of investigating the practice, and in the present very able paper details the results he has obtained.

Regarding gonorrhoea as a specific inflammation of the urethra (blennourethritis), he believes our object should be to destroy this "specificity" and reduce the disease to the condition of an ordinary or "normal inflammation." This he believes is best accomplished by the prompt use of injections. He animadverts upon the opinion advocated by Baumès and others, that the sudden suppression of the discharge in this way is sometimes followed by the outbreak of secondary symptoms. In 600 patients treated by the abortive method by Dr. Poullain, during the last fifteen years, he has never met with an instance of this, and in 200 other cases, whose subsequent history he has been in the position to assure himself of, not one occurred. He fully agrees with M. Ricord, as we believe most other observers now do, that the apparent examples of constitutional symptoms following gonorrhoea, are really examples of concealed urethral chancre. To this opinion it has been objected, by Baumès and others, that the chancrous matter applied at the orifice of the urethra can scarcely be expected to travel to the prostatic portion before producing its local effects. But these observers are guilty of the inconsistency of attributing this very power to gonorrhoeal matter when they state the vicinity of this portion of the urethra to be its commonest source. But the possibility is best decided by facts. A soldier who had been long fruitlessly treated for gonorrhoea was carried off by typhus, and, on examining the urethra, a well-characterized chancre was found at 10 or 12 lines behind the fossa navicularis. In two other cases of gonorrheal patients, dying of other diseases, well marked cicatrices of venereal ulcers were found at nearly three inches from the orifice.

As in all other inflammations the prevention of the formation of a chronic stage, and the consequent pathological changes in the parts implicated, is highly important, and M. P. believes this has not hitherto been accomplished by injections because they have been employed too tardily. Reversing the ordinary procedure, he always uses them in the acute stage, rarely in the chronic one; and it is their having been confined to this last that has obtained for them the ill-reputation of producing various ill-effects which really result from the disease having already passed into a chronic condition. The object in recommending early injection is not to procure the cessation of the discharge, but a change in the character of the inflammation; for, this once accomplished, as the diminution of pain and other symptoms prove it to be, the discharge usually soon disappears of itself, or is easily removeable by means of balsams and revulsives. The prejudice against their use, founded upon their supposed tendency to the production of stricture, is a very erroneous one; for we cannot suppose this to be formed without the prior existence of inflammation.

In fact, they are the best means for the prevention of this affection. If stricture arises from the use of injections it ought to be formed at the various portions of the canal the stimulating fluid comes in contact with; but in the vast majority of cases it is so in a very limited portion of the canal and one to which the injection hardly ever obtains access. If, too, we question persons suffering from stricture we find that they have rarely made use of injections, and that they have found the canal become narrowed

18471

Early Use of Injections in Gonorrhea,

55

only after protracted duration of the discharge. Injections are indicated then during the whole of the acute stage, and no other means is so efficacious for calming the ardor urinæ, and for relieving painful erections. All these symptoms, however violent they may be, yield, as if by enchantment, to the use of injections, and, so far from contra-indicating them, form the strongest argument for their employment. "In this way I constantly arrest numbers of gonorrhoeas without any ill-effects resulting." Dr. Poullain employs the following modification of Bell's formula-Sulph. Ziaci, a scruple, Aq. Destil. 10 oz. Dissolve and add Liq. Plumb. Acetat. gtt. 20, Laudanum of Sydenham 1 drachm. The last ingredient he regards as an important one. This injection is to be employed as soon as slight irritation, redness, or discharge is seen, the sooner the better. Three jets should be thrown in three or four times daily, and the fluid retained in the canal by slight pressure for half a minute. In most cases the pain and inflammation disappear in 24 hours, or at farthest in a day or two, and the patients often are quite surprised at the rapidity of the relief. The injections must, however, be continued until the discharge becomes sparing and colourless, which generally occurs in about from five to ten days. They may be then discontinued as the discharge soon ceases, or may be removed by ordinary means. Although injections act most beneficially when employed at the very commencement, they are still useful at a more advanced stage, and we must not allow the severity of the symptoms to prevent our employing them, as they will promptly alleviate these. The eight or ten first days constitute the most eligible period for their use, but we may still have recourse to them at the fifteenth or twenty-fifth day, when however their success becomes less prompt and less complete; and, although they may be used without danger, they do not always then arrest the discharge; but require the aid of balsams or cubebs administered internally.

