorrhoeal infection, 44 Barker, Dr. Fordyce, on a particular dis- ease of the interior of the womb, 16 Barnes. Dr. R. , on the seat of gonorrhoea in the female, 38 Bath, cold hip, in gonorrhoea in the female, 149 hot, in gonorrhoea, 96 hot, in scalding, 161. 162 its power of developing gonorrhoea questioned, 154 Bathing, hot, in gonorrhoea, 98 Baudin, M., case of gonorrhceal endocar- ditis related by, 250 Beale, Dr , on cause of acidity of urine, 154 alkalinity of urine after meals, 155 Becquerel. M., on state of urine in gonor- rhoea, 154 Bell, Sir Charles, mode of injecting prac- tised by, 130 on the pathology of chordee, 162 Benedetti possibly acquainted with gonor- rhoea. 8 Beneke, Herr, on alkalinity of urine after meals, 156 296 INDEX. Benzoate of soda in gonorrhceal ophthal- mia, 265 Beroaldus, probable mention of premature emission by, 8 Bethencourt, James, on pathology of gon- orrhoea, 10 Bird. Dr. Golding, on cause of acidity of urine, 154 Black, Dr. John, on use of suppositories in vaginal gonorrhoea, 144 Bladder, excessive irritability of, 222 inflammation of, 221 irritable, 169 Bleeding as a remedy in gonorrhoea, 88 as a remedy in orchitis, 110 as a remedy from urethra, strong ten- dency to, 169 Blister, mode of applying, 139 Blistering in acute gonorrhoea, 137 in chronic gonorrhoea (See Gleet), 286 in orchitis, 200 Bond, Mr., on mode in which gonorrhoeal rheumatism is called into activity, 255 proportion of gonorrhoea patients at- tacked by gonorrhoeal rheumatism, 242 Bonnafont, M. , on treatment of orchitis with collodion, 196, 197 Bonniere, M., on the seat of gonorrhoea in the female, 39 on the seat of gonorrhoea in the male, 35 Bougie, method of passing, 283 mode of action of, in gleet, 284 passing of, as a cause of gonorrhoea. 24 suggested kind of, 282 Bougies, soluble, in treatment of gonor- rhoea, 118 Brandes, M. , cases of gonorrhoeal rheuma- tism related by, 247 on mention of gonorrhoeal rheumatism by Monteggia, 235 Brodie, Sir Benjamin, on cause of acidity of urine, 154 on iodide of potassium in enlarged prostate. 227 on non-existence of gonorrhoeal rheu- matism, 236 on relaxing action of warm water on stricture, 99 on treatment of acute inflammation of bladder, 224 .on treatment of inflamed prostate, 228 \ recognition of obstinate nature of ' gonorrhoeal rheumatism by, 235 Bruck, Dr., on treatment of gonorrhoea with corrosive sublimate, 95 Bubo, sympathetic, 169 Bumstead, Dr. J. Freeman, mode of in- jecting recommended by, 129 on chances of aboitive treatment in | gonorrhoea, 124 Bumstead, Dr. J. Freeman, on copaiba in acute stage of gonorrhoea. 77 on impossibility of injecting bladder with short syringe, 131 on pathology of chordee. 165 on purgatives in gonorrhoea, 89 on repeated connection as a source of gonorrhoea in the female, 27 CAMPBELL, MR. MACFIE, on average dura- tion of gonorrhoea under treatment, 71 Camphor, value of, in chordee, 167 Carmichael, Richard, not an advocate for strong nitrate of silver injections, 123 Castelnau, M., 011 disposition of orchitis to become chronic. 202 statistics of orchitis given by, 187 Cataneus, James, acquainted with gonor- rhoea, 7 Caustic -holder, Lallemand's, objections to, 136 recommended in preference to Lalle- mand's, 136, 218 Caustic plug in gonorrhoea, 134 Cauterization of the urethra. 136 Celsus, supposed mention of gonorrhoea and orchitis by, 2 Cervix uteri, treatment of gouorrhoeal af- fection of canal of, 145 Chabalier, M. , on the antiquity of gonor- rhoea, 1 Chambers, Dr. T. K. , on the expectant treatment of gonorrhoea, 68 on the prognosis of gonorrhoea, 40 Change of injections, necessity for, 127 Charteris, Dr., cases of gonorihceal pyaemia reported by, 253 on post-mortem appearances in gon- orrhoea, 35 Cheyne, Mr. Watson, on antiseptic soluble bougies in gonorrhoea, 119 on the presence of micrococci in gon- orrhoeal pus, 48 Chloride of zinc in gonorrhoea (See Zinc), 113 Chloroform injections, 103 Chordee, pathology of, 162 prognosis of, 165 proposed treatment of, 167 results of, 165 treatment of, usually adopted, 166 Cicero quoted by M. Chabalier as ac- quainted with gonorrhoea, 3 Cockburn on the extension of gonorrhoeal inflammation backwards, 34 on the treatment of gonorrhoea, 62 Cold as a cause of orchitis, 174 an exciting cause of gonorrhoeal rheu- matism. 238 Cold water injections, 104, 280 Colles, Mr. , on the extension of gonorrhoeal inflammation backwards, 35 Complications of gleet, 288 of gonorrhoea in men, 153 INDEX. 297 Complications of gonorrhoea which do not interfere with treatment, 153 of gonorrhoea which interfere with treatment, 207 of gonorrhoea in the female, treatment of, 140 of.gonorrhoea, search for, 140 Connection as a source of gonorrhoea, 13 Constantino of Carthage, description of gonorrhoea by, 6 Cooke, Mr. Weeden. on action of alkalies in scalding, 158 on consumption of copaiba, 74 Cooper, Sir Astley, gonorrhoeal rheumat- ism described by, 235 mode of injecting recommended by, 130 on extension of gonorrhoeal inflamma- tion along the urethra, 34, 171 on the treatment of gonorrhoea, 65 Coote, Mr. Holmes, case of rheumatism of eyeball related by, 267 on results of orchitis, 188 Copaiba in acute stage of gonorrhoea, 77 in gonorrhoea, 73 dose and mode of giving. 