PROVINCIAL MEDICAL & SURGICAL JOURNAL. CLINICAL LECTURE ON VENEREAL Delivered to the Students of the Queen's Hospital, GENTLEMEN, The presence of a case of primary venereal sore in the urethra, in the hospital, leads me to make some remarks on the nature and treatment of this form of disease, until lately but imperfectly known, but yet one of the most important varieties of primary venereal affection. Cases of syphilitic ulcers in the urethra have been cursorily alluded to by many surgical writers. Hunter mentioned them, but certainly had no clear idea of their true character and effects; they are also noticed by Mr. R. Carmichael in his clinical lectures on venereal diseases. The late Dr. Wallace spoke of some discharges from the urethra of venereal origin, which were only curable by mercury, but it has been left to modern surgical pathologists, amongst whom must be particularly mentioned Monsieur Ricord, to demonstrate that primary venereal sores, precisely resembling in their nature and consequences sores situated externally, may exist in the canal of the urethra itself, at variable points between the meatus urinarius and the bladder. peared under medical treatment. Disregarding the discharge from the urethra, which never disappeared, and fancying himself well, our patient now married. His first child died a few months after birth, covered with blotches; a second and a third child shared the same fate, and died under the same circumstances. The wife also had sores and bloody discharge from the vagina, and blotches on the body, the husband still having no affection except the slight running from the urethra, which sometimes attracted his attention, and at others was totally disregarded. During these periods M'Knight had, at several times, fresh constitutional symptoms, for which he underwent a variety of treatment, but was never free from the running from the urethra. In November, 1843, between six and seven years after M'Knight contracted his primary disease, he came under my care as a patient of the Queen's Hos pital. He was then in the following state :-The head and face were covered with foul blotches, which consisted of incrustations or scabs, concealing deep, irregular, and ill-conditioned ulcers; there was superficial redness of the fauces, but no ulceration at this time; he was feeble and emaciated from long continued disease. The skin disease was evidently pustular in its commencement, as one or two fresh formed pustules were on the face: these pustules were situated on an inflamed base, and when they broke and discharged, ran into ulcers, covered with flat or conical crusts—thus constituting a variety of disease to which the term I will relate to you first the case of Robert" pustulo-crustaceous" has been applied. M'Knight, and then make some general remarks on chancres of the urethra, illustrated by cases from hospital and private practice. He denied at first having anything the matter with the genitals, but on closer questioning admitted that he had a running so slight as to be hardly worthy of notice. On examination I perceived a sanious oozing from the urethra, very different from that which characterizes chronic gonorrhoea or gleet. About an inch from the meatus, immediately behind the glans penis, existed a circumscribed induration, about the size of a hazel nut: this was painful when pressed between the fingers, and the pressure occasioned some blood and portions of white tenacious sloughs to issue from the urethra. On separating the lips of the meatus urinarius, by Robert M'Knight, by trade a Scotch hawker, aged 29, contracted from the same connexion sores on the penis and a running from the urethra, seven years ago. The ulcers on the penis were cured, very likely by a mercurial course, as M'Knight has been repeatedly salivated. The treatment which cured the external sores had no effect upon the discharge from the urethra; this continued: it has been repeatedly treated, but never cured. Soon after this scaly blotches appeared on the forehead and other parts of the body, which disap-means of a small speculum made for the purpose, No. 5, May 1, 1844. F 52 CLINICAL LECTURE ON VENEREAL DISEASES. the commencement of ulceration, which appeared of gonorrhea; it may be sanious, bloody, or of a to extend deep into the urethra, could be perceived. | sloughy character, and commonly does not flow This case is remarkable under many points of unless the indurated portion before described be view. In the first place the disease itself (primary pressed forcibly between the fingers. venereal sore in the urethra), is not of every day occurrence, although I have seen many instances of it; again, the time which the sore has existed is remarkable. There is no evidence that M'Knight had ever contracted a venereal disease subsequent to his marriage; the evidence of his wife and himself is conclusive upon this point. The sores which M'Knight contracted at the same time he contracted the running were cured previous to his marriage, the running still remaining; some days he perceived none; yet having no other disease than that in the urethra, we observe the wife becoming diseased, and three children dying, with unquestionable venereal affections. This case is one, then, of primary venereal sore in the urethra, contracted at the same time with external primary sores. The primary sores were healed, but the urethral sore remained uncured, and marrying in this state his offspring all die diseased, and his wife also is affected. The