Gleet.-The means advocated does not require any especial abstinence, save from wines or spirits, &c., and will, as a general rule, effect a cure in fifteen days, and frequently in ten, five, or fewer still. When injections have been delayed until the decline of the acute stage the discharge may persist under the form of gleet or military gout. The persistence of gleety discharge seems dependent upon four different conditions of the urethral mucous membrane. 1. A simple state of local relaxation. 2. A superficial but circumscribed ulceration. 3. A concealed chancre; and 4. A commencing or already-formed stricture. The first of these is the most common variety, and generally arises from an atonic state of the exhalent vessels of the urethra, consequent upon a condition of excitement which had been treated by demulcents, antiphlogistics, and diuretics. In such cases, tonic rather than astringent injections best succeed, and Dr. P. usually employs aromatic wine, diluted with equal parts of water, or cold water to which a sixth part of alcohol has been added. In some cases, cold lotions to the penis and scrotum succeed. This variety of gleet always exists without pain, even during the passage of urine or instruments, or the presence of erections. The discharge varies in appearance, according to the manner it has been already treated. It is opaque, milky, or yellowish if it has been left to itself, or what is nearly the same thing, treated by de

mulcents. It is clear and transparent if injections have been employed. Contagious in the first case, it is never so in the second-an additional advantage for the abortive method. (An advantage, if true, which is not the case.-Rev.)

(2.) If this discharge persists for a certain period the portion of the mucous membrane wherein it originates becomes excoriated, constituting the second variety, which may always be easily recognized by the change in colour of the discharge, which becomes a dirty white or sanguinolent. In urining too, the patient experiences a sharp pain at the excoriated spot, and he is much tormented by nocturnal erections. In this case, the nitrate of silver (1 to 2 grains to the ounce of water) forms the best injection, throwing it in once daily, while in other cases, much success attends its use in the solid form. The discharge, however, after disappearing, returns again with the greatest ease, and upon the slightest excess: and in such cases, a large blister applied to the upper and inner part of the thigh, kept open for a fortnight or even a month, rarely fails in entirely suppressing it.

The third variety depends upon a concealed chancre. The author relates two remarkable cases of gleet which, obstinately resisting all other modes of treatment, yielded readily to the use of mercury, which such obstinacy and the local suffering induced him to administer. In this way he explains similar examples of the utility of mercury in gonorrhoea recorded by various authors. In consequence of the passage of the urine, the cure of a chancre, under such circumstances, is always tedious and difficult; and even those which are situated near the orifice of the urethra are months in healing, protect them how we may. The diagnosis of a concealed chancre is usually obscure, and we must much depend upon the prior history of the case and upon the presence of certain symptoms, especially an almost constant pain at one point of the canal, increased by urining, by external pressure, or the passage of an instrument. Erections, too, are often as frequent and as painful as in the acute stage of the disease. The discharge is of a sanious and purulent character, sometimes sanguinolent, and, after urining, drops of pure blood may be passed.

The

The fourth variety, that dependent upon stricture, is to be relieved only by the cure of the latter. Stricture, as a consequence of venereal affection, may form in two modes. In the first, the canal in one or more places is obstructed by a kind of vegetation or fleshy excrescence, which M. P. has often met with in opening the urethra after death, sometimes disposed in a parallel direction to the canal, and at others forming a transverse bridle. Upon the passage of an instrument, during life, these are sometimes detected by the readiness with which they bleed. This species of stricture is neither the most common or the most difficult of cure. removal of the vegetations by cauterization, and the subsequent employment of mercury constitute the treatment. The most common variety of stricture is formed very gradually, and the calibre of the canal is narrowed, generally just anterior to the prostatic portion, in consequence of the thickening of its mucous membrane induced by chronic inflammation. There is usually but little pain, unless the narrowing be sufficient to produce great obstruction to the expulsion of urine. Bougies form the appropriate means of treatment, and it is an error to substitute cauterization

1847]

Marchal (de Calvi) on Chanere.

57

for them. They must, however, be most perseveringly employed, and allowed to remain in the urethra for a longer or shorter period, or the stricture will soon re-appear.

IV. FREQUENCY OF TENIA IN ALGERIA.

From the Reports furnished to the compilers of the Recueil this parasite seems especially to infest the soldier in Algeria, although the relative degree in which it does so would have been better judged of if the respective numerical amount of soldiers in the different localities had been stated. The military hospitals of the interior of France furnished, during the years 1840-6, only two cases of tænia, and those of Corsica no case; while no less than 34 cases were observed during the same space of time in Algeria.