77 percentage of volatile oil in, 79 serious results from use of, 73 table of cases treated with, 75 Corpora cavernosa, gonorrhoeal inflamma- tion of, 206 Corpus sponqiosum, gonorrhoeal inflamma- tiou of, 2QQ Cowper's glands, gleet of ducts of, 276 Coxwell, Mr. Grinfield, kind of syringe recommended by, 129 Critchett, Mr. Geo. , successful treatment of a case of gonorrhoeal ophthmalia by, 265 Cruize, Dr. Francis, on distinction between two kinds of gonorrhoea, 25 on extension of gonorrhoea backwards, 34 Cubebs in gonorrhoea, 80 and copaiba combined in gonorrhoea, 80 Curling, Mr., employs ice in orchitis, 195 on absence of spermatozoa in semen after double orchitis, 188 on non-arrest of the discharge in or- chitis, 200 DAVIES-COLLEY, MR. , case of gonorrhoeal pericarditis related by, 250 cases of gonorrhoeal (?) endocarditis, related by, 250 on cause of great oedema of soft parts in gonorrhoeal rheumatism. 238 on frequency of gonorrhoeal rheuma- tism in women. ','46 on pathological changes in gonorrhoeal arthritis, 257 Death from gonorrhoeal endocarditis, 247, 249 from gonorrhoeal inflammation of cav- ernous bodies, 206 Death from gonorrhceal orchitis, 187 from gonorrhceal peritonitis, 230 from gonorrhceal prostatic abscess, 227 from gonorrhoeal pyaemia, 253 from gonorrhceal (?) pyelitis, 233 Debeny, M., advocates strong injections of nitrate of silver, 123 Deferentitis, case of, mentioned by M. Gosselin, 195 Demarquay. M. , cases of wasting of testi- cle from puncture in orchitis, seen by, 190 De Meric, Mr., on acute ovaritis from gonorrhoea, 146 injections of trisnitrate of bismuth in gonorrhoea, 102 Demulcents, action of, in scalding, 157 Dentition as a cause of gonorrhoea, 24, 25 Desnos, M,, cases of gonorrhoeal cardiac affection, related by, 248, 249 his unfavorable experience of salycin in gonorrhoeal rheumatism, 258 Desormeaux, M., on the changes seen in the urethra in gonorrhoea, 273 Despres, M. , on pathology of relapsing orchitis, 187 Diday, M., his mode of injecting, 112 on the genesis of gonorrhoea in the male, 24 on hot bath as a remedy in gonpr- rhcea, 97 on value of ice in orchitis. 195 on value of sandal-wood oil in gonor- rhoea, 85 Diet in gleet, 288 in gonorrhoea, 150 Discharge, gonorrhceal, arrest of, by or- chitis, 186 gouorrhceal, method of preventing from staining linen, 131 gonorrhoeal, pathological significance of, 27, 29, 43 gonorrhoeal, restoration of, as a rem- edy in orchitis, 199 gonorrhceal, urethral, from leucor- rhcea, milder nature of, 16 gonorrhceal, mechanical means, milder nature of, 24 Diuretics, action of, in gonorrhoea, 94 action of, in scalding, 157 Dor, M. , case of successful treatment of gonorrhceal ophthalmia reported by, 265 Dreadnought Hospital, results of gonor- rhoeal rheumatism seen at, 258 Dron. M., serious results of a case of chordee reported by, 165 Dufour, M. Charles, on innocuous nature of gleet, 293 Duncan, Dr. Mathews, on gonorrhoeal af- fection of Cowper's glands in female, 148 Duplay and Rrun, MM., on frequent oc- currence of gonorrhoeal rheumatism in. women, 247 298 INDEX. Duplay and Brun, MM., on rapid disor- ganization of joint tissues in gonorrhceal arthritis, 257 Dupouy, M. , on. kava-kava as a remedy in gonorrhoea, 81 Durham. Mr. , kind of syringe recommend- ed by, 129 on influence of diet on urine, 153 Durkee, Dr. Silas, on the abortive treat- ment of gonorrhoea, 124 on the employment of large doses of copaiba in acute stages of gonor- rhoea, 77 on the genesis of gonorrhoea by leucor- rhoea, 15 on purgatives in gonorrhoea, 90 on the significance of pus-cells in dis- charge from male urethra, 29 on the treatment of phimosis, 203 Duverney's glands, gonorrhoeal affection of, 148 Edinburgh Medical and Surgical Journal, table of cases of gonorrhoea from, 71 Egan. Dr., on extension of gonorrhoeal action backward in male urethra, 35 on seat of gonorrhoea in the female, 38 Electricity, atmospheric, as a cause of orchitis, 186 Elliotson, Dr., on non-existence of gonor- rhoeal rheumatism, 236 Endocarditis, gonorrhceal, 247 Endoscope, the, as an aid to diagnosis, 272 Epididymis, principally affected in orchitis, 172 Erectile tissue of vagina, gonorrhoeal in- flammation of, 149 Eric!. sen, Mr., on pathology of gonorrhoeal rheumatism, 257 Erigeron oil as a remedy in gonorrhoea, 87 Errors of diet as a cause of gonorrhoea, 24 Ether, employment of, in orchitis, 195, 199 Expectant treatment of gonorrhoea, 68 Eye, gonorrhoeal affections of, 262 Eyeball, gonorrhoeal rheumatism of, 267 gonorrhoeal rheumatism of, pathology of, 267 gonorrhoeal rheumatism of, prognosis of, 267 gonorrhoeal rheumatism of, treatment of, 267 FAINTING from the use of injections, strong tendency to, as a complication of gonor- rhoea, 