patient has repeated attacks of constitutional disease in the most alarming forms, which have recurred as often as they have been cured, and this I explain by the sore in the urethra being still open and poisoned, and thus forming as it were a well of poison, which is constantly tainting the system. It is proved by the history of this case, then, which has been very carefully watched and examined, and the history very correctly taken, that primary venereal sores may exist within the urethra for a long period of time. M. Cullerier has recorded a case of this nature, which had, when presented to his notice, continued upwards of a year, and was then uncured, although the patient has been submitted to repeated treatments. These sores may be seated in any part of the urethra, and even in some rare cases extend to the bladder itself.† OF THE SYMPTOMS OF CHANCRE IN THE URETHRA. These are heat, itching, or irritation in the urethra, occuring after a suspicious connexion, unaccompanied by discharge; pain or tenderness in a particular part of the urethra when it is rolled between the fingers; the presence of a distinct induration at the point where the pain is complained of; pain also increased during micturition, and referred to the same point. Discharge from the urethra occurs at various and at irregular periods after the setting in of the first symptoms already described. It is very different from the discharge Recherches pratiques sur la Therapeutique de la Syphi lis. Paris. 1836. See the account of two fatal cases of this nature, with the state of the parts when examined after death, presented to the Academy of Medicine by M. Ricord, and figured in bis Clinique Iconographique de l'Hôpital des Veneriennes. Plate 8. A gentleman consulted me for a disease in the urethra, which had existed many months, and which he said consisted at first in a small sore, visible when the lips of the meatus were separated. This part had healed; but it was evident that the ulcer had extended its ravages down the urethra, since, on pressing an induration which existed behind the glans between the fingers, there escaped from the urethra a tenacious slough, precisely resembling that covering an indurated or Hunterian chancre in its first or ulcerating stage. The only disease for which chancre of the urethra can be mistaken is gonorrhoea. From this it is to be distinguished by the history of the case, the character and quantity of the discharge, the presence of a distinct circumscribed induration in some part of the urethra, most commonly seated in or immediately behind the glans penis. This circumscribed induration must not be mistaken for that general induration of the corpus spongiosum urethra which accompanies acute gonorrhoea, and results from an effusion of lymph, &c., into the cells of the spongy body. This state in gonorrhoea is generally accompanied by chordee, a symptom absent in chancre of the urethra, I believe always, for I never saw it. In some rare cases I believe it possible that a primary venereal sore in the urethra and gonor. rhoea may be contracted by the same connexion. I will mention a case which seems to bear upon this from a suspicious connexion a discharge from the point. A gentleman, fifty years of age, contracted urethra, which had all the characters of ordinary gonorrhea; he placed himself under the care of an eminent practitioner, and took for a month the ordinary remedies, such as copaiba and cubebs: with this treatment the discharge disappeared. At this time a slight ulceration was perceptible round the meatus, which seemed to come from within the urethra. This spread rapidly, soon involving the whole under surface of the glans, and the urethra for an inch and a half, which were entirely destroyed by ulceration and sloughing. I was consulted on this case, which was succeeded by extensive nodes, and a pustular eruption, and what is very remarkable, the nodes were the first constitutional symptoms which occurred, an exception to the law which seems to regulate the appearance of constitutional symptoms generally. I believe the poisons of gonorrhoea and syphilis to be perfectly distinct, but yet there are cases occasionally presented to our notice where both chancres and gonorrhoea exist at the same time. sores and a true gonorrhoeal discharge from the It is not uncommon to see patients with external urethra at the same time; neither, in the female, is 53 very common seat of chancre of the urethra is the fossa navicularis, and the glans is sometimes scooped out as it were by the spreading of venereal ulceration in this situation. I have seen this passage behind the glans opened for an extent of an inch and a half by the ravages of an urethral chancre. it rare to see true primary venereal sores in the vulva, vagina, or uterus, co-existing with purulent discharge from the os uteri or urethra. In the male, however, more particularly, these two primary forms of disease are not curable by the same remedies. In the case I have just quoted, it appeared that the two forms of primary venereal infection existed simultaneously in the urethra at the commencement, since the symptoms of gonorrhoea disappeared under the use of the ordinary specific remedies; whilst the venereal ulcers continued to spread, and ultimately produced the most serious mutilation. We have no farther proof of the opinion I have hazarded than is to be drawn from the effect of remedies, a fact to which I am dis-in spite of all our care and attention, will someposed to attach very considerable importance. 