In the earlier and more acute stages of the disease, it is not prudent to have recourse to the speculum to ascertain whether the gonorrhoea is complicated with venereal ulcerations or not; our first duty is to subdue the acute inflammatory symptoms, and then, if the chronic stage be protracted, or do not yield to treatment, and there is reason to suspect the existence of deepseated ulcers, the speculum may with propriety be used to clear up our diagnosis.

The internal treatment of gonorrhoea in the female is very limited. The remedies which are considered specific in this disease in the male, as copaiba, cubebs, &c., are here almost inert. Their action upon the vaginal forms of the disease is very feeble; their exhibition must be limited to the urethral varieties. Aperients, alkalies, sedatives, with diluent and demulcent drinks, constitute nearly the whole of our resources under the head of internal treatment.

The local treatment of acute vaginitis or urethritis in the female consists in the use of emollient and narcotic fomentations and injections, such as decoction of poppies, tepid water, &c., used alone, or rendered slightly astringent by the addition of the diacetate of lead or sulphate of zinc, in the proportion of from two to four grains to the ounce. This treatment, however, should not be long continued, if ineffectual; for we frequently find rest, emollient and narcotic applications of little use, the patient still continuing to suffer from severe pain and an abundant puriform discharge, whilst the mucous surfaces of the vagina, &c., continue red, and turgid with blood. Under these circumstances, or when the acute stage has in some measure given way, we may have recourse to astringent injections, with a view of preventing the discharge assuming the chronic form, and thus continuing for an indefinite period. The preparations of lead, alum, zinc, or the nitrate of silver, may be employed

for this purpose.

1 B Plumbi diacet.,

Zinci sulph., aã ¦j-3j;
Aquæ, Oj. M.

2 B Aluminis exsiccatæ, ij ad 3ij;

Decoct. papaveris, Oj.

M. ft. injectio.

SB Agent. nitrat., 3ss-3j;

Aquæ dest., Oj.

When the more acute stages of disease are passed, and the chronic form continues but little influenced by remedies, it will be well to examine the mucous surfaces of the vagina, &c., by means of the speculum. These may be found in several pathologic conditions; simply red, turgid, and hypertrophied, or covered with red isolated patches, aphthæ, vesicles, pustules, or superficial ulcerations. After the continuance of the disease for some time, the os uteri is always more or less affected; its lips are turgid, red, and everted, and generally covered with small ulcerations, granulations, or other changes, the result of chronic inflammation.

In the chronic forms of the disease, unattended by change of structure, as local applications or injections, we may employ solutions of tannin,' the decoctions of oak bark, tormentilla, or the walnut-tree leaf, or the tincture of iodine more or less diluted. The solutions of the chlorides of soda or lime are of use when the discharges are offensive and accompanied by ulceration.2

M. Bonnet ('L'Union Médicale,' Sept. 1853) speaks highly of the tincture of iodine applied to the mucous membrane of the vagina in the gonorrhea of women; it is chiefly indicated in mucous or muco-purulent discharges without much vaginitis. MM. Becquerel and Rodier recommend tannin dissolved in equal parts of distilled water.

Many of the injections spoken of coagulate the mucus of the vagina ; before using them, the parts should be well cleansed with tepid or cold water, to remove all the clots formed by the preceding injection. In fact, in all cases the parts should be well washed out with water before the injection is used: it is in vain to attempt a cure without a proper syringe, such as I have recommended; and in many cases the injections or applications must be made through the speculum, or the parts affected will not be reached. Of these remedies, the concentrated solution of tannin is one of the best. It should be applied every three or four days, and in the intervals injec tions of cold water should be used. In estimating the value of injections in the treatment of the various forms of gonorrhoea or vaginitis in the female, I should say that the preparations of lead or zinc in cold or tepid water are suited to the acute stage, tannin more or less concentrated in the subacute, and the tincture of iodine in the purely chronic.

When the gonorrhoeal discharge is secreted by the mucous surfaces of the vagina only, these applications may be thrown up with an ordinary female syringe; when, however, the os uteri or the canal of the cervix is the seat of the disease, it becomes absolutely necessary to use a syringe, by which a continual irrigation can be kept up; in this way a pint or several pints of injection may be thrown slowly up, without removing the pipe or tube of the syringe. For this purpose the syringe known as Higginson's answers very well, fitted with a vagina tube. In gonorrhoea of the uterus, injections of small quantities of the remedies already mentioned may be required to be made into the canal of the cervix itself; and in such case the injection must be made through the speculum, and only a few drams used.