207 Faucon, M., on sub -peritoneal inflamma- tion from gonorrhoea, 230 Female, genesis of gonorrhoea in, 26 period of incubation of gonorrhoea in, 39 seat of gonorrhoea in, 38 treatment of gleet in, 293 treatment of gonorrhoea in, 142 Fereol, M., case of glandular inflammation complicating gonorrhoeal rheuma- tism related by, 254 on concurrence of gonorrhoeal rheuma- tism with mild form of gonorrhoea 255 views of, as to existence of gonorrhceal lues, 40 Foot, Jesse, on injurious effects of allow- ing gonorrhoea to run its course, 70 on the treatment of gonorrhoea, 64 Form for calculating action of remedies, 96 Fourestie, M., on different nature of early and late gonorrhoeal rheumatism, 255 Fournier, M., account of aquo-capsulitis by, 267 account of gonorrhoeal rheumatism by, 239 account of gonorrhoeal sciatica by, 244 on cessation of pain in sphacelus of testicle, 188 on communication of gonorrhoea by a woman not infected, 23 on distinction between urethritia and gonorrhoea as causes of gonorrhoea! rheumatism, 237 on proportion of gonorrhceal synovitis to gonorrhceal rheumatism, 242 on treatment of true orchitis, 198 on venereal excess as a cause of gonorrhoea, 24 France, Mr., his treatment of gonorrhceal ophthalmia, 264 Freezing the testicle as a remedy in orchi- tis, 195 Fungus, a, origin of gonorrhoea from, 45 GARIOPONTFS of Salernum describes gonorrhoeal cystitis, 5 Gaussail, M., account of post-mortem ap- pearances in orchitis by, 173 Gay, Mr., his treatment of orchitis, 196 Genesis of gonorrhoea in the female. 26 of gonorrhoea in the male. 12 Gleet as a source of gonorrhoea in the fe- male, 28 as a source of gonorrhoea in the male, 20 complications of, 288 divisions of, 269 employment of blistering in, 286 employment of bougie in, 281 employment of caustic in, 284 muco-purulent, 270 muco-purulent, treatment of, 277 of Cowper's ducts. 276 of Cowper's' ducts, treatment of, 292 pathology of, 269 prognosis of, 277 prostafcic, 270 prostatic, treatment of, 290 pure mucous, 271 pure mucous, treatment of, 292 treatment of, in the female, 293 INDEX. 299 Gleet, treatment of, in the male, 277 treatment of complications of, 288 Glycero-tannin rods, 120 Gonorrhoea, a critical flow, 10 abortive treatment of. 122 as a cause of stricture, 70 complications of. (See Complications. ) declining, infectious power of, 30 expectant treatment of, 68 genesis of, in the female, 26 genesis of, in the male, 12 great variety of remedies for, 54 history of, 1 history of, treatment of, 57 homoeopathic treatment of, 72 incipient, infectious power of, 30 infection of system by, 40 infectious power of, 20 in the female as a cause of gonorrhoea in the male, 1 2 in the male as a cause of gonorrhoea in the female, 28 inveterate, 269 inveterate, treatment of, 289 in woman, treatment of, 142 latent. 43 little alteration in treatment of, dur- ing last century or two, 58 milder nature of, in subsequent at- tacks, 39 of long standing, 269 of long standing, treatment of, 280 ordinary treatment of, 124 pathology of, 12 present treatment of, 73 produced generally by connection with an infected person, 17 prognosis of, 40 proposed treatment of, in acute cases, 122 proposed treatment of, in chronic cases, 277 rarity of, in earlier days, 11 results of, 40 seat of, in the female, 38 seat of, in the male, 32 specific nature of, 18 term of incubation of, 37, 39 treatment of, 54 varying duration of. 49 Gonorrhoeal action, extension of, back- wards. 33 adenitis, 2.14 affections of the eye, 262 endocarditis and pericarditis, 247 meningitis, 251 myelitis, 252 ophthalmia (See Ophthalmia), 262 peri-nephritic abscess, 232 peritonitis. 229 pyaemia, 2r>3 rheumatism (See Rheumatism), 234 sciatica, 244 synovitis, 242 Gonorrhoeal (?) hepatitis, 252 Gonorrhoeal (?) pleuritis, 234 (?) pyelitis and nephritis, 233 (?) nephritis, 253 Good, Dr. Mason, on amputation of part of penis in paraphimosis, 204 Gordon, Bernard, evidence of, as to exist- ence of gonorrhoea, 5, 7 Gosselin, M., case of deferentitis related by, 202 gonorrhceal peritonitis related by, 229 on inflammation of vaginal tunic in orchitis, 172 on mode in which gonorrhoea in the female escapes detection, 20 on the prognosis of gonorrhoeal rheu- matism, 257 Graromer, Dr., his treatment of orchitis, 195 Greenhow, Dr., case of gonorrhceal (?) pye- litis and nephritis mentioned by, 233 Guerin, M. , on the form of discharge which precedes gonorrhoeul rheumatism, 255 Guerin and Pidoux, MM., belief of, in ex- istence of a gonorrhceal lues, 40 Gurgun (wood-oil) in gonorrhoea, 87 Guy de Chauliac, evidence of his knowl- edge of gonorrhoea, 5 HAGEMANN on the seat of gonorrhoea in the female, 38 Haby Abbas, mention of symptoms of gonorrhoea by, 4 Hancock, Mr., discovery by, of prolonga- tion of muscular coat of bladder, 154 his treatment of gonorrhceal ophthal- mia, 264 Hardy, M. , case of failure with salycilate of soda in gonorrhoeal rheumatism related by, 258 gonorrhoeal rheumatism complicated with nephritis related