4. The urethra itself may be completely destroyed to a greater or less extent. Of this also I have seen one example, where the passage was destroyed by ulceration for two inches, and the urethra opened on the under surface of the body of the penis. I can conceive of nothing more horrible to a young man than mutilation of this character, which, times take place, if the disease assume a phagedenic form, and spread by rapid ulceration or sloughing. They are not however so likely to happen if the disease have been at once diagnosticated and properly treated from the commencement. Chancres in the urethra may be met with as a solitary form of primary venereal infection, or they may co-exist with sores situated externally. The case of M'Knight, already recorded, is a proof of this. It very commonly happens also, that the Constitutional symptoms are just as likely to presence of external sores, and the absence of dis-occur in consequence of primary venereal diseases charge from the urethra, prevent any examination in the urethra, as when such sores are situated of the latter. In examining, however, a patient, externally. who applies to you with a primary venereal affection, the canal of the urethra should always be pressed between the fingers, and the lips of the meatus opened. A gentleman contracted several small sores situated on the glans and prepuce; they were free from pain and irritation, and healed quickly under ordinary treatment; the glans, however, became swollen, red, and shining, and yet there was no external symptom to account for it. It at length occurred to me to examine the urethra, and on everting the lips of the meatus a small sore was discovered, upon which the condition of the glans was evidently dependent, since it disappeared as soon as the sore in the urethra healed. The prognosis of chancres in the urethra is not always favourable; the two cases I have quoted from Ricord show, that by extension to the bladder they may terminate fatally. The prognosis is again unfavourable as regards the integrity of the organs of generation, since, however carefully they may be watched, severe mutilations are occasionally produced. The chief evils I have seen arise from chancres in the urethra have been the following: 1. Contraction of the orifice of the urethra by the cicatrix of the chancre. I attended a gentleman who had a chancre of the orifice of the urethra, which, in healing, so contracted the meatus orifice, that it would not admit the bulbous extremity of an ordinary silver probe. 2. Contraction of the urethra by the cicatrix of the chancre where the sore has been situated lower down. To this species of stricture the term traumatic has been applied. It does not readily yield to the bougie. 3. Perforations of the urethra. These are variable in extent and situation, but are commonly situated immediately behind the glans. I have said that a The question next arises-how are primary venereal sores situated within the urethra to be treated? In these cases it is perhaps easier to say what plan of treatment will not be applicable, than what will. The situation of these sores precludes the adoption of the practice I have recommended to be employed in primary venereal sores situated elsewhere.* The use of caustics is clearly impossible, unless the sore be situated immediately within the urethra, and even then their application will require great care and attention, and is not generally to be recommended. From the situation of a primary venereal sore in the urethra, we are prevented employing the local remedies commonly used in the treatment of chancre; and an indiscriminate course of mercury is still more useless and injurious. and We will suppcse a patient presents himself to you with a primary venereal scre in the urethra, the existence and nature of which are unequivocal. You may order lotions, injections, ointments, low diet, aperients, mercury, and the usual remedies which are commonly successful in other cases, at the end of weeks, and even months, you will find your patient worse rather than better. I do not think it possible, certainly not probable, and I speak from considerable experience in this matter, that you will materially benefit your patient, unless you confine him entirely to bed, and the recumbent position. We know how obedient in hospitals the ordinary cases of primary sores are to very simple treatment, where the patient is confined to bed and submitted to a regular and proper regimen. We know also that such confinement, and the application of simple bread and water, will bring speedily into • Provincial Medical Journal, April 1, 1843. a healthy condition sores which, whilst the patient pursued his ordinary occupation, careful though he might be, were rebellious to the most seemingly judicious treatment. Rest in bed is the most powerful adjuvant in the treatment of all primary and even constitutional syphilitic diseases. Cullerier says of it; repose in the bed in the recumbent position, so useful in all forms of syphilis, is absolutely indispensable in many of them. It removes every species of irritation from the parts affected, such more particularly as could be occasioned by the friction of the clothes, and the gravitation of blood. It also throws the patient into a kind of debility, very favourable to the cure of his disease. In such a situation also the diet can be much more easily regulated. reduce all inflammation by fomentations, poultices, rest, low diet, and unirritating aperients. You may then have recourse to mild astringent injections of nitrate of silver, alum, zinc, or tannin and opium in wine. At the same time a very mild and carefullywatched mercurial course may be employed. Above all, carry, if you can, the patient with you in the treatment of his disease; explain to him its nature and its occasional consequences if neglected, such as mutilations, perforations of the urethra, its extension to the bladder or deep-seated parts, and even its occasional termination by death. If this be done firmly and sensibly, a patient will make any sacrifice to get cured; and under such circumstances you will add to your reputation by convincing your patient that you have a thorough knowledge of the nature and consequences of the malady you are called to treat. In this disease truly may it be said that "forewarned" is indeed forearmed." It commonly happens that venereal sores in the urethra will resist all the ordinary means of cure, unless the patient be confined to his bed," and restricted to the simplest possible diet. The treatment then becomes easy, and is very generally successful. Mild opiates and mercurials, with simple astringent injections, will now in almost all cases work a cure; but it is next to impossible to cure these sores as long as the patient goes about and pursues his ordinary occupation, even in a minor degree. I would have nothing to do with the management of a patient with chancre of the urethra unless he laid up entirely, knowing from experience that I could neither benefit him nor myself by attempting to treat him under ordinary circumstances. I have known these sores assume a healthy character in two or three days in patients when confined to bed, which had previously resisted every mode of treatment. A gentleman connected with the London press contracted venereal sores externally, and one on the urethra, during the last general election. He placed himself under my care, with the reservation that I must not confine him. I undertook the management of his case with great reluctance, and, as I expected, the sore in the urethra got daily more irritable, and disposed to spread, although the other sores had healed. I at length determined to practise upon his fears, and at the next visit I said to him, "Now, Sir, you must either take to your bed, or probably undergo some horrible mutilation; there is no alternative." My manner alarmed him, and he became obedient; and at the end of three days a sore, which had resisted everything, yielded to rest in bed, and the simplest medication. I consider it the greatest kindness to alarm a patient in this state; the more you frighten him the more easily will he be cured. Some writer says, the more seriously the patient and the surgeon look upon the disease the more quickly will it be eradicated. If, then, a patient with primary venereal sores in the urethra seeks your advice, in the first place Traité de la Thérapeutique de la Syphilis. p. 110, ON THE THERAPEUTIC POWERS OF THE By W. S. OKE, M.D., Southampton. CHRONIC RHEUMATISM. I. X., a female of middle age, has been subject to severe attacks of rheumatism. In August, 1842, she suffered another attack. It had existed for five weeks, and finding that the symptoms did not yield to the means prescribed, she consulted me on her case. The pain was mostly felt in the right shoulder joint, extending to the cervical vertebræ. The pain was constant and so intense as to deprive her of all rest; and she felt as if "a ton weight" were on her shoulder. The tongue was not much coated, nor the arterial system excited. five grains thrice a day in some aromatic water. After the medicine had been taken 24 hours, a peculiar kind of eruption made its appearance on the arms and upper part of the trunk. It came out in papulæ, which were in some parts distinct, in others comfluent; but its principal peculiarity was its bright scarlet colour, which was as vivid as that of a boiled lobster. The itching was extreme. As I had before seen a similar eruption after the employment of the iodide in chronic rheumatism, I attributed the outbreak to the action of the medicine. It was therefore suspended for a few days. Whether the rash through the operation of the remedy was critical, it is not easy to say; but at any rate, as the rash appeared the resuming the iodide in three grain doses she was: severity of the rheumatic pain left her; and by I gave her my usual dose of the iodide of potassium, speedily cured. CASE II. A young man, a labourer, aged 20, had been long afflicted with chronic rheumatism, which had so crippled the motion of his joints that he had not the power of raising either hand to his head. His general IODIDE OF POTASSIUM. appearance bore sad marks of severe and continued suffering, which had reduced him to a state of great debility and attenuation. There was no febrile disturbance. He was placed under the four-grain dose of the iodide three times a day; and three weeks afterwards, when he came in from the country, the improvement was remarkable, the stiffness of the joints was in a great measure removed, so that he could carry his hands to his head without difficulty; his general health was much ameliorated, and he afterwards gradually convalesced. 