conical crusts, thus constituting a variety of disease to which the term "pustulo-crustaceous" has been applied. 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 characterises 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 means of a small speculum made for the purpose, the commencement of ulceration, which appeared to extend deep into the urethra, could be perceived. This case is remarkable under many points of view. In the first place, the disease itself (primary 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 R. M. had ever contracted a venereal disease subsequent to his marriage; the evidence of the wife and himself is conclusive upon this point. The sores which he contracted at the same time with 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 had 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 was 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 had 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. CASE XIV. Thickening and contraction of the urethra, from the cicatrices of venereal sores situated in the fossa navicularis; chancre of the fossa navicularis. R. T. came to consult me respecting what he termed an obstruction in his urethra; he gave the following history of his case:-About eighteen months ago (September, 1843), shortly after a suspicious intercourse, he perceived a slight discharge from the orifice of the urethra, from which there issued some drops of pus; on separating the lips of the urethra he perceived within them a small sore. He applied to a druggist, who furnished him with an ointment which irritated the sore and made it worse. Some time after this, a surgeon was consulted, who recommended mercury; this was taken till salivation was produced. The sore, however, did not amend under its use; it was still to be perceived when the urethra was examined, and the same discharge of drops of pus continued. He consulted, some time after this, a second surgeon, who cauterised the sore daily with the nitrate of silver; this produced hardness of the glans penis, and discharge of sloughs and blood from the urethra. This state of things continuing the patient began to lose confidence in the mode of treatment, which he abandoned, and, three weeks after the last application of the caustic, he consulted me. Copper-coloured spots made their appearance on several parts of the body, the arms, and trunk, at this time. When the patient pressed the urethra forcibly between the fingers, he brought from it a thick tenacious slough, exactly resembling that which covers a chancre in its first or ulcerating stage. The under surface of the glans penis was red and inflamed, and, when this part was examined between the fingers, a considerable induration was perceived, which appeared to exist in the lower part of the fossa navicularis, just within the urethra. When this induration was pressed, there issued from the urethra pus, sometimes mixed with blood, and at times tenacious shreds or portions of sloughs similar to those already spoken of. I examined the interior of the urethra for an inch and a half or more, with a small speculum made for the purpose. A white smooth cicatrix occupied the whole of the fossa navicularis on its upper part and sides; I could not obtain a clear view of the bottom of the fossa, where I believe ulceration still existed. This I inferred from the induration, the redness opposite this part, and the character of the discharge forced from the urethra when the induration was pressed between the fingers. There were no constitutional symptoms in existence either in the throat or vicinity of the anus; some copper-coloured blotches only occupied the arms and legs. In primary venereal sores of the urethra, the local treatment is a main point to be attended to. I recommended the patient to inject the urethra three times a day with tepid olive oil, and in the intervals introduced into the passage a thin shred of soft lint soaked in a solution of tannin and extract of opium. The lint was kept constantly in the urethra, merely being removed when the patient wished to make water. The patient was also directed to take one grain of the iodide of mercury with three of the extract of conium, in a pill, every night, and to be strictly regular in his mode of life. With very slight modification in the mode of treatment at first laid down, this case was brought to a successful issue; the induration and discharge disappeared from the urethra, and the copper-coloured blotches from the body. There 1 B Tannin, gr. x ; remained some contraction of the urethra, produced by the first cicatrix, which was materially relieved by the bougie. This constitutes what has been termed by some writers "traumatic stricture," very commonly produced by the cicatrices of primary venereal sores thus situated, which, when they do not actually contract the urethra, partially destroy its elasticity, and produce many troublesome symptoms, more particularly a dribbling away of the urine for some minutes after the patient has done making water. This constitutes a species of incontinence of urine whose cause is to be sought for, not in the bladder, but in the urethra. CHAPTER X. OF PHAGEDEN A. INSTEAD of following the regular course, the primary ulcer assumes a character of rapid ulceration or sloughing, to which the term phagedena is applied. Phagedenic ulcers assume various forms: sometimes they are intensely painful, the surface covered with a tenacious yellow slough, the edge red and hard, and the surrounding integuments little or not at all affected. This species of sore spreads rapidly by ulceration, and if not arrested frequently occasions fearful mutilation.1 Soft or simple chancres frequently assume this character at the commencement, without any evident cause; but it is again a secondary condition, produced by the habits or constitution of the patient, the injudicious exhibition of mercury, or improper local treatment. Either a primary or secondary syphilitic ulcer may become phagedenic: hence there are two kinds of phagedena, primary and secondary. Primary ulcers may assume a phagedenic appearance from an excess of local inflammation; in such cases the penis is lividly red, much swollen, and the sore itself covered by an adherent dark parti-coloured or black slough. With these local conditions the constitution of the patient sympathises more or less; there is, in some cases, smart symptomatic fever, the pain prevents sleep, and there are profuse night perspirations. 1 This is ulcerative phagedena, and it is a condition into which simple chancres frequently degenerate; it also attacks those ulcers which succeed to a bubo which has suppurated specifically. It is a simple, slow, destructive ulceration, in which the edges of the chancre are thick, jagged, overhanging and irregular, and its surface red, shining, and without granulation. I have seen two instances in which these ulcerations have continued, one for twelve, the other for eighteen months. |