by, 253 metastasis in gonorrhceal rheumatism related by, 255 prognosis of. 257 Harley, Dr., on cause of acidity of urine, 154 on alkalinity of urine after meals, 155 Harrison, Mr. Reginald, on Dr. Otis's treat- ment of stricture, 283 recommends cold-water injections in gleet, 281 Hassall, Dr. , on cause of acidity of urine, 154 Healthy state of organs in the female as a source of gonorrhoea in the male, 23 Heat and cold, therapeutic action of, 99 Henderson. Dr. Thomas, on the use of gur- gun in gonorrhoea, 87 on sandal-wood oil in gonorrhoea, 84 Hensler on absence of gonorrhoea during first period of syphilis, 7 on conflicting nature of testimony about gonorrhoea, 6 Hepatitis, gonorrhoeal (?), 252 300 INDEX. Herodotus, disease of the Scythians de- scribed by, 2 Hervieux, M., case of gonorrhoeal cardiac affection related by, 250 endocarditis related by, 247 Hewitt, Dr. Graily, on the seat of gonor- rhoea in the female, 38 Hill, Mr. Berkeley, on the antiquity of gonorrhoea, 1 on frequent occurrence of purulent dis- charge from the womb among pros- titutes. 22 on permanganate of potass as an injec- tion in gonorrhoea, 102 Hiller, Dr. A., on transmission of uvethral discharge from male to female, 32 Hip-bath, hot, in gonorrhoea in the female, 142 Hippocrates, forms of leucorrhoea described by, 2 Hippuric acid as a factor in acidity of urine, 155 History of gonorrhoea, 1 of gonorrhoeal rheumatism, 234 Holmes, Mr. Timothy, on puncture of tunica albuginea in orchitis, 191 Home, Sir Everard, cases of gonorrhoeal sciatica related by, 244 Homoeopathic treatment of gonorrhoea, 72 Howard, Dr., on site of lingering gonor- rhoea in the female, 21 Howard, Mr., on connection between in- veteracy and diathesis, 49 on treatment of gonorrhoea, 64 Huguier, M., on gonorrhoeal affection of vulvo-vaginal glands. 148 Hunter, mention of gonorrhoeal rheuma- tism by, 235 mention of peritoneal inflammation from gonorrhoea by, 229 on incubation of gonorrhoea, 38 on milder nature of gonorrhoea in subsequent attacks, 39 on origin of stricture from gonorrhoea, 70 on post-mortem state of urethra in gonorrhoea, 35 on the pathology of chordee, 163 on the specific seat of gonorrhoea. 34 on the treatment of gonorrhoea, 63 on the way in which a bougie acts in stricture, 284 Hypodermic injections in endometritis following on gonorrhoea, 147 injections in gonorrhoeal rheumatism, 261 Hyoscyamus in scalding, 156 ICE, employment of, in treatment of in- veterate gonorrhoea, 290 employment of, in orchitis, 195 Incubation of gonorrhoea, 37, 39 Infection of gonorrhoea, point from which it starts in the male, 32 Inhalation as a remedy in gonorrhoea, 82 Injections, 100 as a cause of orchitis and stricture, 105 great variety of, 100 in gonorrhoea in the female, 143 mode in which they act, 114 mode of giving, 123, 126, 143 necessity for changing questioned, 127 time at which they may be safely be- gun, 109 various opinions as to the strength of, 104 Insufflation as a remedy in gleet, 293 Internal remedies in gonorrhoea, 73 Inveteracy, connection between and dia- thesis, 48 Iodide of potassium. (See Potassium.) Iritis, gonorrhoeal, 266 gonorrhoeal, pathology of, 266 gonorrhoeal, prognosis of, 267 Irritants, mechanical, as a cause of gonor- rhoea in the male, 24 JACKSON, MR. T. CARR, employment of potassa fusa in stricture by, 285 John of Gaddesden describes gonorrhoea, 5 Johnson, Mr., account of inflammation of spongy and cavernous bodies by, 206 on the connection between inveteracy and diathesis. 49 on the genesis of gonorrhoea, 28 on the results of antiphlogistic treat- ment of orchitis, 189 on the value of sedatives in chordee, 166 Jones and Sieveking, Messrs., on pathol- ogy of chordee, 163 on state of urethra in gonorrhoea, 35 Jones. Dr. Bence, on alkalinity of urine after meals, 155 Jordon, Mr. Furneaux, on treatment of gonorrhoeal rheumatism with nitrate of silver, 261 on treatment of orchitis with nitrate of silver, 1 95 Judd, Mr., cases of orchitis treated with leeches related by, 189 his treatment of gonorrhoea. 65 table of cases treated by, 118 Jusseaume, M., maintains that gonorrhoea is due to a vegetable parasite, 45 KAVA KAVA as a remedy in gonorrhoea, 81 LABIA MAJORA, treatment of gonorrhoeal abscess in, 149 Laboulbene, M., on difference between pathological products of simple and gonorrhoeal rheumatism, 240 Lacassagne, M., case of gonorrhoeal endo- carditis related by, 248 Lactic acid as a factor in acidity of urine, 155 INDEX. 301 Lacunas of urethra, strong tendency to in- flammation of, 213 Laforgue, M. , case of gonorrhoeal peri- nephritic abscess related by, 232 Lagneau, M., fils, on mode of formation of peri-urethral abscess, 215 Lallemand's caustic-holder, objections to, 136 Langlebert, M. , his treatment of orchitis, 196, 197 Lasegue, M., account of gonorrhoeal syno- vitis by, 242 on atrophy as a result of gonorrhoeal synovitis. 