V. REPORT OF THE VENEREAL PATIENTS UNDER THE CARE OF M. MARchal (de Calvi), of the Val de GRACE. BY M. Souhaut.

This is an interesting account of the practice pursued by M. Marchal in the cases of between 600 and 700 patients, who passed through his hands in this military hospital during four months of 1846. The doctrines of M. Ricord upon syphilis were put into practical operation to a greater extent than we should have expected or can approve of. For example, the following positions are, in our opinion, full of the most dangerous fallacies.*

"If the chancre continues simple that is not indurated, there is no cause to fear general symptoms. To this primary law, laid down by M. Ricord, we have met with no one exception. Suppurating bubo is always coincident with simple chancre, and excludes constitutional syphilis. We might say that the inflamma tion developed in the gland prevents the virus passing further, and that this is eliminated by the suppuration. We have met with facts which throw doubt over the first portion of this second law. Induration, according to M. Ricord, is the first general or constitutional phenomenon of syphilis."

Chancre varies in its form, duration, and nature. In treating of its seat, several cases of urethral chancre are detailed. A reddish appearance of the discharge from the canal is much relied upon as a sign of this, added to which, induration may be sometimes felt by external examination, although, in other cases, a simple inflammatory engorgement may be mistaken for this. The two, however, are distinguished by the dispersion of engorgements by suppuration or antiphlogistics. A severe pain at one point in urining, though not pathognomonic of concealed chancre, deserves attention. Chancres attacking the side of the frænum, burrow under it until they leave only, as it were, a little bridge, which, containing in its

* For some excellent criticisms upon the views of M. Ricord, as well as for a most masterly estimate of the various debateable points in the history and treatment of this disease, we beg to refer our readers to Mr. Porter's Lectures, publishing in the Dublin Medical Press of the present year.

substance a small arterial branch, remains undestroyed. The duration of the treatment is abridged by the division of this portion, which M. Marchal accomplishes in the manner recommended by M. Ricord. Two threads are, by means of a needle, passed under the frænum, and the posterior one is first tied round this part, giving the patient much pain, which however he does not feel when the other thread is tied. The frænum is divided between these two, and no blood flows. When chancres exist in considerable numbers around the free margin of the prepuce, a phymosis, sometimes necessitating operation, is often induced. The case is thus expedited, providing the incision can be made at some little distance from the chancre, so that it may cicatrize as a common wound.

In respect to form, the chancre is usually circular, or, as in the case of that of the frænum, very elongated. There is every variety as to size; but it is an error to suppose that small chancres are more readily healed. They sometimes seem to require a time inverse to their size. The chancre may be elevated, superficial, or excavated. In respect to this last, there is one form which may be termed the pigeon's nest chancre, which is produced when the ulceration, having destroyed the entire thickness of the preputial mucous membrane, has for its basis only the extremely loose cellular tissue which unites this membrane to the external skin. This cellular tissue becomes excavated beyond the borders of the ulcer, giving the pigeon's nest appearance. The same effect is produced by the chancre commencing externally, and destroying the skin of the prepuce down to the cellular tissue. This variety is especially distinguished by its tedious reparative process.

The average period of duration of chancre at Val de Grace was 28 days, some healing far sooner, and others much later. Some chancres may, from their rapid disappearance, be well termed ephemeral, and yet these possess all the characteristics and virulence of ordinary chancre. These cases may furnish matter for a bubo which does not appear until after the sore is cicatrized, and then may be taken for a primary bubo. These are not the only cases in which bubo may form after cicatrization. Sometimes patients apply a month after their dismissal, having an open bubo without any new infection.

In respect to the nature of chancre, as long as it is not indurated, it is a mere local disease, but no sooner does induration present itself, than a general infection of the system is imminent or acquired. Simple superficial chancre may be confounded with herpes, but herpetic ulcerations are usually in clusters, are preceded by pruritus, and accompanied by vesicles in some other portion of the prepuce. In M. Marchal's opinion, however, the distinction is of little practical consequence, as general infection does not follow any simple unindurated ulceration, which promptly cicatrizes. In the hospital many chancres were of a phagedanic character. M. Ricord describes three varieties of this, the pultaceous or diphtheritic, phagedæna from excess of induration inducing mortification, and phagedæna from excess of inflammation inducing gangrene. It is the first of these that was met with in Val de Grace. This diphtheritic sore, according to M. Ricord, is marked by absence of induration, the aspect and form of hospital gangrene, and great pain and irritability. This is usually correct, but in one case cited of pultaceous chancre, committing great destruction,