55 functions, was still preceded by the same inflation of the stomach; and he could not venture on any solid food without great hazard of bringing on an attack. Putting all these negative and affirmative points together, I was persuaded that the symptoms were the result of functional causes, and that those causes existed in the extreme susceptibility of the pneumogastric nerve. With this view I gave him alterative doses of blue pill, with various tonics; the trisnitrate of bismuth, the sesqui-oxide and black oxide of iron, oxide of zinc, the nitrate of silver, &c., asso I might adduce many more instances of the efficacy ciated with dilute hydrocyanic acid, henbane, hemlock, of the iodide in rheumatic disease. I will now say a few words of its use in chronic gout. When a paroxysm of gout has either subsided or been subdued by colchicum, it not unfrequently happens that it loiters in the system, sometimes plaguing one joint and sometimes another, not in sufficient force to fever the system, but just enough to confine the gentleman to his arm-chair, or to keep the man of business from his counting-house. Under such circumstances I have found the iodide of the greatest service in clearing the system of the disease for a considerable time. I gave it in the following combination: : Iodide of potassium 14 fluidounce This dose to be taken thrice daily for a month or six weeks. The diseases of the third class, in which it had not been before employed, and in which it proved of essential benefit, are certain forms of dyspepsia, apyrexial asthma, and chorea Sancti Viti. DYSPEPSIA WITH ALARMING ASSOCIATIONS. J. D., a merchant, aged 62, the left side of the face showing paralysis of the portio dura; had been subject to dyspepsia, the principal feature of which was, collection of flatulence in the stomach. Fifteen years ago, during one of these inflations, he felt a sudden "movement" at the anterior and lower part of the chest, which flew to his head, and for a moment deprived him of his senses. These alarming symptoms frequently returned, and as they resisted all medicinal remedies, they were attributed to a stricture of the rectum, which had existed for some time. The stricture was examined and dilated. By this means he was in some degree relieved for twenty months, when the same sudden syncopes came back, and continued to harass him from time to time for several years. At length this recurred so frequently as to deprive him of all consciousness many times in the course of a day. This alarming state of things filled his mind with constant apprehension, and those of his friends with the conviction that he would die in one of the attacks, which were attributed to a disease of the heart. &c., together with a variety of external appliances, too numerous to mention. All failed. As he had before obtained benefit from the rectum-bougie, I advised him to have it again used. It was done, and he was benefitted by it for a time. The syncope, however, returned; and I now began to entertain serious fears that the case really was syncope anginosa, caused by valvular disease of the heart. I now, for the first time, gave him the iodide of potassium in four-grain doses three times a day, combined with ten grains of the sesqui-carbonate of soda. After ten days he called on me and reported that the last medicine had taken a decided effect upon the complaint; that he had lost the flatulencies; that the syncope had not returned; and that, strange to say, he could bear light solid food, upon his stomach without hazard! He continued the medicine for some weeks, and from wholly exempt from syncope, I have heard of him this that time to this—a space of three years he has been occasional attacks of gout, to which he has lately been day (March 27th); he enjoys good health, excepting liable. SPASMODIC ASTHMA. A lady, aged 31, in 1838, began to suffer severe attacks from bronchitis, which frequently interrupted the performance of her duties as governess. The disease retained this form for two years, each attack terminating in muco-purulent expectoration. In 1840 the disease assumed the character of spasmodic asthma, the paroxysms of which sometimes commenced with nasal catarrh, and sometimes with violent flatulency, nausea, and vomiting. The course of each paroxysm occupied about a fortnight, and terminated in expectoration, as did the bronchitis. For the last two years these asthmatic attacks have returned every six weeks, threatening suffocation, and alarming her exceedingly. She anxiously tried all the ordinary remedies for this dreadful malady, and consulted divers opinions, some of which were decidedly adverse to any hope of recovery. Finding no relief from medicine she at once relinquished her connexion on which her income depended, and entered a family at Clifton, in the hope that atmospheric change might effect what medicine had failed to do. She then gained a considerable respite, When I saw him in this state, his countenance had and went to Ireland, where she became so much not the appearance of one having organic disease. He worse, that in 1843 she could not lie down for nine had no headache; no pain across the chest or down months together, and during the violence of the the arms; his pulse was sometimes irregular, but for paroxysms was compelled to smoke cigars, till by the most part equal and normal; and no morbid sound faintness the spasm was overcome, and the breathing in the action of the heart could be detected by atten-relieved. At the end of 1843 she decided on returning tive auscultation. He was usually costive. The inter- to Southampton. The change again relieved her for a ruption of the action of the heart, and of the cerebral time, but the paroxysms soon returned with equal |