243 Laudanum in scalding, 156 Lawrence, Sir Win., case of failure with antiphlogistic treatment in gonor- rhoeal ophthalmia related by, 264 on arrest of gonorrhoeal discharge in gonorrhoeal ophthalmia, 263 on excision of the cornea in gonorrhceal opftthalmia, 266 Lawson, Mr. George, his treatment of gon- orrhoeal ophthalmia, 263 Ledeganck, Herr, on seat of gonorrhoea in the male, 33 Lee, Mr. Henry, on healthy state of the female organs as a possible cause of gonorrhoea in male, 23 the origin of abscess complicating gon- orrhoea, 215 recommends strychnine in chordee, 166 Leeches, doubtful value of, in gonorrhoea, 89 doubtful value of, in orchitis, 189 Le Fort, M., on period of incubation of gonorrhoea, 37 on proportion of orchitis to gonorrhoea, 186 Leucorrhoea as a cause of gonorrhoea in the male, 14 degree of contagious power of, 14, 21 Linas, M. , on communication of gonorrhoea by a chaste woman, 23 Liquor potassee in gonorrhoea, 94 Lorey, Dr. , account of treatment of gonor- rhoea with gelatine bougies by, 121 Lotions, evaporating, in gonorrhoea, 95 evaporating, in orchitis, 198 Lloyd, Mr., recommends chloride of zinc as an injection in gonorrhoea, 113 Lupulin in chordee, 166 MACDONALD, DR. ANGUS, on Dr. Noegge- rath's views about gonorrhoea, 43 Macnaraara, Mr., punctures the testicle in orchitis, 194 Mallez, M., mode of insufflation in gleet recommended by, 292 Marten, John, his treatment of gonorrhoea, 60 Marty, M. . case of gonorrhoeal endocarditis related by, 248 Marty, M. , on dangerous nature of gon- orrhoeal endocarditis. 251 Mason, Dr. Erskine, objects to enemata and suppositories in prostatic inflamma- tion, 227 Masturbation as a cause of gonorrhoea, 24 Matico as a remedy in gonorrhoea, 83 Mauriac, M., on forms of nervous pain following orchitis, 188 on origin of gonorrhoeal rheumatism from simple urethritis, 239 progressive retention of urine de- scribed by, 221 Maymou, M. , account of gonorrhoeal syno- vitis by, 242 on the influence of this affection on the gonorrhoeal discharge, 242 on restoration to normal state of ten- dons affected by gonorrhoeal syno- vitis, 244 Medicine as a branch of inductive science, 102 Meningitis, gonorrhceal, 251 Menstrual flow as a source of gonorrhoea in the male, 22 ' Menstruation, excessive, treatment of, 149 Mercury, oleate of, in perineal abscess, 226 Mesue, John, evidence of, as to antiquity of gonorrhoea, 3 Metastasis, in gonorrhoeal rheumatism, 255 in gonorrhoeal orchitis, 170 I Meuriot, M. , case of gonorrhoeal (?) endo- carditis related by, 250 Micrococcus peculiar to gonorrhoea, 45 Microscopic products of gonorrhoea in the female, identity of, with those of leucor- rhoea, 19 Miles, Mr. H. Chalmers, on treatment of acute gonorrhoea by blistering, 137 Monteggia, early mention of gonorrhoeal rheumatism by, 235 Morbid sensibility of the urethra, 215 Morel, M. Emile, cases of gonorrhceal en- docarditis related by, 249 Morgan, Dr., kind of syringe recommended by, 129 Morphia in orchitis, 198 in scalding, 156 Morris, Dr. . his mode of treating gonor- rhoea, 104 Moyle's treatment of gonorrhoea, 59 ; Murchison, Dr. , fatal cases of gonorrhceal ( ?) pyelitis and nephritis communicated by. 232 Musgrave, William, supposed description ot gonorrhceal rheumatism by, 234 Myelitis, gonorrhoeal, 252 NEISSER, DR. ALBERT, on a micrococcua peculiar to gonorrhoea, 46 Nephritis, gonorrbceal (?), 253 Ngan-plang in gonorrhoea, 82 Niddrie, Dr., mode of injecting recom- mended by, 123 302 INDEX. Nitrate of silver. (See Silver, nitrate of.) Noeggerath, Dr. , on results of gonorrhoea, 41 on treatment of gonorrhoea, 146 Norman, Mr., on the value of fresh ground cubebs in gonorrhoea, 57, 80 Nunn, Mr. Thomas, on difference of incu- bation between specific and non- specific discharges, 25 on non-existence of gonorrhceal rheu- matism, 287 successful puncture of tunica albuginea by, 193 OIDTMANK, DR., composition for use in gonorrhoea recommended by, 121 Ophthalmia, gonorrhceal, pathology of, 262 gonorrhosal, prognosis of, 263 gonorrhceal, proposed treatment of, 265 gonorrhoeal, treatment of, usually adopted, 263 Opium as a remedy in chordee, 166 as a remedy in gonorrhceal rheu- matism, 259 as a remedy in orchitis, 198 Orcbitis, causes of, 173 External applications in, 198 origin of, from extension of the disease along the urethra, 170 origin of, from metastasis, 170 origin of, from sympathy, 170 pathology of, 170 . prognosis of, 189 proposed treatment of, 64 results of, 187 statistics of, 171 treatment of, usually adopted, 187 Otis, Dr. Fessenden, kind of syringe re- commended by, 133 on employment of ball-staff, 283 on injecting bladder with ordinary syringe, 130 on pathology of gleet, 271 on treatment of complications of gleet, 288 Ovaritis from gonorrhoea, 146 acute, cases of, 146 treatment of, 146 PAILT,ASSON, M., recommendation of starch and glycerine in gonorrhoea by, 121 Pain in back, treatment of, 149 Panas, M., on the communication of the odor of sandal-wood oil to the urine, 85 Paracelsus arrays gonorrhoea among the forms of syphilis, 10 Paraphimosis, treatment of, 203 Park. Mr. Robert, on sandal-wood oil in gonorrhoea, 85 Pastilles of nitrate of silver in gonorrhoea, 118 Payne, Mr., on treatment of orchitis with tincture of iodine, 198 Penis, inflammatory swelling of, 27 Pericarditis, gonorrhceal, 247 Perineal abscess, 224 Perineum, blistering of. in gleet, 287 Peri-nephritic abscess, gonorrhceal, 233 Peritonitis, gonorrhceal, 229 gonorrhceal, prognosis of. 230 gonorrhoeal, treatment of, 230 Permanganate of potass. (See Potass.) Peter, M., case of gonorrhoeal peritonitis and pleuritis related by, 230 Phillips, Mr. Benjamin, free employment of hot baths in gonorrhoea by, 9? on the termination of inflammation of the prostate in gangrene, 227 on the treatment of urethral fistulas, 215 Phillips, M. Charles, on results of gleet, 293 Phimosis. treatment of, 203 Pidoux, M. , on difference between simple and gonorrbceal rheumatism, 240 and Guerin, MM . on existence of a gonorrhceal lues. 40 Piles as a cause of gonorrhoea, 17 Pills, aperient, in gonorrhoea, 125 Pitman, Dr. . case of death from abscess of prostate occurring in practice of, 227 Pleuritic, gonorrhoeal (?), 233 Plug, caustic, 134 Point at which infection takes place in the male, 32 Potass, acetate of, in gonorrhoea, 94, 124 chlorate of. in gonorrhoea, 125 nitrate of, in scalding, 157 permanganate of, as an injection, 101 Potassa fusa in stricture, 285 Potassium, bromide of, as a remedy in chordee, 166 iodide of, as a remedy in gonorrhoea, 95 iodide of, in inflammation of the pros- tate, 227 iodide of, in orchitis, 201 Practitioner, injection of cold water in gleet recommended in, 281 Prettyman, Dr. J. S., on erigeron-oil as a remedy in gonorrhoea, 87 Prostate, abscess of, 227 inflammation of, 226 inflammation of, acute, 226 inflammation of, divisions of, 226 inflammation of, mucous, 226 inflammation of, pathology of, 226 inflammation of. prognosis of, 227 inflammation of, results of, 227 inflammation of, subacute, 226 treatment of inflammation of, 227 Prostatic gleet. (See Gleet.) Purdon. Dr. H. S., on sandal-wood oil in gonorrhoea, 85 Pure mucous gleet. (See Gleet.) Purgatives in gonorrhoea, 89 in gonorrhoea, great use of, by old surgeons, 90 INDEX. 303 Purgatives, table of cases of gonorrhoea treated with, 90 Pus-corpuscles in leucorrhoeal secretion, significance of, 19 in male urethral discharge, significance of, 30 Pyaemia, gonorrhoeal, 253 Pye-Smith, Dr., case of gonorrhoeal endo- carditis related by, 250 on absence of eye affection in com- mon rheumatism, 255 occurrence of gonorrhoeal rheumatism in patients previously attacked by rheumatic fever, 237 state of urine in gonorrhoeal rheuma- tism, 240 QUININE in gonorrhoeal ophthalmia, 263 in gonorrhoeal rheumatism, 258 Quinquaud, M., on gonorrhoea as a factor in gonorrhoeal rheumatism, 257 feverishness in gouorrhoeal rheuma- tism, 238 RAGAZZONI AND APPIANI, MESSRS., re- port by, of cases of orchitis treated with puncture of the tunica vaginnlis, 194 Rectum, excessive irritability of, 224 Remedies, variety of, recommended in gonorrhoea, 54 Remy. M. , on origin of ovaritis from gon- orrhoea, 54 Rhazes, mention of a case of gonorrhoea by, 234 Rheumatism, gonorrhoeal, brief history of, 234 gonorrhoeal, cases showing extreme obstinacy of, 245 gonorrhoeal, complications of, 247 gonorrhoeal, divisions of, 240 gonorrhoeal, in women, 246 gonorrhoeal, mode in which it is set up, 254 gonorrhoeal, pathology of, 236 gonorrhoeal, prognosis of, 257 gonorrhoeal, proposed treatment of, 258 gonorrhoeal, treatment of, usually adopted, 257 Richmond, Mr., report by, of cases of orchitis treated with puncture of the tunica vagiualis, 194 Ricord, M., on the abortive treatment of gonorrhoea, 123 on the development of gonorrhoea by the hot bath, 54, 96 on the genesis of gonorrhoea in the male, 19, 23, 24 on a healthy state of the female or- gans as a possible cause of gonor- rhoea in the male, 23 on long duration of gonorrhoea, 69 on specific nature of discharge from the female urethra, 27 Ricord, M., on the treatment of abscess of the vulva, 149 on the treatment of chordee, 166 on table of cases treated by, 117 Ricordi. Dr. Amilcar, on gleet of Cowper's ducts, 276 on treatment of gleet of Cowper's ducts, 292 Robert, M. Melchior, on communication of gonorrhoea by the male, 31 on excision of conjunctiva in gonor- rhoeal ophthalmia, 266 on reappearance of spermatozoa after orchitis, 188 on treatment of inflammatory swell- ing of penis, 205 on results obtained by, in treatment of gonorrhoea, 89 Roberts, Dr., on cause of acidity of urine, 154 Rocchi, Dr. , on importation of gonorrhoea into country districts, 19 Rochoux, M , on swelling in orchitis being due to effusion into tunica vaginalis, 173 Rollet, M., claims to have discovered con- nection of gonorrhoeal rheumatism with rheumatism of eyeball, 267 recognition of gonorrhoeal synovitis by, 242 Rowley on death from use of purgatives, 89 SALISBURY, DR., on origin of gonorrhoea from a fungus, 45 Salleron, M. , case of orchitis treated with bleeding and leeching related by, 189 on limitation of inflammation in or- chitis to epididymis, 172 Salmon, M. , case of gonorrhoeal affection of ducts of Duverney's glands related by, 148 Sandal-wood oil in gonorrhoea, 153 Savory, Mr., on value of chloroform in spasmodic stricture, 222 Scalding, causes of, 155 effect of alkalies upon, 158 effect of anodynes upon, 156 effect of demulcents upon, 157 effect of diuretics upon, 157 pathology of. 153 probable explanation of, 161 proposed treatment of, 161 treatment of, usually recommended, 156 Scarenzio, Dr. Angelo, on non-existence of gonorrhoeal rheumatism, 237 Schuster, Dr., on glycero-tannin rods as a remedy in gonorrhoea, 1 20 on sulphur bath in subsequent hard- ness and tenderness of prostate, 228 Sciatica, gonorrhceal, 244 Scrofula as a cause of inveteracy, 49 Scrotal veins, puncture of, in orchitis, 190 304 INDEX. Scrotum, blistering of, in orchitis, 200 puncture of, in orchitis, 190 Scythian disease, the, described by Hero- dotus, 2 Seat of gonorrhoea in the female, 38 in the male, 32 Sedatives in the treatment of orchitis, 196, 198 Seminal vesicles, inflammation of. (See Vesicles.) Sensibility, morbid, of urethra, 134 Severity of urethritis not evidence of its contagious power, 27 Sigmund, Professor, his unfavorable expe- rience of soluble bougies, 120 Silver, nitrate of, cauterization with, in acute gonorrhoea in men, 110 nitrate of, cauterization with, in acute gonorrhoea in women, 143 nitrate of, cauterization with, in gleet, 284, 292 nitrate of, cauterization with, in stric- ture, 218, 284 nitrate of, cauterization with, in strong tendency to stricture, 218 nitrate of, injections of, 110 nitrate of, injections of, causes of failure with, 128 nitrate of, pastilles, 118 nitrate of, removal of stains caused by, 126 nitrate of, strong injections of, 111, 133 nitrate of, table of cases of gonorrhoea treated with, 111 Simon, Mr. John, on treatment of irritable bladder, 169 Simon, of Hamburg, on copaiba eruption, 79 Simpson, Sir J., introduction of suppos- itories in the treatment of gonorrhoea in the female by, 144 Skin diseases, suppression of, as a cause of gonorrhoea, 25 Smith, Dr. W. Tyler, on the generation of gonorrhoea in the male from leucor- rhoea, 19 on the identity between microscopic products of gonorrhoea and leucor- rhcea, 19 on the secretion of lencorrhoea, 21 Smith, Mr. Henry, on puncture of tunica albuginea in orchitis, 191 Smith, Mr. Johnson, on puncture of unde- scended testicle for orchitis. 193 Smith, Mr. Noble, on necessity for vary- ing injections, 128 Smoking in gonorrhoea, 151 Specific seat of gonorrhoea in male, 32 Specifics in gonorrhoea in the male. (See Copaiba, etc.) Spermatic cord, inflammation of, 202 Spongy and cavernous bodies, inflamma- tion of, 206 Stains caused by nitrate of silver injec- tion, removal of, 126 Stein, Professor, on erigeron-oil in gonor- rhoea, b'8 Sterility as a result of gonorrhoea, 41 Stern, Dr. Adolf, on glycero-tannin rods as a remedy in gonorrhoea, 120 I Stoll, Dr.. on after- death appearances in gonorrhoea, 35 ! Strapping the testicle in orchitis, 195 Stricture, origin of, from gonorrhoea, 70 as a cause of persistency of gleet, 272 strong tendency to, 216 treatment of, 216, 285 Strychnia as a remedy in chordee, 166 Sub-peritoneal inflammation from gonor- rhoea, 230 prognosis of, 231 treatment of, 231 Suppositories, employment of, in gonor- rhoea in the female, 144 inflammation of the prostate, 227 Suppuration as a result of gonorrhceal ar- thritis, 244 Suspension of testicle in orchitis, necessity for, 200 Swediaur, mention of gonorrhceal rheuma- tism by, 235 on opium as a remedy in orchitis, 197 on orchitis being due to extension of gonorrhceal inflammation, 171 on restriction of orchitic inflaro matioii to epididymis, 172 remarks on experiment performed by, 28 Swelling, inflammatory, of the peuis, 205 Sydenham's treatment of gonorrhoea, 58 Synovitis, gonorrhoeal, pathology of, 242 proportion of, to gonorrhceal rheuma- tism, 242 Syphilitic gonorrhoea, question of existence of, 95 Syringe, long urethral, 132 Syringes, best form of, 128 System, infection of, by gonorrhoea, 40 TABLE I., 71; II., 75 ; III, 90; IV., 91 ; V., Ill; VI., 115; VII., 117; VIII., 118 ; IX., 175 Tachard, M., his treatment of orchitis, 195 Talamon, M. , cases of suppuration from gonorrhoeal arthritis related by, 245 Tanner, Dr., on the genesis of gonorrhoea, 28 on infection of system by gonorrhoea, 40 on ovaritis from gonorrhoea, 147 on the specific nature of gonorrhoea, 18 Tartar-emetic in treatment of orchitis, 189 frictions with, in treatment of or- chitis, 194 Taylor, Mr. John, on acute ovaritis as a complication of gonorrhoea, 147 Taylor. Dr. R. W., kind of syringe recom- mended by, 133 INDEX. 305 Taylor, Mr. Robert, on rarity of gonor- rhceal iritis, 266 Teevan, Mr., on connection between irri- table bladder and stricture, 169 on relaxing power of ice in stricture, 100 on value of ball-staff in diagnosis of stricture, 282 Thomas, Dr. Gaillarl, on employment of suppositories in treatment of gonor- rhoea in the female, 144 on the origin of gonorrhoea, 20 Thompson, Sir Henry, on action of alka- lies upon urine, 159 on soluble bougies in gonorrhoea, 118 on triticum repens in irritable bladder, 169 Thorburn, Dr. , on Noeggerath's theory of gonorrhceal infection, 44 Thorn, Mr., on a particular preparation of copaiba, 57, 78 Tixier, M , case of gonorrhceal meningitis related by, 251 case of gonorrhceal myelitis related by, 252 case of gonorrhoeal adenitis related by, 254 case of gonorrhceal (?) hepatitis re- lated by, 252 case of gonorrhoeal (?) pleuritis re- lated by, 234 cases of gonorrhoeal cardiac affection related by, 247 on the form of discharge which pre- , cedes gonorrhoeal rheumatism, 255 on the non suppression of discharge in j gonorrhoeal affections of the eye. 263 j Tomowitz. M , on glycero- tannin rods as a remedy in gonorrhoea, 120 Tonics in gleet, 281 in gonorrhoea. 141. 150 Trias romaua, gonorrhoea mentioned in, 8 Triticum repens in irritable bladder, 169 Tunica albuginea, puncture of, in orchitis, 191 vasrinalis. 194 Turner's treatment of gonorrhoea, 61 Turpentine in gonorrhoea, 82 Tyrrell, Mr., his success with Thorn's prep- j aratiou of copaiba, 57, 78 ULCERATION of mouth and neck of womb as a cause of gonorrhoea, 21 Urethra, cauterization of, for gleet, 284 cauterization of, for gonorrhoea in men, 136 cauterization of. for gonorrhoea in women, 148 morbid sensibility of. 2! 5 post-mortem state of, in gonorrhoea, 35 tender state of. as a source of gonor- rhoea in the female, 28 Urethral gonorrhoea in the female, specific nature of. 2('< treatment of, 148 20 Urethritis from leucorrhoea or vulvitis, non-specific nature of, 13 from mechanical irritants as a source of gonorrhoea in the female, 27, 32 from mechanical irritants, low infec- tious power of, 32 milder nature of, when set up by mechanical irritants. 24 Uric acid as a cause of acidity in urine, 154 Urine, acidity of, 153 possibility of making alkaline, ex- amined, 158 retention of, 221 retention of, treatment of, 221 VAGINA, cauterization of, 144 Valescus of Tarentum acquainted with gonorrhoea, 6 definition of gonorrhoea by, 9 Veale, Dr. , on mode of giving copaiba, 77 Yelpeau, M. , on frequent inflammation of seminal vesicles from gonorrhoea, 228 puncture of scrotum in orchitis prac- tised by, 190 Vesicles, seminal, inflammation of, 228 Vidal de Cassis, puncture of tunica albu- ginea practised by, 191 Villeneuve, M., fatal case of chordee re- lated by, 165 Virus of gonorrhoea, specific nature of. (See Pathology of Gonorrhoea.) Voelker, M. . cases of gonorrhoeal cardiac affection related by, 247 on cold as a determining cause of gonorrhoeal rheumatism, 238 on climate as a determining cause of gonorrhoeal rheumatism, 238 on temperament as a determining cause of gonorrhceal rheumatism, 238 Vulvitis, simple, as a cause of gonorrhoea, 13 WAGNER on action of carbonate of soda on urine, 159 Wallace, Mr. W. , on connection between inveteracy and diathesis, 49 on the pathology of chordee, 162 Wasting (see Atrophy), 190, 193, 240, 243 Water, cold, free injection with, in the treatment of gonorrhoea, 104 hot, as an application in chordee. 163 hot, as an application in gonorrhoea, 98 Waterman, Dr. , his treatment of orchitis, 195 Watson, Mr. Spencer, cases of orchitis treated by, with puncture of tunica vaginalis, 193, 194 W T atson, Sir Thomas, on action of heat and cold as outward applications, 100 on cause of acidity of urine, 154 Weakness, great natural or induced, 209 Weather as a cause of orchitis. 209 306 INDEX. Weber, Dr. Hermann, on action of salycin and its congeners in gonorrhceal rheu- matism, 258 West, Dr., on treatment of gonorrhceal inflammation of uterus, 145 Whately, mention of gonorrhoea! rheuma- tism by, 2o5 on purgatives in gonorrhoea, 90 Windsor, Mr , mode of injecting used by, 105 Winternitz, Herr, experience of, with cold water injection in gleet, 281 Womb, purulent discharge from, as a cause of gonorrhoea, 21 purulent discharge from, treatment of, 145 ulceration of mouth and neck of, as a cause of gonorrhoea, 21 Women, genesis of gonorrhoea in, 26 gonorrhoeal rheumatism in, 246 Women, period of incubation of gonorrhoea in, 89 seat of gonorrhoea in. 38 treatment of gonorrhoea in, 142 ZEISSL, HERR, case of sloughing and ex- pulsion of mucous membrane of urethra related by, 112 on Langlebert's treatment of orchitis, 195, J98 on the necessity for changing injec- tions, 128 ou want of curative power in kava- kava. 82 Zinc, chloride of, as an injection in gonor- rhoea, 113 injections of. as a possible cause of stricture, 113 table of cases of gonorrhoea treated with injections of, 115 Date Due PRINTED IN U.S.A. CAT. NO. 24 161 000 522 409 WC150 M662 o 188U Milton, John L. On the pathology and treatment of gonorrhea WC150 M662 o 1881* Mi It or , John L. On the pathology and treatment of gonori^ea MEDICAL SCIENCES LIBRARY UNIVERSITY OF CALIFORNIA, IRVINE IRVINE, CALIFORNIA 92664