When the chronic state of gonorrhoea in the female is accompanied by any alterations of tissue, these changes demand our first attention, since it is useless to attempt to check the discharge as long as these conditions remain upon which it depends. Ulcerations or papulous granulations should be cauterised with the nitrate of silver, or, what is better, with the liquor hydrargyri pernitratis, Ph. D. This caustic is to be applied by means of a camel-hair pencil, or a small roll of lint, to touch the diseased surfaces, these having been previously cleansed by dry lint or a soft sponge. When ulcerations themselves have destroyed the tissues more or less deeply, caustics must be employed with extreme caution. In these cases, the surface of the ulcers may be covered with calomel, upon which may be placed some dry soft lint, and afterwards passed into the vagina some lint soaked in one of the astringent or tonic injections previously mentioned. Where the disease has extended more or less into the canal of the cervix, and has assumed the form of uterine gonorrhoea, the solid nitrate should be introduced, and the mucous surface lining the neck well rubbed with it.

A true vaginal gonorrhoea may be confounded with vaginitis. arising from other causes; and hence arises a question of great delicacy and importance, whether we are in possession of any facts which will enable us to establish a correct differential diagnosis between the two diseases.

In gonorrhoea the discharge is generally more abundant and

more purulent, and the inflammation more acute, than in ordinary leucorrhoea. In the former disease, the glands of the groin are more frequently enlarged, tender, and painful; and in gonorrhoea the affection extends to the urethra in about two-thirds of the cases.1

Many causes contribute to render the treatment of gonorrhoea in the female tedious and unsatisfactory, and a disease more difficult to cure in this sex than in the male. The recurrence of the menstrual period is constantly interfering with the success of treatment; and a gonorrhoea that has been almost subdued in the interval, is renewed with all its intensity at the time of menstruation.

I believe that gonorrheal diseases in the female are very rarely completely cured. They become chronic, and degenerate into what is called leucorrhoea. This, in most cases, arises either from neglect on the part of the patient, or the want of a proper knowledge of the disease, careful examination of the parts affected, and an appropriate topical medication on the part of the surgeon. If Mr Whitehead's notion be correct, that the canal of the cervix is the first part affected, and the vaginal or urethral mucous surfaces are only secondarily diseased, the malady is not likely to be cured without topical applications to the primary seat of complaint. Many modern writers have described gonorrhoeal affections of the ovaries, and carrying out an anatomical to a pathological analogy, have considered a gonorrhoeal ovaritis in the female as the analogue of a swelled testicle in the male.2

1 See the paper of M. Ricord, Mémoires de l'Académie Royale de Médecine,' 1833.

2 Acute gonorrhoeal ovaritis has been noticed by Ricord, Vidal de Cassis, and others, as a result of gonorrhea; also by Dr Tilt ('On Diseases of Women and Ovarian Inflammation,' 2nd edit., p. 220), who, with Dr Simpson, thinks it a rare disease. I have frequently noticed women who have been under treatment for gonorrhea complain of pain and tenderness in the region of the ovary; this has been especially marked when discharge has diminished under the use of astringent injections. These pains are not in the groin, and must not be confounded with the symptoms produced by an inflamed inguinal gland. They generally yield to one or two relays of leeches, low diet, and gentle aperients, and diminish altogether should the discharge reappear or become more abundant. These symptoms are doubtless due to inflammation of the ovary, of a more or less acute character.

CHAPTER VIII.

OF THE SECOND CLASS OF PRIMARY SYPHILITIC DISEASES, CHANCRES, ULCERS, THEIR VARIETIES AND CONSEQUENCES.

THE effects produced by the application of the syphilitic poison or virus upon healthy tissues are very dissimilar; and this difference is so marked, that it has given rise to an opinion, prevalent amongst many modern surgeons, that there exists more than one syphilitic poison. Many distinguished men have lately maintained the duality of syphilis; though differing from each other in the explanation of the circumstances under which the double symptoms are manifested. Whether the different symptoms which are seen to follow the application of the syphilitic poison upon different persons, are due to the nature of the poison itself being different; or whether the difference is produced by the constitution of the individual to whom it has been applied; or whether, again, the variations are due to a mere local pathological condition on the part of the recipient, is difficult to say, each of these theories having found supporters in writers of great experience on the disease in question.1

เ

1 See Bassereau, Affections de la Peau Symptomatique de la Syphilis,' Paris, 1852; also, Ricord, Leçons sur le Chancre, par Fournier,' Paris, 1858. The 'Lettsomian Lectures on Syphilis, by Mr de Méric,' contain a very good and full account of these various theories: London, 1858, Churchill.

It has been supposed by some that the soft chancre is due to the virus being implanted on a subject previously tainted with syphilis, and that it is not, per se, a primary uncomplicated manifestation of syphilis. This is a mere theory. Chancres generally produce their like: a soft chancre produces a soft chancre, and an indurated chancre gives rise to an indurated chancre. To this rule there are some exceptions, which seem to favour the truth of the theory just mentioned. M. Ricord believes it probable that—

1. The simple or soft chancre of virgin subjects, i. e., of subjects not previously afflicted with syphilis, is transmitted under the same form, that is, as a soft or simple chancre: