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Cornell University Library 
 RC 201.1.C69 
 
 Selections from the works of Abraham Col 
 
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THE NEW SYDENHAM 
 
 SOCIETY. 
 
 INSTITUTED MDCCCLVIII. 
 
 VOLUME XCII 
 
LONDON : 
 FEINTED BY WEST, NEWMAN AND CO., 
 HATTON GARDEN, B.C. 
 
c^^. 
 
SELECTIONS FROM 
 
 THE WORKS 
 
 ABRAHAM COLLES3 
 
 CONSISTINS CHIEFLY OF HIS 
 
 PEACTICAL OBSEEVATIONS 
 
 ON THE VENEEEAL DISEASE, AND ON THE 
 
 USE OP MEECUEY. 
 
 EDITED, WITH ANNOTATIONS, 
 
 EOBEET McDonnell, m.d., f.e.s., 
 
 EX-PRESIDENT OF THE EOYAl COLLEGE OF SURGEONS IN IRELAND, AND OF THE PATHOLOGICAL 
 
 SOCIETY ; MEMBER OF THE COUNCIL OF THE UNIVERSITY OF DUBLIN ; ONE OF THE 
 
 SUKGEONS TO DR. STEEVENS'S HOSPITAL, DUBLIN; ETC., ETC., ETC. 
 
 LONDON : 
 
 THE NEW SYDENHAM SOCIETY, 
 
 188 1. 
 
CONTENTS. 
 
 PAGE 
 
 EDITOB'S PREFACE xv 
 
 MEMOIR OP ABRAHAM COLLES . . . . 1 
 
 DEDICATION . . 18 
 
 AUTHOR'S PREFACE .... ... 20 
 
 PAET I. 
 ON THE USE OF MERCURY IN VENEREAL COMPLAINTS. 
 
 CHAPTER I. 
 
 ON THE NATUEAL HISTORY OF THE VENBEEAL DISEASE. 
 
 A knowledge of the course of a Disease leads to fixed principles for its 
 treatment, page 25 — Mr. Hunter's Treatise contains the first systematic 
 description of the Venereal Disease, 28 — His History imperfect, as it did 
 not trace the Symptoms through their various gradations, 28 — Oppor- 
 tunities for further investigating the Natural History of this Disease are 
 rare, 28 — The use of Mercury a great obstacle to prosecuting this in- 
 quiry, 29 — It alters the character of the Symptoms, and changes the 
 order of their succession, 30 — This information may confidently be 
 expected from those who have devoted themselves to the Non-Mercurial 
 plan, 31 — The lengthened duration of the Disease another obstacle, 31 
 — A knowledge of the course of this Disease may be acquired by each 
 practitioner contributing his observations, 31 — Course, as occasionally 
 observed, 32 — Sometimes, instead of acute Eruptive Fever preceding 
 the Secondary Symptoms, we find marks of wasting, and of Hectical 
 state, 33 — Eruptive Fever no longer ushers in fresh Symptoms, 33 — 
 From ignorance of these natural changes in the Disease practitioners 
 cannot with justice estimate the value of different plans of treatment, 
 and hence the contradictory reports of different remedies ; How the 
 patients are afflicted and carried off in the last stages of this Disease, 
 35 — Secondary Symptoms capable of infecting, 36 — Case, 37 — 
 
 Pr. 's case and its consequences, 37 to 40 — Dr. E, Barry's 
 
 statement, 40. 
 
VI CONTENTS. 
 
 CHAPTER II. 
 
 ON THE ADMINISTEATION OF MBECUEY. 
 
 Accurate knowledge of the most judicious mode of administering a 
 Medicine essential to its ef&oaoy in curing Disease ; this particularly 
 applicable to Mercury, 46 — Preparatory process necessary, especially 
 where a protracted course of Mercury is required, 47 — And in emaciated 
 habits, where any morbid state exists which does not arise from the 
 Venereal Disease, 48 — ^Why Mercury so often fails in. Primary Syphilis, 
 although so successful in many Inflammatory Diseases, 48 — On the 
 curative action of Mercury : this is contemporaneous with its action 
 on the SaUvary System, 51 — Ef&caoy of Mercury not according to the 
 amount of Sahvation, 53 — Regimen to be observed under a Mercurial 
 Course, 53 — Mercury in under-doses, not pushed to Ptyahsm, has done 
 more mischief than have over-doses of Mercury in Primary cases, 57 
 And in Secondary Symptoms, 58. 
 
 CHAPTER III. 
 ON THE ADMINISTRATION OF MERCURY. 
 
 Mode of administering Merom'y by Friction, 59 — When the influence of 
 Mercury begins to be felt, 61 — From the third to the seventh day we 
 should closely watch the effects of the Mercury, 62 — Effects of Mercury 
 on the Salivary System various, 63— Salivation, at an earlier or later 
 period, not to be reUed on for the cure of the Venereal Disease, 64 — 
 Great care required during the first eight days of the "Mercurial 
 process, 65 — Importance of Ptyahsm for the cure of aU. other Diseases 
 as well as Lues Venerea, 66 — How to revive Ptyalism when it has died 
 away, 67 — Obstacles which may prevent salutary Salivation, 68 — When 
 too suddenly induced, when too slowly, 68 — When it excites Fever 
 without any effect on the Salivary Organs, 69— When the action of 
 Mercury is resisted, although no Fever attends, 70— Profuse Salivation, 
 71 — How to treat such cases, 73 — Some few cannot be salivated, 74 — 
 Declines offering an opinion on the respective merits of different 
 preparations of Mercury, 75— Hints for an improved method of using 
 Mercurial Fumigations, 2g;;^Fumigation applied to the sound skin only 
 will not mduce Pytahsml 7S — How to fumigate with Mercurial 
 Candles, 76 — ^Regimen to be observed after a Mercurial com-se, 76 — Ery- 
 thema Merouriale, 77 — Appears very early, 77 — Attendant Fever not 
 of any particular type, 77— Local treatment of, 78— Venereal Symptoms 
 amend when this Eruption appears, 78— This Rash never appears after 
 Ptyahsm has been established, 79 — Erythema Mercuriale may come 
 on at a late period of the Mercurial course, but only when the Mercurial 
 Fever ib first induced, 79— Some affected with Erythema Mercuriale 
 
CONTENTS. VU 
 
 by a very small quantity of Mercury, 80^— This peculiarity of constitu- 
 tion rare, 80 — Plan of treatment in such cases, 81 — Eemarks on 
 Mercurial Erythema inapplicable to those who evince extreme tendency 
 to it, 81 — Distinction between Erythema Mercuriale and another more 
 partial eruption from the use of Mercury, 83 — Excoriation of the Skin 
 another effect of Mercury, 84 — Distress caused by this affection, 84 — 
 Duration and treatment of it, 85 —The use of Mercury to be suspended 
 on the occurrence of these eruptions, 86 — These effects of Mercury dae 
 to its first impression on the System, 87 — The early period of a Mer- 
 curial course to be anxiously watched to guard against them, 87 — 
 Ptyahsm once established, the use of Mercury may be continued to an 
 indefinite period, without the risk of producing Meroixrial Erythema, 87 
 Mercurial Erethismus of Pearson, 87 — Its treatment, 89. 
 
 CHAPTER IV. 
 
 ON CHANCBB. 
 
 The term Chancre, or Primary Venereal Sore, not to be confined to 
 Ulcers answering to Mr. Hunter's description of Chancre, 91— Defini- 
 tion of a Primary Venereal Ulcer, 91— Error of opinion with regard to 
 Primary Sores, 91 — Proper treatment of the Hunterian Chancre, 92 — 
 Mr. Hunter's opinion as to the time in which a Chancre becomes 
 affected by Mercury questioned, 93— Fallacy and danger of the notion 
 of a Chancre having lost its Venereal characters being incapable of 
 conveying mfection, 95— Interruptions to the progress of an Hunterian 
 Chancre towards heaUng noticed, 95 to 99— Chancrous excoriation, 102 
 —Instances to show the changes which Excoriations may undergo 
 before they assume the Venereal characters, 102 to 105— An appearance 
 in Chancres healed by local means only noticed, 105— Has only seen 
 one instance of it, 105— Pecuharities of Chancres depending on the 
 pecuUar structure of the part on which they are situated considered, 106 
 —A form of Venereal Chancre not hitherto described, and its cha- 
 racters, 106— The Prepuce the situation of Ulcers, 107— Chancre on 
 either side of the Frsenum, 108— At the orifice of the Urethra, 108— 
 Stricture from this situation of Chancre, and discovery of a mode of 
 treating it, 109— Has seen cases of Chancre seated altogether withm 
 the Urethra, notwithstanding Dr. Hunter's assertion to the contrary, 
 109-Declines to undertake any classification of the endless varieties 
 of Primary Venereal Ulcers from theii' differing so constantly, 110— 
 Patients with these Ulcers very difficult to salivate, 110-Explanation 
 ^j,y, iil_Mercury proved to disagree with the constitution, not with 
 the Ulcers, 111. 
 
Viii CONTENTS. 
 
 CHAPTBE V. 
 
 ON BUBO. 
 
 The Profession indebted to Mr. Hunter for correct notions concerning 
 Bubo, 112— The occurrence of Bubo with relation to Chancre, 112 — 
 Treatment when Chancre and Bubo co-exist, 112 — Treatment of 
 Phagedenic Bubo, 115— Consequences of Bubo, treatment and history 
 of a case, 116 to 121— Eemarks upon the treatment of it, 121— Bubo 
 occasionally but rarely precedes by a few days the appearance of 
 Chancre, 123 — Lymphatic Bubo, 123. 
 
 CHAPTER VI. 
 
 ON A DISEASE OF THE LYMPHATIC GLANDS OF THE GROIN 
 
 ATTENDED WITH PECULIAR SYMPTOMS. 
 
 Seat and Characters of the Disease, 125— Treatment, 127— The use of 
 MercTiry in the treatment of this Complaint to be apprehended, 127 — 
 Later observations with regard to treatment, 128. 
 
 CHAPTER VII. 
 
 ON SECONDARY SYMPTOMS. 
 
 Secondary Symptoms with relation to Primary, 129 — Combination of 
 these when treated by Mercury, 129— Deficiency of the description of 
 the Secondary Symptoms by Mr. Hunter to be regretted, 130— His 
 accuracy in the description of the order of parts successively attacked, 
 181 — Time when the Secondary Disease appears considered, 131 — 
 Symptoms by which it is preceded, and character of the Sore Throat, 
 133 — Treatment, 133 — The facility with which morbid sensations are 
 renewed a source of great alarm to the patient after a perfect cure, 184 
 — The Venereal Ulcer of the Throat sometimes concealed from view, 
 134 — Directions for ascertaining its situation, 135-^Muriate of Anti- 
 mony to be used in such cases, and directions for its employment, 135 
 — Ulcer of the Pharynx, 185 — Venereal Ulcer close to the insertion of 
 the Anterior Palatine Arch into the Tongue, 136 — Treatment when the 
 Ulcer is seated behind the velum, 136 — An Affection of the Throat not 
 confined to those labouring under Venereal Disease described, 138 — 
 The characters of Ulcerated Venereal Throat influenced by an unsuit- 
 able line of treatment, 138 — These appearances to be attended to, 139 
 — Incessant flow of Saliva from the Mouth in Venereal Sore Throat, 139 
 — The regurgitation of drink through the Nose, 139 — No surgical disease 
 so liable to be materially changed in appearance, symptoms, and line 
 
CONTENTS. IX 
 
 of treatment as Secondary Syphilis, 140 — Eelapse of Sore Throat, 141 
 — Description of an alarming aspect of Venereal Sore Throat, 142 — In 
 such a state very small doses of Mercury of signal service, supported 
 by the history of a case in which this line of treatment was adopted, 
 143 — Illustration of the mischievous effects of injudicious courses of 
 Mercury in the treatment of Venereal Ulcers of the Throat, 147 — 
 PecuUar Affections of the Throat and Mouth after a course of Mercury, 
 152 to 163. 
 
 CHAPTER VIII. 
 OF VENEREAL DISEASES OF THE MOUTH, &C. 
 
 Forms of Venereal Affections to which the Tongue is subject, 164 — 
 Scrophulous Ulceration of the Throat spreading to the Tongue, 166 — 
 Superficial Ulcerations of this organ, after a course of Mercury, not to 
 be mistaken for Venereal Ulcers, 166 — Appearance on the Dorsum of 
 the Tongue, 166 — Ulcers of the Tongue arising from deranged digestion, 
 167 — Venereal Fissures on this organ, 167 — Circular Excoriated Spots 
 on the hard Palate, 167 — Venereal Ulceration of the Gums, 168 — 
 Ulcers of the Nose, 169 — Venereal Iritis, 170 — Secondary Venereal 
 Ulcers, 172 — Their characters, 173 — Eemarks on these, illustrated by 
 a case, 173 — Its treatment enlarged on, 177. 
 
 CHAPTER IX. 
 
 VENEREAL ERUPTIONS, NODES, AND DISEASES OF THE TESTICLE. 
 
 Cutaneous Eruptions of Secondary Syphilis not to be considered as 
 characteristic of distinct forms of the disease, 179 — Reasons, 179 — 
 Venereal Eruptions ushered in by Fever, 180— Characters, ISO- 
 Venereal Eruption mistaken for and treated as Measles, 181 — Treat- 
 ment of various forms of Syphilitic Eruptions, 181— Eupia, 182 — 
 Mercury in Papular Eruption, 183— Sequence of Venereal Eruptions, 
 184 — Treatment best suited to such cases doubtful, 185— Venereal 
 Nodes, 185 — These simulated by Periostitis, 186— Mercury in the 
 treatment of pure Venereal Nodes, 188— Constitutional treatment of 
 Nodes, 189— Node on the Femur, 189— Nodes sometimes excited by 
 the injudicious use of Mercury, 190— Affections of the larger Joints, 191 
 — Effusions into, and distensions of, the Synovial Membranes and 
 Bursse of the large Joints, 191— Affection of the Elbow- Joint, 191- Of 
 the Knee, 191— Venereal Affections of the Testicle, 192— Features of 
 the Venereal Swelled Testicle, 192 — Sometimes assumes different 
 characters, 193— Remarks on protracted Syphihs, with cases and 
 treatment, 193 to 204. 
 
X CONTENTS. 
 
 CHAPTEE X. 
 
 ON THE USE OF MEBCtJRY IN VENEBEAL HECTIC FEVER. 
 
 The subject of tlie judicious management of Mercury in the various 
 forms and combinations of Syphilis considered in detail, 205 — Case to 
 estabhsh the beneficial effects of Mercury in extreme attenuation from 
 Venereal Hectic Fever, 206— Eemarks upon it, 208— Another case, 209 
 — Remarks upon it, 211— Case showing the small quantity of Mercury 
 sometimes necessary, 213 — Eemarks upon it, 215 — The objection that 
 this case was not Venereal disproved by another, 215 — Remarks upon 
 it, 216 — A position of Mr. Hunter's hable to be overthrown by such 
 eases, 217. 
 
 CHAPTER X.* 
 
 MEECUKY DURING VENEREAL ERUPTIONS. 
 
 The rule that Mercury should be withheld until a Venereal Eruption is 
 completed may be departed from with advantage, 218— Two cases in 
 support, 218 to 221 — Remarks upon the treatment, 221 — Advantages 
 of the early exhibition of Mercury enumerated, 222 — The doses of 
 Mercury to be apportioned to the state of the System, 224 — Further 
 evidence of the safety and advantages of the above practice, 225 — 
 Ravages that may be committed during the withholding Mercury, 228 
 — Directions for the quantity of Mercury to be administered, 229 — 
 Concluding remarks, 229. 
 
 CHAPTER XI. 
 ON THE TREATMENT OF SYPHILIS IN SCEOPHULOUS PATIENTS. 
 
 Dread of Scrophula with regard to the use of Mercury in Syphilis carried 
 too far, 231 — Considerations necessary to decide the question, 232 — 
 The treatment of the complication of Eruptive Fever with enlargement 
 of the Cervical Glands considered, 232 — Cases in support of the 
 position that such Scrophulous Affections yield to the action of Mercury 
 as the Syphilitic Symptoms do, 238 to 241 — Whence has arisen this 
 abhorrence of Mercury in such cases ? 286 — Another class of cases 
 adverted to, a combination of Scrophulous Disease with Secondary 
 Venereal Symptoms, 239 — The question, is the use of Mercury 
 forbidden ? discussed, 240 — Instances adduced of its judicious adminis- 
 tration, 240 — Eemarks upon, 241. 
 
CONTENTS. Xi 
 
 CHAPTER XII. 
 
 MINUTE DOSES OF MEECUEY IN LATE AND CHEONIC BUBO. 
 
 A rare form of Bubo, to be treated by very minute doses of Mercury, 
 described, 244 — Instance given, 244— Further characters of this 
 disease, 245— Case in illustration, 246— Difficulty of a true Diagnosis in 
 this form of Bubo, 247— Chronic Venereal Bubo to be distinguished 
 from indolent Constitutional Bubo, 250 — Mercury to be employed in 
 very small doses, 261— Concluding observations, 251. 
 
 CHAPTEE XIII. 
 
 SYPHILIS IN INFANTS. 
 
 Great interest that attaches to the disease Syphilis Infantum, 252 — 
 Infection of a Wife with Secondary Syphilitic Symptoms, although 
 the husband is free from Syphilis, 253 — Case in illustration, 253 — The 
 doctrine of the Infant being infected by coming into contact during 
 parturition with Ulcers in the Vagina of the Mother, overthrown, 255 
 — Cases in which the Foetus in utero has been infected difficult of 
 explanation, 256 — A case of Dr. Beatty's, 256 — Remarks upon it, 257 
 — Manner in which the Syphilis of Infants more generally makes its 
 appearance, 257 — Muco-purulent discharge from the eyes, 258 — The 
 infant may receive the infection by sucking a Nurse affected with 
 Secondary Symptoms, 260— Case of infection from Ulcerated Nipple, 
 260 — Case of an Infant infected by a Dry-nurse, 261 — Importance of 
 forming a correct Diagnosis, 263 — Distinction between Moist Button- 
 scurvy and Syphilis, 263 — Eruption of Copper-coloured Spots, 264 — 
 The Anus subject to Fissure, 264 — Superficial Ulcer on the rugous skin 
 of the Anus, 264 — Both Child and Nurse to be subjected to the use of 
 Mercury, 264— Case in support, 264 — Directions for the administration 
 of Mercury to the Child, 268 — Topical remedies, 269 — The appearance 
 and nature of those Diseases which are communicated by the Infant 
 to the Nurse, 270 — Case, 271 — Remarks, 272 — Treatment of Nurse and 
 Child, 273 - Ulcerations on the Genitals of the Nurse's Husband, 274 — 
 Soreness in the Throat, Lips, and Tongue of the Husband, 274 — The 
 manner in which the Disease contaminates all the Members of the 
 same family, 275 — Its propagation by contact, 275 — Cases adduced, 
 276 — Concluding remarks, 287. 
 
XU CONTENTS. 
 
 CHAPTEE XIV. 
 
 PSEUDO-SYPHILIS. 
 
 Venereal Disease subject to the irregularity of simulating some other 
 disease in its symptoms, 291 — No rules can be laid down as to the 
 nature of these simulations, 291 — Variety in the effects of Mercury 
 tends to embarrass the judgment, 292 — The number of diseases which 
 simulate Syphilis not so great as supposed, 293— The designation by 
 which the Disease is marked not so material, provided a cure is 
 effected, 294-Oase of "Cachexia SyphUoidea," 295. 
 
 CHAPTER XV. 
 ON THE NON-MEKCUBIAL TREATMENT OF SYPHILIS. 
 
 General remarks, 301 — The profession indebted to those who have 
 introduced the Non-mercurial treatment, 302 — Has not fully answered 
 the expectations of its advocates, 803 — This line of treatment not to be 
 given up, 303 — Parallel drawn between Mercury in Syphilis and 
 Peruvian Bark in Intermittent Fever, 305 — Eeasons why Mercury 
 should be considered as a specific for Syphilis, 806. 
 
 PAET II. 
 
 ON THE USE OP MERCUEY IN AFFECTIONS OF THE 
 NERVOUS SYSTEM. 
 
 Mercury much more frequently employed in certain Diseases than 
 formerly, 307 — Partiality to this Medicine not easily accounted for, 307 
 — Cases adduced to prove Mercury an invaluable Medicine in Derange- 
 ments of the Brain and Nervous System accompanied with Paralysis 
 of the Voluntary Muscles, 308 — Hemiplegia, 808 — Paraplegia, 809 — 
 Total Paralysis, 810 — " Great confusion in the back of the head," 811 — 
 Characters of another case, 313 — Paralysis, 315 — Epilepsy, 316 — 
 Mercury one of our most valuable Therapeutic Agents, 818 — Any 
 theory of the modus operandi of Mercury in this class of Diseases, 
 declined, 319— Case of Gastrodynia treated by Mercury, 319 — Mercury 
 used in obstinate Ulcers of the Extremities free from Venereal Taint, 
 322— Case of Ulcerated Tongue, &c., treated by Mercury, 823— 
 Mercury used in Chronic Tumours of the Abdomen, 326 — Concluding 
 remarks, 327. 
 
CONTENTS. Xlll 
 
 PAET III." 
 
 SELECTIONS PBOM MINOE WOEKS AND ESSAYS OF 
 ABEAHAM COLLES. 
 
 PAGE 
 
 On the Opeeation of Lithotomy 328 
 
 On the Operation of Tying the Subclavian Aetery . . 337 
 Practical Observations upon Certain Diseases of the Anus 
 
 and Eectum 867 
 
 Fatal Consequences resulting from Slight Wounds received 
 
 in Dissection 383 
 
 Observations upon some Morbid Affections of the Great Toe 402 
 
 On the Fracture of the Carpal Extremity of the Eadius . 411 
 
 a By mistake printed "Past II." at p. 338. 
 
EDITOR'S PREFACE. 
 
 When I was invited, on the part of the Council of the New 
 Sydenham Society, to edit selections from the works of 
 Abraham CoUes, I gladly undertook the task. I felt that it 
 would not be labour thrown away to collect into one volume 
 the scattered fragments of work accomplished by one whom I 
 have always admired as having done much for the School 
 of Surgery in his own country, and who is an example to all 
 of what may' be achieved by accurate observations, and 
 truthful record of those observations. 
 
 I will confess, however, that I had little idea of how difficult 
 a task I had undertaken, in proposing to introduce such 
 comments and annotations as I might think proper. The 
 truth is, I found that it was not possible to annotate the 
 greater part of CoUes's writings, with a view to bring them 
 up to the present day. Such writings form a part of the 
 classical literature of the subject of which they treat; they 
 must be read as such, the reader ever bearing in miud the 
 period at which they were written. Thus and thus only can 
 we form a fair idea of the part such works take in the gradual 
 advancement of knowledge. We must compare them with 
 the views and doctrines put forth before they appeared. We 
 must see how far they aided in accomplishing the further 
 steps of progress made in later times. 
 
 Abraham Colles prided himself chiefly upon his introduction 
 of the treatment of syphilis by small doses of mercury. 
 
xvi editoe's PBEFACE. 
 
 With evident satisfaction, he writes such passages as this — 
 " Now this is precisely one of those cases in which very small 
 doses of mercury will be found of the most signal service ; 
 although I make no doubt that many surgeons will be startled 
 by the mere proposal of using mercury under such dis- 
 couraging circumstances." 
 
 His solution of the question as to whether secondary 
 venereal symptoms are capable of infecting and of communi- 
 cating the disease, but still more notably his observation that 
 syphilitic children nursed at the breast often infect wet- 
 nurses, but never their own mothers, are great fundamental 
 propositions. The latter observation is, in fact, the basis of 
 what Mr. Hutchinson has aptly called " CoUes's law." 
 
 Many of the shorter memoirs are now difficult, if not 
 impossible, to find, save in public libraries. 
 
 Although feeling the difficulty, as well as conscious of my 
 incapacity of properly annotating the writings of such a man 
 as Abraham Colles, I confess that I have found even my 
 endeavour to do so not an uncongenial task. I esteem it an 
 honour that my name should be associated in any way with 
 one whom I have learned so greatly to admire. 
 
MEMOIE 
 
 •Of 
 
 ABRAHAM COLLES. 
 
 BY THE EDITOB* 
 
 Thiety-six yeaes have now elapsed since the death of 
 the eminent Surgeon whose works are, in great part at least, 
 reproduced in this volume. He was at that time in his 
 seventy-first year. 
 
 To estimate with justice what he achieved during his life- 
 time, we should endeavour to cany ourselves back to the 
 opening years of the present century. The University of 
 Dublin, it is true, long before this had possessed a Faculty of 
 Medicine which enjoyed a bond fide existence. From the 
 time of the Eestoration a Eegius Professorship of Physic had 
 existed as a separate institution. As early as the year 1711 
 chairs of Anatomy, Chemistry and Botany had been esta- 
 blished. Sm'gery was combined with Anatomy, and students 
 who sought a purely medical education were permitted to 
 attend lectures along with students in Arts whose names 
 were on the books of the University. The Eoyal CoUege of 
 Surgeons in Ireland was not foimded imtil the year 1784. 
 The increased demand for naval and military surgeons on 
 the breaking out of the French war gave a stimulus to 
 surgical education, but certainly not of the highest kind. 
 
 * The materials out of ■wHcli this sketch has been composed were 
 placed at my disposal by my Mend and colleague Mr. WUUam CoUes, 
 Eegius Professor of Surgery in the University of Dublin, — a worthy 
 son of a distinguished father. The sources from which I have compiled 
 it are manuscripts and notes, books left by Abraham CoUes and in his 
 son's possession, and also in great part from a memoir, pubhshed at the 
 time of his death, in the ' Dublin University Magazine.' 
 
 B 
 
53 MEMOIR OF ABEAHAM COLLES. 
 
 The hospitals of Dublin, and the rich supply of subjects for 
 dissection obtained by the lawless methods practised before 
 the passing of the Anatomy Act, attracted many young men 
 anxious to qualify themselves to enter the public service with 
 the least possible expenditure of time, labour, or money. 
 
 The profession of Surgery at this time did not stand high 
 in the estimation of the public. It was, as yet, not very 
 far in advance of the trade with which it had been once so 
 intimately associated. The Surgeon did not, as an accom- 
 pKshed, highly educated professional gentleman, occupy a 
 social position alongside the Physician, as he does in the 
 present day. The literature and science of Surgery had been 
 raised by the labours and writings of such men as Percival 
 Pott and John Hunter ; yet they were but pioneers, and the 
 errors into which Hunter had fallen (as we now know),. in 
 perhaps the most important as certainly the most classical 
 of his works, gave ample scope to those who followed to 
 investigate and correct them. Mr. Hunter's erroneous doc- 
 trines naturally struck deep root. They had been set .forth 
 by a man of earnestness and genius, and they took hold upon 
 his disciples, as teaching always does when accompanied by 
 a sincere conviction of its truth. 
 
 Such of our readers, therefore, as desire to form a just 
 appreciation of the merits of the subject of the present 
 memoir, should strive to picture to themselves what the 
 teachings and the science of Surgery were about the year 
 1800, when Mr. Colles became a member of the Eoyal College 
 of Surgeons in Ireland. They should compare this with the 
 state of things when Mr. Colles resigned the Professorship of 
 ■Surgery in the College in the year 1836. It will be stUl in 
 the memory of many, that on this occasion the assembled 
 College voted an address expressive of their feelings, and 
 assuring him, amongst other things, that " it was the unani- 
 mous feeling of the College that the exemplary and efficient 
 manner in which he had filled the chau- of the Theory and 
 Practice of Surgery, for thirty-two years, had been the prin- 
 cipal cause of the success and consequent high character of 
 the school of Surgery in this country." 
 
 It is only to the members of the medical profession that 
 
MEMOIR OP ABRAHAM COLLBS. 3 
 
 medical biography forms a very interesting portion of that 
 branch of literature which records the lives and preserves the 
 inteUeetual portraits of distinguished medical men. Even a 
 rapid and imperfect sketch of one who, while living,, was 
 the object in a high degree of their respect and admiration, 
 cannot fail to be interesting to the members of his own 
 profession. To young men about to start in the same arduous 
 course, an outline of a course so honourable is peculiarly 
 instructive. Mr. CoUes won his way to eminence by means 
 which are, to some extent, within the reach of all. He may 
 be said to have wrested success from the hands of adverse 
 fortune by his energy and indomitable perseverance. A finer 
 model of every attribute and moral quality, essential to the 
 achievement of high success in the practice of Surgery and 
 Medicine, can hardly be offered for imitation. 
 
 Mr. CoUes was born in the city of KiUkenny, of a highly 
 respectable family long settled in that county. His family 
 was of the class of gentry, and previous to their immigration 
 into this country occupied an honourable position in England, 
 where some members of it had represented the city of 
 Worcester in Parliament. The first settler in Kilkenny was 
 himself a Physician who made a coijsiderable fortune. 
 Mr. William CoUes, father of Abraham CoUes, was educated 
 at BaUytore by Mr. Ebenezer Shackleton, who some time 
 before had been the preceptor of Edmund Burke, with whom 
 William contracted a friendship, and at whose house in 
 England he was subsequently a respected guest. 
 
 Abraham CoUes was the second son of this gentleman. He 
 was born in 1773 at MUmount, on the banks of the Eiver 
 Nore, about two miles from KUkenny. His early education 
 was received in the endowed school of KUkenny, under the 
 ^uspices of Dr. EUiotson, formerly FeUow of Trinity CoUege, 
 Dublin. An incident is mentioned as having occurred whUst 
 he was under the care of this gentleman, which had, perhaps, 
 its influence in deciding his professional destiny. The flank 
 of a house on the river's side near St. John's Bridge, inhabited 
 by a Dr. Butler, then a Physician in KUkenny, happening to 
 be swept away by a sudden flood in the Eiver Nore, a treatise 
 upon Anatomy was carried down by the stream and picked 
 
4 MEMOIll OV ABEASAM COLLES. 
 
 up by the schoolboy in a meadow near his father's house. 
 He restored the volume to Dr. Butler, but putting some 
 pointed questions respecting the contents, satisfied that 
 gehtleman that his young friend had looked into its pages. 
 The book was probably of no great value, for the Doctor 
 made it a present to Abraham CoUes, who carried it home in 
 triumph and soon preferred it to his Horace or Lucian. Not 
 long after, during a visit to Dublin, at the house of an uncle 
 who was a member of the Bar, he discovered to that relative 
 the passion he had conceived for medical studies, and his 
 mother was advised to permit him to follow the bent of his 
 talents. 
 
 In the year 1790 he entered the University of Dublin. His 
 progress at school had been such as to promise the highest 
 collegiate success. But he aimed at success in life rather 
 than success in coUege. He left his brother to gather 
 academic laurels, and to obtain premium and scholarship. 
 He limited his own studies to the object of passing through 
 the course respectably, and at once, after matriculation, 
 commenced his medical studies. He became apprentice to 
 Dr. Woodroffe then resident Surgeon in Steeven's Hospital. 
 From the first he devoted himself with extraordinary earnest- 
 ness to the profession of his choice. He embraced it with 
 ardour and paid to it no divided allegiance. There are still 
 in existence case-books filled with notes of cases taken during 
 his apprenticeship. 
 
 An anecdote connecting his name with that of Edmund 
 Burke ought not to be omitted. His uncle, Mr. Eichard 
 GoUes, at whose house he was now a frequent visitor, had 
 some dispute with a London bookseller concerning the 
 publication and copyright of a satirical poem. He had also 
 a correspondence with Mr. Burke on the subject. Edmund 
 Burke's letter suggested to the young Surgeon some remarks 
 " On the condition of political satire," which he committed to 
 paper and showed to his uncle, who privately sent them to 
 his illustrious friend in England. Edmund Burke returned 
 them with enconiums on their spirit and good sense, even 
 recommending their publication. The author, however, when 
 requested by his gratified relative to prepare them for the 
 
MEMOIR OF ABEAHAM COLLBS. 5 
 
 press, thrust the papers into the fire; and when his uncle 
 talked of the name he was sacrificing, replied "that he had 
 deliberately determined not to aUow himself to be drawn 
 aside from the career he had laid down for himself." 
 
 Mr. CoUes obtained his diploma from the Eoyal College of 
 Surgeons in Ireland in the year 1796, and then repaired to 
 Edinburgh. He resided during two sessions in the Scottish 
 metropolis, where he obtamed his M.D. degree. His letters 
 at this time, some of which are preserved, show the steady 
 earnestness with which he worked. They give proof also, 
 even at this early age, of that strong common sense which 
 formed so important an element in his character, and of his 
 desire for early improvement. He says, in a letter dated 
 1796 : " Since my arrival here I have not made the 
 acquaintance of any Irishman, or one of any other nation. 
 Indeed, I am afraid to get acquainted with men to whose 
 character I am an utter stranger. On Tuesday I took my 
 seat at the Speculative Society, which consists almost 
 entirety of Scotchmen." February, '96: "You may have a 
 specimen of my oratory, for I am resolved to attempt speaking, 
 and have actually begun to manufacture a speech for next 
 night's meeting. As it is of home-spun material, I fear the 
 texture will be but rude and coarse ; but you may depend on 
 having a true account of it." In April, 1796, he writes : 
 " I must begin by telling you that I am much improved in 
 point of personal appearance and accomplishments; for, 
 having this day cast aside my winter clothes and put on my 
 summer dress, my landlady could not be restrained, even by 
 the dictates ef female modesty, from telling me that I was a 
 very 'spry buck,' and recommending me very strongly to 
 wear hair-powder. I need scarcely teU you that, strong as 
 my pride is, it could not persuade me to go to the expense of 
 six guineas a year." . ..." I neither pay nor receive 
 a visit tiU after eight o'clock in the evening, when I and a 
 friend take a walk together ; and we have entered into a most 
 extravagant plan, but I must not be the one to rail against it 
 as it took its rise from me. It is neither more nor less than 
 dining together and spending the evening together every 
 Sunday. As you may wish for a pattern of a nice entertain- 
 
6 MEMOIB OF ABRAHAM COLLBS. 
 
 ment, I give you, as an example, my first dinner : — a hind 
 quarter of lamb, two shillings ; salad, one penny ; but as this 
 lasted me three days, perhaps my party was not very 
 expensive. Ten pence for a cod-fish, which also served for 
 dinner for three days. As for my landlady, Mrs. Williams, 
 she is ipositively afraid I shall read myself into a coffin, and 
 actually comes to keep me idle at different times, out of her 
 desire to keep me in health." 
 
 After residing in Edinburgh for two winter seasons, he 
 
 obtained his M.D. degree, and with this honour he started on 
 
 foot for London, a tour of some difficulty, in the year 1795. 
 
 Mr. CoUes has left behind him an interesting diary of this 
 
 expedition, giving proofs in every page of his professional 
 
 ardoy, and his manly, independent character. In London he 
 
 attended assiduously the principal Hospitals, and devoted 
 
 himseK with great earnestness to the study of Anatomy. At 
 
 this period of his life his acquaintance with Sir Astley Cooper 
 
 commenced, one which afterwards ripened into intimacy. 
 
 He entertained for this distinguished Surgeon the sincerest 
 
 admiration and respect, as is seen by his dedication to him of 
 
 the most important of his works, in which he speaks of his 
 
 " having the vanity to wish it to be known that he is honoured 
 
 with his friendship " ; and he adds : " I cannot neglect the 
 
 only opportunity that may ever present itself of paying such 
 
 a tribute as I have to offer, not only to the highest professional 
 
 station and celebrity, but to a juster object of admiration-^ 
 
 that zeal in the cultivation of Science which has outlived in 
 
 you all the Ordinary incentives to human industry." 
 
 ' Mr. Cooper (as he then was) was a young man engaged in 
 
 the investigation of the anatomy of Hernia; and preparing for 
 
 publication the results of his labours. Mr. CoUes rendered 
 
 hini assistance in making the dissections from which were 
 
 executed the engravings illustrating this work. It was 
 
 probably at this time that he himself conceived the idea of 
 
 publishing his 'Treatise on Surgical Anatomy,' which, 
 
 although never completed, forms a fragment of an important 
 
 Vro'rk, and one which in fact marks an era in the teaching of 
 
 Anatomy. Although now surpassed by others of the same 
 
 kind, it was one of the ifirst in which Anatomy was taught 
 
MEMOIR OF ABRAHAM COLLES. 7 
 
 strictly in its bearings on practice and in its relations to 
 Surgery. It was probably while studying Anatomy with 
 Sir Astley Cooper that Mr. CoUes first became impressed with 
 the inefficiency of the older modes of teaching Anatomy, and 
 the desire to instruct himself and others in this all-important 
 subject after better methods. He constantly dwells on the 
 fact that the language in which anatomical descriptions are 
 conveyed is no less tedious than trifling, by striving after 
 minute and unattainable accuracy, which serves only to 
 impress the idea of difficulty when no difficulty really exists. 
 In' the introductory 'Address on the preparatory Education 
 necessary for the Surgical Student,' which forms the opening 
 pages of his ' Treatise on Surgical Anatomy,' he particularly 
 dwells on this subject : — 
 
 " The profound and comprehensive mind of the philosophic 
 Bacon, having discovered and demonstrated the necessity of 
 methodical arrangement in the cultivation of the Sciences, 
 Anatomists hastened to avail themselves of its advantages. They 
 accordingly divided this Science into several distinct branches, as 
 Osteology, Myology, Neurology, corresponding to the different 
 distinct parts of the animal home. These divisions they termed 
 'Systems.' Each system they described separately, without 
 taMng any notice in this description of its connexion with other 
 systems, unless where it happened that that which was the 
 immediate subject of examination should have remained absolutely 
 unintelligible without such a reference. And succeeding Anatomists 
 have ever since contiaued to tread implicitly in the footsteps of 
 their predecessors. By these means we are constantly enabled to 
 examine the several parts with an accuracy, and to describe them 
 with a precision, before. unknown. But though the description of 
 each particular part be now perfect, yet the plan is stifl so far 
 defective that the description of any one part seldom reminds the 
 Student of any other, the examination of any one system seldom 
 leads him to trace its connexions and relations with the other 
 systems, nor do so many detached views of the several parts enable 
 him to take any general and connected view of the whole. Thus 
 the Student, who has been shown the distribution of the venous, 
 arterial, and nervous systems of the arm, does not know how each 
 of them ues with respect to the other at the bend of the elbow, 
 and therefore he does not know how he should attempt, in cases of 
 Aneurism, to pass a ligature round the artery without at the same 
 time including its accompanying nerve which communicates 
 sensation to the principal part of the limb. Nor can he, in the 
 common operation of blood-letting, account for that sharp pain of 
 which the patient particularly complains when the basilic vein is 
 
8 MEMOIR OF ABRAHAM COLLES. 
 
 opened, because these detached descriptions of the different 
 systems did not lead him to observe that some considerable 
 branches of the nerves run down along the face of this vein. In 
 short, an attempt to explain the nature and structure of the 
 animal machine, by dividing the several parts of which it is 
 composed into distinct classes, and then giving only a detached 
 and vmconnected description of each class, without even considering 
 them as the component parts of one organized whole, is, in my mind, 
 as preposterous and unavailing as would be an attempt to explain 
 the mechanism of a watch by taking it to pieces, and giving a 
 separate description of each particular wheel and spring without 
 afterwards attempting to show by what contrivance the one moves 
 the other, or how each wheel contributes, by its particular motion, 
 to regulate the general movement of the whole machine. Is it 
 then to be wondered at, that a plan so little calculated to excite 
 industry or stimulate curiosity — a plan which, so far from showing 
 the subservience of Anatomy to Surgery, does not even teach 
 Anatomy itself as a distinct Science — a plan which leaves the 
 whole weight to press on the memory, and that, too, in the most 
 unfavourable manner, should have but few attractions for the 
 youthful student ? Is it surprising that he should consider the 
 study of the Science a drudgery rather than a pleasure ? — that he 
 should take it up with disinclination and tm-n from it with disgust ? 
 In fact, the Student who has been employed in acquiring an 
 anatomical knowledge of the different divisions or systems of the 
 human body, has but encountered all the difficulties without 
 securing any of the benefits. For such a plan of study can 
 neither enable him to form a perfect idea of the structure of any 
 part of the body, nor can these partial and detached views of the 
 Anatomy in any degree qualify him to perform a Surgical operation. 
 The study of Anatomy too generally ends at that point where it 
 
 begins to be useful If the present work shall enable 
 
 you to trace for yourselves in the dissecting-room those parts 
 which are most necessary to be known ; if when you retire to your 
 closet it shall assist to imprint on your memory a knowledge of 
 those parts which you had previously dissected ; if it shall explain 
 to you the different operations in Surgery, and demonstrate to you 
 the anatomical principles on which each step of every Surgical 
 operation is founded, the views of its author will be fully 
 aocompUshed." 
 
 In 1797 Mr. Colles returned to the Irish metropolis. His 
 connexions were not numerous, but he determined to try 
 his fortune. His industry was astonishing. He was 
 blessed with excellent health and the most amiable of 
 tempers. The frankness and vigour of his character were 
 written on his countenance, while his robust and weU-made 
 frame showed tha,t he was well suited for physical exertion, 
 
MEMOIR OF ABRAHAM COLLES. 9 
 
 It needed some courage at this time, without friends or 
 interest, and we may add, without much money, to plunge 
 into such a career as he had before him. Even with all the 
 fortitude which he possessed, his purpose was sometimes 
 shaken, and he thought of seeking a regimental Surgeoncy, or, . 
 sinking into the retirement of a provincial Dispensary. 
 Having resolved, however, to enter on practice in Dublin, 
 his determination was not easily shaken. He became 
 attached at first to the Sick Dispensary in Meath Street, a 
 Charity which had been first established by the Society of 
 Friends. He also became an active District Visitor to the 
 Sick and Indigent Eoomkeeper's Society, where it was his 
 duty to visit applicants for rehef and ascertain the truth of 
 their condition. This self-imposed duty, ho'wever, was not 
 professional: it was a work of benevolence which brought 
 him in contact with the poor, and gave him unbounded 
 opportunities of exercising the kindly skill of his profession. 
 The humanity and zeal with which he performed the duties 
 thus confided to him attracted the notice of his professional 
 friends, and amongst others, of Mr. Stuart, at the time Surgeon 
 General, who, perceiving the peculiar bent of his talents, urged 
 him to give up Medicine and devote himself to the Surgical branch 
 of his profession. At his solicitation he became a candidate 
 for the post of Eesident Surgeon in Steeven's Hospital, which 
 he obtained in the year 1799. At this early period in his 
 career he commenced Clinical teaching : he inaugurated the 
 system of giving regular Clinical Lectures and also lectured 
 on Surgery in his own private rooms. 
 
 This marked the first great step in Mr. CoUes's professional 
 life. He has left behind him a small book containing notes 
 of the commencement of his career, in which he gives an 
 interesting record of his small beginnings as regards fees. 
 In 1798 we find the following entry : — " Sum total of fees 
 received, £8 10s. 7jd.," and the accompanying remark: 
 " Apparently a trivial sum, yet considering the time I was 
 sick and in the country, and that this is the first year' after 
 my return from Scotland, I do not look upon it as a dispiriting 
 circumstance that my fees have been so small." In the 
 following year he indicates a marked improvement : — " Total 
 
10 MEMOIR OF ABBAHAM COLLES. 
 
 of fees and salaries received from January 8rd, 1799, to 
 January, 1800, ^9178 4s. 4^d.," and the observation—" This 
 is a very great sum of money for my second year's praetieei : 
 compare it -with the previous year's total, and the com* 
 -parison is very flattering." The third year is a still more 
 remarkable advance : — " My fees, ^6133 17s. 5d. ; salary, ^660; 
 two apprentice-fees, £227 10s. ; — total received, £421 7s. 5d." 
 The fact of his already at this early period of his career, 
 receiving apprentice-fees, shows that he had commenced to 
 enjoy some reputation as a teacher. Some of his entries 
 show the peculiar humour which those of his pupils who still 
 remember him describe as characteristic of Mr. Colles. 
 " For giving ineffectual advice for deafness, £1 2s. 9d. ;'for 
 attempting to draw a stump of a tooth, — -. Another fee 
 for I know not what service, imless he may have thought the 
 last fee too small." April, 1799, is marked " fee-less.'" "For 
 teUing him that he was not dyspeptic, one guinea." Such 
 were the early beginnings on an annual professional income 
 which attained its maximum in the year 1826. During this 
 year Mr. CoUes received in fees £6128; from 1823 io' 1834, 
 his income was nearly although not quite so much, being 
 always over £5000, and sometimes closely' approximating 
 £6000 a year. ' " 
 
 From the very commencement he kept notes of his cases. 
 We perceive a constant tendency to make memoranda of his 
 own shortcomings, and the points in diagnosis as well as -in 
 operation which were difficult or puzzling. — 
 
 " September 8th, 1799. A man came into the long ward With 
 his arm badly wounded by glass. I was very cool, seeing at one 
 view what actually might be necessary. So far I was 'pleased, 
 but when the nurses and other attendaiits Seemed to 'bfe too Slow 
 or to commit any error, then I was entirely too hasty and too 
 anxious for them to hurry." , 
 
 September I7th, 1799, we find the following memorancfupi: — i- 
 
 "This day I removed a cancer. My anxiety for my own 
 character was the predominant sensation at the commencement of 
 the operation ; but this gradually wore offj.an^ I soon felt for the 
 success of the operation as if it had been a child of my own„-or 
 rather I felt as if I had performed some piece of mechanical W6rk 
 
MEMOIR OP ABRAHAM COLLES. 11 
 
 and was anxious for its success. My anxiety at the beginning of 
 the operation was greater than I wish it to be on any future 
 occasion, but on the whole I was well pleased that my state of 
 mind had been such as it was." 
 
 In the year 1802 Mr. Colles had already attained sufficient 
 eminence as a lecturer to justify him in seeking for the chair 
 of Anatomy and Surgery in Trinity College. He was not 
 Buccessftil on this occasion, having been beaten by Dr. Hartigan. 
 As. to the valiclity of the election some doubts existed. With 
 his wonted energy Mr. Colles took legal proceedings to defeat 
 it. The election, however, stood, and Mr. Colles had to turn 
 his energies into other channels. He became an active 
 membeir of the Medico-Chirurgical Society, where he read 
 (Communications on Medical and Anatomical subjects. He 
 threwhiihBelf with great earnestness into the proceedings of 
 this body. He attended its meetings with regularity, and 
 exercised his mental powers in its discussions. He became 
 President of this Society, aiid in this office he had to dehver 
 an address at the close of each session. The ability with 
 which he discharged this duty raised him still higher in the 
 esteem of his professional brethren. 
 
 In the year 1804 the Eoyal College of Surgeons in Ireland 
 secured Mi. CoUes's services as a lecturer. In that year the 
 chair of Anatomy and Surgery became vacant, and Mr. CoUes 
 was appointed to it in conjunction with Mr. Dease. This was 
 the second great step in his pubhc Hfe. This important and 
 honourable Professorship he held for thirty-two years, 
 discharging its duties with assiduity, zeal, and ability. It 
 •was not long after his appointment that the present edifice in 
 'Stephen'3 Green (the College of Surgeons) was erected. 
 Every "year added to its reputation. The classes increased 
 tapidly in hujnber, and at one period it counted more pupils 
 than an^ such Institution ia Great Britain. It success was 
 in a. great degree, due to Mr. Colles. Like that of all such 
 inen, Ms energy was contagious. It not only infected his 
 pupils : it infected his collaborateurs. The taste for study 
 pec^f) diffused': the spirit of enquiry was excited, and a vast 
 *^eneM impulse was given to professional education. Some 
 idea of the advance made in Surgical education in Dublin 
 
12 MEMOIR OF ABRAHAM COLLEg. 
 
 may be gathered from the fact that, in the year 1800, when 
 Mr. Colles himseK first became a Member of the College of 
 Surgeons, the number of Students of Medicine in Dublin did 
 hot exceed 60, while in the year 1836 they were computed to 
 be about 1000, and were certainly not less than 800. 
 
 Abraham CoUes in the year 1807 married Sophia, the 
 daughter of the Eevd. Jonathan Cope, Eector of Ahascragh, in 
 the Coimty Galway, by whom he had a large family. He at 
 the same time took a moderate-sized house in Stephen's 
 Green, in which he continued to live untn he removed to his 
 larger residence in the same square which he continued to 
 occupy for the rest of his life. At the beginning of the year 
 1835 his health began to decline. He began to find the 
 fatigue of lecturing too much for him, and even his Clinical 
 work overtaxed his strength. It was not, however, until the 
 following year that he resigned his Professorship in the 
 CoUege of Surgeons. He was induced to take this step at the 
 urgent solicitation of his friends, who thought it absolutely 
 indispensable to his health that he should do so. He took it, 
 however, with great reluctance, and it deeply affected his 
 spirits. He cared nothing for the emolument, but it was 
 painful to him to relinquish its duties. He did not, however, 
 resign his appointment of Steeven's Hospital until the year 
 1841, when he was obliged also to restrict his hours of 
 practice. His practice continued until about the close of his 
 career. He died on the 16th November, 1848, in the 71st 
 year of his age. 
 
 The best evidence of the excellence of his life was the 
 manner in which the news of his death was received by all 
 who knew him. All the Medical Schools in the Irish 
 metropolis suspended their proceedings. The College of 
 Surgeons met and resolved to pay to his memory the tribute 
 of a public funeral. The same step was taken by the College 
 of Physicians and the Apothecaries' Company. His remains 
 were interred in the cemetery of Mount Jerome, and the 
 entire hody of the Medical profession in Dublin followed them 
 to their last resting-place. A vast concourse of private 
 friends took a part in the procession, so universally beloved 
 was he both within and without the circle of his profession. 
 
MEMOIR OF AiEAHAM COLLES. 13 
 
 The popular notion which finds expression in the saying 
 that few men are found to he heroes in the eyes of those who 
 see behind the scenes of their private hfe, gets but Httle 
 support from the consideration of Mr. Colles's character. 
 There were perhaps none who formed so high an estimate of 
 his merits — so true a judgment of the genuine heroism of 
 such a life as his — as those who enjoyed the closest intimacy 
 with him. He held in contempt alike hypocrisy and 
 fanaticism in religion, as he did any semblance of artifice or 
 charlatanism in his profession. The principal features of his 
 character were little calculated to catch the public eye or 
 attract idle curiosity. He was an accomplished gentleman in 
 the truest sense of the word; amiable, upright, modest, 
 intellectual, seemingly unconscious of the high estimation in 
 which he was held by those around him ; simple in manners, 
 cheerful in disposition, of the most kindly good nature, 
 endowed with the charm of natural courtesy which made him 
 the dehght of his intimate friends and absolutely the idol of 
 his own family circle. An acute observer, emuiently sagacious, 
 he knew the world well, but was not corrupted by it. Having 
 a healthy and well-balanced mind, he possessed solid judgment, 
 sound understanding, and the kindest of hearts. He was a 
 man of rare benevolence, a generous giver, ever forestalling 
 solicitation and sparing the pain of an appeal. 
 
 His likeness is well preserved both in marble and on canvas. 
 The halls of the CoUege of Surgeons in Ireland are ornamented 
 with his full-length portrait, and a marble bust stands in their 
 museum. Both are striking likenesses and good specimens of 
 art. He had a shrewd, clear, good eye, a fine forehead, and 
 a character of marked decision around the mouth. He was 
 about the middle size, his figure well-proportioned, and his 
 manner unaffectedly dignified. He was an early riser from 
 the beginning to the end of his career. He liked rural 
 retirement, and preferred the society of his own house and 
 intercourse with his intimate friends to all other pleasures. 
 
 As an author his language is correct, strong, and explicit. 
 He strove rather to express his ideas simply than to aim at 
 eloquence or show. The simplicity of his language gives a 
 kind of classical elegance united with a profound acuteness. 
 
14 MEMOIR OF ABRAHAM COLLES. 
 
 He studiously avoided reference to obscure and general 
 principles. He reasoned by analogy and induction from 
 established facts. His mind appears to have been somewhat 
 deficient in speculative power, a pardonable fault when we 
 remember what a deceptive guide analogy often is in scientific 
 reasoning and argument. He never confused his reader with 
 uncertain hypotheses founded on shifting principles. 
 
 In early life it is evident that he took great pains to acquire 
 the faculty of speaking readily. He undoubtedly trained 
 himself to do so with great point and energy, enforcing wh^it 
 he said with an expressive but simple elocution. Those .who 
 recollect him as a lecturer speak with genuine enthusiasm of 
 the vivid pictures of disease which he sought to paint in 
 words for his pupils. iSis lectures, which were delivered 
 extempore, but from copious manuscript notes which, however, 
 he rarely used in the lecture-theatre, bear comparison with 
 those of Sir Astley Cooper. He possessed the art of touching 
 briefly on the salient points of his cases, and was gifted with 
 what Dove has called " the incomprehensible talent ", of 
 separating the essential from the immaterial in complicq,ted 
 phenomena. Though lacking that boldness pf invention 
 possessed by more imaginative minds, yet he controlled the 
 observations and discoveries of others by the most strict and 
 cautious criticism. He possessed that unremitting attention 
 which allows few circumstances of real moment to pass 
 unnoticed. With so much acuteness, such keenness 6i 
 observation combined with depth of thought, he had the hand 
 of a skilled workman. In short, as a practitioner in Surgery 
 he possessed aU the essential qualifications, sound judgment, 
 cool determination, and great manual dexterity. He shunned 
 affectation and singularity. He held in extrerqe contempt 
 those who aimed at gaining notoriety by assumed eccentricity 
 or anything resembling the tricks of a mountebank. He thus 
 acquired the universal confidence of his own professional 
 brethren, and without any accidental or external help raised 
 himself to one of the highest positions which men can 
 attain — the foremost rank in a liberal profession. 
 
 It is obvious from his manuscript notes (which are im- 
 mensely voluminous, and from the very commencement of his 
 
MEMOIR OF ABEAHAWr OOLLBS. 15 
 
 professional career) that from his earliest days he possessed 
 the character of a re.ally strong man. He did not fear to 
 speak to his pupils of his own errors. He sought to improve 
 them as he did himself, by pointing out his shortcomings and 
 ainiing at avoiding similar errors in future. " Having shown 
 to you," he says, in some memoranda which we find as early 
 as the year 1800, " the manner in which amputation of the 
 thigh should be performed, it will be in conformity with the 
 plan I- have laid down to disclose to you those steps of the 
 operation where I have ierred from confusion, hurry, ignorance, 
 or inadvertency. . The first, and indeed a very capital error, 
 occurred ia my application of the tourniquet, for the tourni- 
 quet -compress had not been applied with sufficient firmness, 
 so that, when the patient brought her body more erect the 
 compress, was thrown off the artery": and so he proceeds, 
 pointing out the errors to be avoided. 
 
 Throughout his entire career as a clinical teacher he lost 
 no opportunity of frankly admitting his blunders, and making 
 them the means of instructing his pupils. The following 
 anecdote is characteristic : — A patient in Steeven's Hospital 
 died after having been treated by Mr. CoUes for stricture of 
 the rectum by the introduction of a bougie. The death had 
 been unexpected. At the post mortem examination a malignant 
 stricture was found', and below it a ragged opening through 
 the coats of the bowel into the peritoneum. The resident 
 Surgeon, when showing the specimen to Mr. CoUes, took some 
 pains to explain that it was probably by extension of the 
 ulcera,tion that the opening had been formed. "It is below 
 the stricture," said Mr. Colles: " give me the bougie." The 
 bougie haying been produced, he passed its tip into the hole. 
 "It fits exactly," he said, and then added, turning to his 
 class, "Gentlemen, it is no use mincing the matter : I caused 
 the patient's death ; " and then, without another word, and 
 amid the absolute silence of his class, he walked out of the 
 theatre. 
 
 No, man less than Mr. Colles took a tradesman's view of 
 his profession. He nevertheless always spoke of it to his 
 pupils as of a calling wherein honourable men, striving to gain 
 a livelihood, confer advantages upon themselves by their 
 
16 MEMOtE Of AiSKAHAM COLLEg. 
 
 service to the public. We frequently find passages similar to 
 the following in the manuscript notes of his lectures : — 
 
 " Let the history of this establishment (the College of Surgeons) 
 serve to animate your exertions. See what progress the_ science 
 and practice of Surgery have made within the few years since the 
 foundation of this institution ; a progress which must in justice be 
 ascribed to the enthusiastic zeal, profound good sense, and incor- 
 ruptible integrity of a few individuals. See how these men,_ by 
 promoting the progress of science, have at the same time raised 
 the profession and its members to a rank, in society far beyond 
 what even their fondest wishes could have anticipated. Be assured 
 that in this, more than in any other walk of life, public benefit 
 and private advantage are so blended together that the most certain 
 means of advancing your private iaterest is to promote the pubUc 
 good." 
 
 " Be assured, by manly fortitude and determined perseverance, 
 you will sooner or later overcome every obstacle, and thus render 
 your future career of practice not only lucrative but honourable to 
 yourselves and most useful to the community." 
 
 In politics Mr. Colles was a liberal. He held his political 
 opinions, as he did all others, with modest firmness, but 
 without the faintest tinge of violence or party fanaticism. 
 He was not one of those who sue for favours, and when, in 
 the year 1839, his claims as undisputed head of his profession 
 in Ireland were overlooked, he was neither offended nor 
 disturbed. The body of the profession, however, not only in 
 Ireland, but, to their honour be it said, in England also, 
 expressed their surpise and dissatisfaction. Sir Astley Cooper 
 was one of the foremost in doing so. He bore witness to the 
 general opinion of the profession in the British empire, and 
 declared that although Mr. CoUes had achieved honour for 
 himself far beyond what any Government could bestow, that 
 nevertheless he was the legitimate channel through which 
 to decorate in Ireland the profession to which he belonged. 
 This opinion was so generally entertained and so strongly 
 expressed as to reach the ear of the dispensers of patronage. 
 They acknowledged their mistake, and strove to repair it. 
 A baronetcy was offered and its acceptance more than once 
 pressed on Mr. Colles. He, however, firmly but modestly, 
 declined the proffered distinction. If, he said, it had been 
 offered to him in the first instance, he should have considered 
 
MEMOIR OF ABRAHAM COLLES. 17 
 
 it due to his profession to accept it ; but that, for himself 
 personally, such distinctions had no attraction, and that in 
 consequence of the distribution he intended to make of his 
 property amongst his children, a hereditary title would be an 
 inconvenient honour. 
 
 Mr. CoUes twice filled the Presidential chair of the Eoyal 
 College of Surgeons in Ireland (in 1802 and in 1830). His 
 great reputation as a skilful practitioner, his works as repro- 
 duced in this volume, established for him a world-wide fame 
 beyond what any title could bestow. His family and de- 
 scendants may point with just and honourable pride to the 
 unadorned name of Abraham Colles, and boast that they are 
 sprung from one who merited a title but declined it. 
 
TO 
 
 SIR ASTLEY P COOPER, BART.. 
 
 ETC., ETC. 
 
 My dear Sie Astley, 
 
 Two motives influence me in placing your 
 distinguished name in the front of the book which I now 
 publish. I have the vanity to wish it to be known that 
 I am honoured with yom- friendship ; and I cannot neglect 
 the only opportunity that may ever present itself of paying 
 such tribute as I have to offer, not merely to the highest 
 professional station and celebrity, but to a juster object of 
 admiration — that zeal in the cultivation of science which 
 has outlived, in you, all the ordinary incentives to human 
 industry. Enjoying a splendid fortune, and an undisputed 
 precedence, you have nothing further in wealth or eminence 
 to desire. In such circumstances the world can ascribe your 
 unabated ardour and energy in those fields of inquiry, where 
 you have already had such brilliant success, to nothing 
 but the purest love of truth, and the virtuous ambition of 
 promoting the interests of humanity. An example such as 
 you set will always have more admirers than imitators : 
 amongst the former permit me to claim a high place ; and 
 believe me, 
 
 My dear Sir Astley, 
 
 With these and every other sentiment, 
 of regard and respect. 
 
 Your devoted friend and servant, 
 
 ABEAHAM COLLES. 
 
 Stephen's Green, Dublin, 
 20th Jan. 1837. 
 
AUTHOE'S PREFACE. 
 
 I HAVE long been of opinion that, in the -whole range of 
 surgical diseases, there is not one which naay with more 
 justness be styled the opprobrium of Surgery, than the 
 Venereal Disease. 
 
 When we recoUect that, for three centuries and upwards, 
 medical men throughout all Europe have been employed, 
 most extensively and uninterruptedly in the treatment of this 
 disease; that during almost the entire of that period a remedy 
 has been known which possessed the power of curing this 
 disease ; that this remedy, since its first discovery, has under- 
 gone a variety of modifications and combinations supposed 
 to render it more suited to particular states or forms of the 
 disease; that, in addition to this, some other remedies, and 
 other plans of treatment, have been found to effect its cure : 
 when, I say, we take all these plans iato account, surely it 
 might be reasonably expected that, with all these advantages, 
 we should by this time have arrived at a knowledge of fixed 
 rules for its treatment, and have acquired such a command 
 over it, as to be able to say that we can control its course and 
 check its ravages. 
 
 Yet I think it is not an exaggeration to assert that at no 
 period, since the disease was first subdued by mercury, has 
 the opinion of practitioners been more divided and unsettled, 
 or their treatment more wavering and unsuccessful. 
 
 Anxious to have this reproach wiped out, not merely 
 because it involved the character of the Profession, but 
 rather because it too clearly showed that the human race 
 was suffering severely from our imperfect knowledge of the 
 treatment of this disease, I sought to discover the cause of 
 our backwardness. After mature consideration, I was led to 
 attribute it principally to two causes ; — 
 
22 PREFACE. 
 
 First. The imperfect knowledge we possess of the natural 
 course, or natural history, of the Venereal Disease. 
 
 Seeond. The very imperfect knowledge we possess of the 
 means of directing the operation of mercury, so as to make 
 it act in a salutary manner; and the equally imperfect 
 knowledge we have of the earliest phenomena which would 
 indicate that it is beginniag to act as a poison rather than as 
 a remedy. 
 
 If this opinion as to the causes which have so long 
 prevented us from acquiring the command over this disease 
 be well founded, it will then be seen how vain must be the 
 attempt of any single individual, however extensive his oppor- 
 tunities, to supply all these material defects : this can only 
 be hoped for from the co-operation of very many. 
 
 In conformity with these sentiments, I have stated in 
 detail such observations as I have made as to the progress 
 or natural history of the Venereal Disease; and I have 
 offered some remarks on the mode of administering mercmry, 
 so as to induce the salutary action of this medicine. I have 
 also attempted to point out a few early indications, which 
 denote that its action will become poisonous if its use be 
 persevered in ; and I have detailed many of the symptoms 
 of Syphihs, and stated my opinion as to their appropriate 
 treatment. 
 
 Although I fear it wUl be found that I have not shed much 
 light on this obscurity, yet I trust that the attempt will be 
 favourably received by the Profession ; and that it will have 
 the effect of stimulating others, more capable, to pursue the 
 same line of investigation. It is only from the contribution 
 of many inquirers that a complete development of a subject 
 of such a nature is to be looked for ; and I trust that no one 
 will withhold the result of his observation merely because he 
 has but little to offer ; for the delineation of one new feature 
 in the character of the disease, and even a single additional 
 rule to guide us in the management of mercm-y, must prove 
 a valuable acquisition to our present stock of knowledge. 
 
 Prom this statement, then, the reader wiU not expect to 
 find in the following pages a systematic treatise on the 
 Venereal Disease ; on the contrary, some symptoms have not 
 
PREFACE. 23 
 
 even been mentioned, and others have been noticed only in 
 a cursory manner. The remarks which I have offered are 
 merely the result of my own observations and reflections. 
 Of what value these may prove I leave to my professional 
 brethren to decide, only assuring them that the facts are 
 stated with the most scrupulous fidelity. 
 
 To the observations on the use of mercury in Syphilis 
 I have added some observations on the use of this medicine 
 in the treatment of diseases not venereal. In this second 
 part of the work I have studiously avoided any mention of its 
 use in the diseases in which its efficacy is generally known 
 and long established; and I have designedly and strictly 
 confined myself to those in which it has been only very rarely 
 employed, but in which I have had the good fortune to have 
 found it a most active medicine, and a most speedy and 
 invaluable remedy. 
 
 In conclusion, I beg to remark that I feel fully sensible of 
 the many inaccuracies, both in style and composition, which 
 occur in'the following pages. My great object has been to- 
 convey my own meaning in a clear and perspicuous manner ; 
 if I have frequently expressed myself in common-place and 
 too famihar language, it must be attributed to my being but 
 little accustomed to literary composition, and long in the 
 habit of delivering lectures extemporaneously. I trust, how- 
 ever, that these deficiencies will be excused, or, at least, not 
 regarded as of any material consequence in a work the sole 
 object of which is practical utiUty. 
 
PRACTICAL OBSERVATIONS, 
 
 ETC., ETC. 
 
 PART I. 
 
 ON THE USE OF MERCUEY IN VENEREAL COMPLAINTS. 
 
 CHAPTEE I. 
 
 ON THE NATURAL HISTORY OF THE VENEREAL DISEASE. 
 
 Value of a knowledge of the Natural History of this Disease — Obstacles 
 to our acquiring this knowledge — Order of Symptoms— Mode in 
 which this disease ultimately proves fatal— Secondary Symptoms 
 are capable of communicating this disease. 
 
 That morbid like healthy action has its laws, and that 
 disease in many of its apparently fickle changes and Protean 
 forms, is but proceeding in obedience to certain rules, are 
 positions established by innumerable examples and by 
 convincing proofs ; witness the progress of many fevers ; the 
 whole history of small pox; most of the eruptive or exan- 
 thematous diseases ; the influence of vaccination, &c. &c. 
 
 These, and many other similar facts, have taught us that 
 certain diseases appear to be under a certain influence as to 
 the course they take, or as to the order in which theii- 
 several symptoms appear, and that morbid poisons, in 
 particular, excite a peculiar train of action, each producing 
 one particular set of symptoms, and none other, and that 
 these occur at regular periods, and proceed in a certain 
 regular order, in a sort of fixed succession ; and that in the 
 constitution they infect, as well as in the part to which they 
 are applied, they never fail to give rise to certain morbid 
 processes, and to effect certain changes, which finally either 
 
26 ON THE NATURAL HISTOEY 
 
 lead to their own extinction, or to the destruction of the 
 system or of the part in which they have resided. When we 
 reflect on these facts, and on the almost unerring certainty 
 and undeviating regularity with which these occurrences take 
 place, we must at once come to the conclusion, that to trace 
 these laws — that is to expose the course and progress of 
 disease, so as to he enabled, even beforehand, to predict the 
 next symptom it will produce — must be a task not only 
 interesting, but one of essential service in a practical point of 
 view, for without this knowledge, at least to some extent, the 
 practitioner must be in frequent uncertainty and doubt, and 
 consequently liable to commit many errors and to meet many 
 disappointments in his practice. 
 
 Accordingly in those diseases in which the attention of the 
 medical profession has been most successfully exerted in 
 developing the particular coiu'se they are to run, and in 
 tracing the order in which their several phenomena are to 
 occur, we find that the plan of treatment to be adopted for 
 their cure has been proportionately weU established on 
 principles simple and intelligible : let us hope that, in the 
 treatment of that disease to which these pages more par- 
 ticularly apply, similar exertions may produce similar effects, 
 for I cannot refrain from expressing my strong conviction 
 that one yery principal cause of those unsteady rules of 
 practice which exist even in the present day in respect to the 
 treatment of Syphilis, is to be found in the want of a real 
 knowledge of the natural progress of this disease ; and that it 
 is to an ignorance of the laws under which it proceeds, or to 
 a want of knowledge of its natural history, that we must 
 attribute the vacillation of some, and the contradictory 
 assertions of others, who have expressly treated of this 
 affection, its consequences, and cure. 
 
 [There is stiU ample room for enquiry before it can be said that 
 we have gained much knowledge of the natural progress of this disease. 
 It is indeed surprising how little has yet been learned as to its natural 
 history. Messrs. Lane and Gasooyne, in their valuable memoh- on 
 Syphilization, pubhshed in the Medioo-chirurgical Transactions, have 
 not been able to assign, with anything approaching to deflniteness, the 
 true therapeutic action to syphihzation, simply because so little is still 
 
OF THE VENEEEAL DISEASE. 27 
 
 known as to the cause which simple, uncomplicated syphilis runs. Thus, 
 Mr. Lane believes that it does exercise some beneficial specific influence 
 over the progress of the disease. Mr. Gasooyne, on the other hand, 
 thinks that the natural tendency to recovery which an uncomplicated 
 constitutional syphilis exhibits with the lapse of time and under circum- 
 stances favourable to the general health, is suflcient to aecount for 
 the subsidence of the secondary symptoms during syphiHzation. It is 
 obvious that untU something more positive is known as to the natural 
 progress of the malady, —until, in fact, there is some definite standard of 
 ooraparison, — it is not only difficult but impossible to assign its true 
 therapeutic value to any remedy. Carmichael did much in this direction. 
 Mr. Bose, of the Coldstream Guards, followed up what he had begun. 
 They proved what had been, in fact, unknown up to that time, that all 
 primary syphihtic affections could be cured without mercury, and that 
 the secondary lesions which follow, also in time give way to mild and 
 simple treatment. " In my opinion," says Sir William Lawrence, " this 
 is the most important step that has been made towards understanding 
 the nature and treatment of the venereal disease, and I should place the 
 truth thus established far beyond any of the speculations even in the 
 work of John Hunter."] 
 
 We meet with nothing like a scientific description of the 
 venereal disease in any of the earlier authors ; in their 
 writings we find only a mere enumeration of various local 
 symptoms, without any arrangement or reference to their 
 order of succession, and without any account of the course 
 which any one symptom pursues through its different stages. 
 Strange as it must appear, yet it is most true, and has proved 
 most unfortunate for our science, that, prior to Mr. Hunter's 
 treatise on the venereal disease, the profession possessed no 
 systematic account, no accurate description either of its 
 primary symptoms, or of the period or the order in which its 
 secondary effects usually occur. This invaluable treatise 
 poured a flood of light, not only on the natural history of this 
 disease, but also on its pathology and treatment. It was 
 Hunter who first demonstrated with clearness and precision 
 that secondary symptoms succeed the primary at an interval 
 of six or seven weeks, and that they are generally preceded by 
 an eruptive fever, which is ordinarily of an inflammatory 
 type ; he also described the third order of symptoms ; and all 
 this he has done with an accuracy and fidelity which the 
 subsequent experience of the profession has amply confirmed. 
 
28 ON THE NATURAL HISTORY 
 
 It is much to be lamented that Mr. Hmiter did not prosecute 
 his enquiries still further — that he did not, for example, trace the 
 full progress of secondary symptoms, or mark their natural ten- 
 dency to amend, and then again to relapse, each unfavourable 
 change being preceded by constitutional disturbance, — and that 
 he has omitted to notice the probable period of time which 
 these symptoms occupy from their origin to their acme, and 
 thence to their decline. Whether these omissions proceeded 
 from want of time, or from his having adopted the opinion 
 that the venereal disease " had no tendency to cure itself, or 
 that the constitution was unequal to the cure of this disease," 
 is now of httle moment. But does it not appear strange that 
 subsequent writers have not made some effort to supply these 
 deficiencies? Every person, even of those superficially 
 acquainted with the medical literature of this disease, who 
 has perused the brief history and the clear classification of its 
 symptoms which this distinguished surgeon has given, must 
 have observed with satisfaction the great improvements which 
 have been effected thereby in its pathology and treatment ; 
 and it was reasonable to expect that a sense of those benefits 
 would have impelled some later writer to investigate with zeal 
 the most minute particulars in the progress of its symptoms. 
 No doubt, the opportunities for prosecuting these enquiries 
 must have been but rare, as a little reflection will show ; for 
 after the first series of secondary symptoms have appeared, it 
 must be extremely dif&cult to trace the further steps of the 
 disease, because every practitioner is so impressed with the 
 sense of duty to do all in his power for the relief of his 
 patient, that he cannot, consistently with that feeling, 
 withhold such medicine, or refrain from such means as may 
 be best adapted to the case : hence the further course of the 
 present, as well as of any future symptoms, must be more or 
 less altered from that which they would have pursued if 
 totally uninterfered with. 
 
 Another obstacle which, tiU within these few years, 
 obstructed all attempts to trace the natural progress of the 
 venereal disease, was the uniform employment of mercury in 
 every form and symptom of Syphilis. If that medicine had 
 been administered in such a manner as to have had merely 
 
OF THE VENEREAL DISEASE. 29 
 
 that effect upon the symptoms which it had in Mr. Hunter's 
 experiments, namely, removing one set of symptoms, without 
 curing the disease, and allowing the next series to appear in 
 their natural time and order, we could then with ease and 
 certainty trace the progress of the disease through all its 
 stages ; but this is by no means the case, for we find in the 
 majority of instances, where secondary symptoms have 
 occurred after the use of mercury, that this medicine has 
 been administered very freely, and that therefore their 
 occurrence is not to be attributed to the too sparing use of 
 mercury; on the contrary, in the majority of patients who 
 have been thus unsuccessfully treated, mercury has been 
 carelessly or injudiciously employed, and has been pushed so 
 far as to injure the general health materially, while at the 
 same time it has so changed the local symptoms that we 
 cannot without great difficulty recognise their true pathogno- 
 monic characters : for example, a venereal ulcer in the throat 
 will no longer present the true specific appearance, if the 
 patient has been overdosed with mercury, but will rather 
 exhibit the features of a scrophulous ulceration, and will 
 ultimately heal with that silvery cicatrix which is the natural 
 termination of scrophulous ulceration in the throat ; here then 
 the treatment has caused such a change in the local character 
 that we have been unable to recognise its true syphHitic 
 nature. Another very important change which is sometimes 
 effected in this disease by this injudicious or overpoweriag 
 use of mercury, is that the order of succession of the 
 symptoms is completely altered ; thus, for example, if it have 
 been administered in this way for venereal sore throat, we 
 shall probably find, that the patient will be attacked, even 
 during its exhibition, with nodes, or venereal swelled testicle ; 
 and that after this third order of parts has been thus affected, 
 a venereal eruption (a symptom of the second series) will 
 make its appearance : hence any history of the course of the 
 venereal disease drawn from the description of its symptoms, 
 during its advanced stages, in cases where mercury has been 
 administered freely and injudiciously, cannot be relied on; for 
 in such, a new set of symptoms will often appear in a quick 
 and in an irregular succession, even while the system is under 
 
30 ON THE NATURAL HISTORY 
 
 the operation of the mercury : one order will be as it were, 
 anticipated, while another, such as the eruption, will be 
 postponed (contrary to the usual course), until after the third 
 order of symptoms shall have appeared. 
 
 Too frequently are the powers of the constitution so lowered 
 by this indiscriminate use of mercury, that it is no longer 
 able, as it were, to exhibit the eruptive fever, but it seems to 
 be prematurely sunk into that weakened state which attends 
 the latest stages of Syphilis. We can only hope to arrive at 
 an approximation to the true history of the course of the 
 venereal disease, by paying close attention to those cases 
 which have been treated on the non-merourial plan ; in such, 
 although the natural duration of each symptom may be 
 distm'bed by whatever treatment is pursued (as the eruption 
 for instance may be made to disappear even quickly by the 
 use of tartar emetic), yet the order in which the subsequent 
 symptoms will occur, and the individual features of each, will 
 be preserved as faithfully as if no medicine whatever had been 
 prescribed. I make no doubt but that many surgeons, who 
 have adopted the non-mercurial plan of treatment, will be 
 ready to favour the profession with most valuable information 
 on this all-important point; for by referring to their daily 
 notes of venereal cases, and collating a number of these, they 
 can trace with unerring accuracy the march of symptoms, 
 their order, their periods of appearing; and with equal 
 certainty can describe the states of the system which preceded 
 and accompanied the various changes in the local symptoms. 
 
 Another obstacle to our arriving at a correct and full 
 knowledge of all the phenomena of the venereal disease, is the 
 lengthened duration of it, when it is not controlled or cured 
 by medical treatment ; for we meet with various instances in 
 which we can distinctly trace back the history of this disease 
 to a period of five or six years. The unfortunate sufferer 
 cannot be supposed to have remained during all this time 
 under the care of the same surgeon, however strongly he may 
 at its commencement have been impressed with a high 
 opinion of his talents and skill; still the melancholy 
 experience that he has not been cured by him, in a period 
 of twelve or eighteen months, must shake his confidence, and 
 
OF THE VENBBEAL DISEASE. 31 
 
 create a desire for change, in the hope that another prac- 
 titioner may prove either more skilful or more fortunate ia 
 the management of his case. The friends of this unhappy 
 patient mil, at all events, insist upon his applying to some 
 other sm'geon, in whom they have more confidence : nor is it 
 to be wondered at, that these changes should take place three 
 or four times during the continuance of such a protracted 
 state of suffering. If we wish to watch the course of this 
 disease in an hospital patient, we are prevented not only by 
 the fact that he also loses confidence in the skill of his 
 surgeon, and becomes anxious to put himself under the care 
 of some other, but also frequently by the rules of the insti- 
 tution, which will not admit of a patient being retained beyond 
 a limited period, when his ease is not in a certain train to be 
 cured. During the long period in which I have been engaged 
 in practice I cannot recollect to have retained, during its 
 entire course, the confidence and treatment of a protracted 
 venereal case except one, and that I was fortunate enough to 
 cure after a period of six years ! 
 
 These obstacles, however formidable they appear, should 
 not prevent us from attempting to gain a perfect knowledge of 
 the course of this disease ; it cannot be expected to be 
 attained by individual observation ; it will require the labour 
 and attention of very many, each of whom however, by 
 contributing some new fact, or confirming one already known, 
 may fm-nish the materials to supply this desideratum, and so 
 complete the natural history of this disease. Should medical 
 men generally look on this matter in the light that I do, I am 
 confident that in a very few years we shall see this very desirable 
 object accomplished, especially as so much valuable information 
 must have been collected by those practitioners who have of 
 late years devoted themselves to the non-mercurial treatment. 
 
 Notwithstanding all these very serious obstacles, still we 
 occasionally enjoy an opportunity of tracing some parts of the 
 progress of this disease; thus we sometimes meet with an 
 individual who either from absolute ignorance of the nature of 
 the disease with which he is troubled, or from an indifference 
 and recklessness of consequences, has totally neglected his 
 disease from its very commencement, and only seeks for 
 
32 ON THE NATUEAL HISTORY 
 
 medical assistance after the secondary symptoms have been 
 estabhshed. If such a person be, from his situation in life, 
 unable for a time to submit to active treatment, or if the state 
 of his health render him unfit for it, we are afforded an 
 opportunity of studying in part the uninterrupted progress of 
 the disease. Under such circumstances I have observed, that 
 when the local .symptoms have become fully established, 
 which is probably in two or three weeks after they make their 
 appearance, they then become stationary, and the constitution 
 is relieved from the febrile disturbance. In this quiescent 
 state the symptoms may remain for about three weeks ; they 
 wUl then show a strong disposition to amend, and sometimes 
 they will proceed so far as to impress the sui-geon with a 
 hope, and the patient with a firm conviction, that he is about 
 to get perfectly well. But this illusion, having lasted for two 
 or three weeks, is dispelled in general by a fresh attack of 
 eruptive fever, and by an eruption or sore throat, although 
 sometimes other symptoms (iritis, for example) be added to 
 those under which the patient had been previously suffering. 
 How long the disease might continue in this condition of 
 alternate improvement and deterioration, I cannot pretend to 
 say, as I have not had an opportunity of witnessing in the 
 same individual more than two, or at the utmost three, of 
 those revolutions : from what I have seen of such cases I am 
 led to say we may calculg,te upon each relapse as likely to 
 recur every third month. These remarks apply to the 
 secondary symptoms as observed for two, three, or four of the 
 first revolutions. 
 
 At a later, and sometimes, though rarely, in an early stage 
 of the disease, we find a somewhat different process ushering 
 in a new attack ; thus we sometimes observe that the patient 
 who during the four or five preceding weeks had been 
 improving in flesh, colour, appetite, and strength, now begins 
 to exhibit a different aspect ; his countenance alters con- 
 siderably, it becomes sickly, his complexion assumes a waxen 
 hue, and he evidently loses flesh from day to day, and all this 
 takes place while the patient himself is not at all aware of the 
 change, and is still less suspicious as to its cause. In some 
 time, however, the patient complains of night sweats, want of 
 
OF THE VENEREAL DISEASE. 33 
 
 sleep, loss of strength, and declining appetite, so that in the 
 course of two or three weeks he is reduced to a state of great 
 weakness and emaciation : this downward course proceeds 
 steadily untH a fresh order of symptoms appears and becomes 
 established. 
 
 I must here remark that I have repeatedly observed these 
 newly appearing symptoms to be, as it were, a repetition of 
 those that preceded them : thus, for example, a patient may 
 have had a papular eruption which remained stationary for 
 two or three weeks, then began gradually to decline, so as to 
 lead him to hope that he was about to become totally free 
 from it ; but this eruption having faded to a certain extent, 
 has then become stationary for two or three weeks, and the 
 general health has improved; at the end of this time, 
 however, the health again begins to suffer in the manner 
 above described, nor does it cease to decline imtil this new 
 train of symptoms has become for some time estabhshed. 
 More commonly, however, this long-continued wasting is 
 followed by some new symptoms, often by those of the 
 third order, succeeding the repeated renewals of secondary 
 symptoms. 
 
 After an attack of this lengthened nature we seldom, if 
 ever, observe a distinct eruptive or premonitory fever appear 
 in this patient ; and I may also add that the local syphilitic 
 symptoms cease to present their characteristic signs as 
 strongly marked as heretofore. Thus it would seem as if 
 each eruptive fever, or rather each succeeding attack, brings 
 the constitution into a weaker and weaker state. In the very 
 advanced stages of the venereal disease we do not see those 
 periodical changes ; the constitution then appears unequal to 
 any struggle, so that one continued and increasing state of 
 debUity, with slow fever and great emaciation, are conjoined 
 to the local symptoms, while the latter also are but little 
 disposed to undergo any change, except a slow and gradual 
 deterioration : thus, I have sometimes, though rarely, seen a 
 tubercular eruption, combined with pains of bones and joints, 
 continuing during four or five years, and undergomg no 
 material change, being at one time a little better, and at 
 another a little worse. 
 
 D 
 
34 ON THE NATURAL HISTORY 
 
 It must be obvious that, without a knowledge of the various 
 changes above alluded to, the practitioner will be very liable 
 to err in forming a judgment of the different plans of treat- 
 ment which have been pursued; for were he to 'admiuister 
 mercury, sarsaparilla, acids, or any medicine at the particular 
 time when the symptoms were spontaneously decHning, he 
 would be disposed to attribute the improvement to his 
 prescriptions ; and on the other hand, if he had commenced 
 the treatment when the health was about to decline (as it 
 always does previous to the appearance of a new set of 
 symptoms), he would be equally disposed to condemn whatever 
 he had prescribed as worse than useless ; I consider, therefore, 
 that inattention to these circumstances has been one and the 
 great soiu-ce of those various contradictory statements which 
 have been made even by men of sound judgment and 
 strict veracity, as to the value of the different modes of 
 treatment, and of the different remedies which have been 
 recommended at various periods for the cm-e of the venereal 
 
 When the disease has arrived at that advanced stage in 
 which the general health has been broken down, and the local 
 symptoms are so much changed as scarcely to be recognised 
 as venereal, it is still a matter of uncertainty how long the 
 patient (if not relieved by art) is to drag on a miserable 
 existence, or in what manner a termination is to be put 
 to all his sufferings. Many of its unfortunate victims are 
 destroyed by what may be considered a continuation of 
 the disease; but by far the greater number appear to be 
 carried off by other complaints to which we may presume 
 they were naturally disposed, or to which they were ren- 
 dered Hable by the very weakened and reduced state of their 
 general health. 
 
 Among the former we may mention an ulceration of the 
 throat, which, creeping downwards, at length seizes upon the 
 larynx, and causes a destruction of a greater or lesser portion 
 of this organ. The lungs quickly suffer from this affection of 
 the larynx, and the patient dies, seemingly worn out by 
 difficult respiration and by severe cough, with profuse 
 expectoration and hectic fever. 
 
OF THE VENEREAL DISEASE. 35 
 
 Others again are destroyed by the repeated exfoliation of 
 the bones, frequently of those of the cranium, and sometimes 
 of the long bones. Moreover, there are others who, having 
 been forced by severe nocturnal pains to have recom'se to 
 opium, cannot afterwards be prevailed on to relinquish this 
 medicine, but are rather disposed to increase the quantity of 
 each dose. • Although now almost free from the pains which 
 had driven them to adopt this medicine in the first instance, 
 such persons, we remark, cannot be induced to rise until late 
 in the day, they have no appetite for breakfast, but wiU 
 probably take some highly- seasoned food for dinner; in the 
 early part of the day they are quite torpid, averse to every kind of 
 exercise ; in the afternoon they seem to revive, become more ani- 
 mated in the early part of the evening, and are unwilling to retire 
 to rest until a very late hour. One or two years may pass on in 
 this manner with little apparent change ; at length they sensibly 
 decline in flesh, a diarrhoea supervenes, which is sometimes 
 attended vfith sickness of stomach and vomiting, and by this they 
 are ultimately carried oS. It is remarkable that from the time 
 these patients give themselves up to the inordinate use of opium 
 their symptoms exhibit but slight traces of a venereal character. 
 
 Many others are carried off by diseases which have no other 
 connexion with the original venereal affection except that by 
 it, or rather by the treatment adopted for its cure, their 
 system has been rendered more susceptible to the attacks of 
 disease in general. Perhaps the greater number of such sink 
 under attacks on the chest, such as pleuritis or pneumonia, 
 terminating in serous effusion. Many of those who are 
 strongly predisposed to phthisis fall victims to that disease ; 
 not a few are found to have the liver enormously enlarged, 
 extending across the abdomen, and even below the umbilicus ; 
 this is followed by slow emaciation, and after some months by 
 ascites and anasarca. Dysentery also at times seems to 
 destroy some of those who have very long suffered under 
 Syphilis, and, as might be expected, ulceration of the 
 intestines is discovered after death. 
 
 From this account then it is very evident that there is no 
 certain period after the appearance of the primary disease at 
 which death terminates such protracted cases of Syphilis. 
 
30 ON THE NATUEAL HISTORY 
 
 We may say that in general this event takes place between 
 the second and fifth or sixth year. * 
 
 A most important point for our considei-ation in the history 
 of the venereal disease is the question, whether secondary 
 symptoms are capable of infecting and of communicating this 
 disease. Contrary to the opinion of Mr. Hunter, and perhaps 
 of most surgeons of the present day, I am convinced that they 
 do propagate this disease, and this opinion I shall endeavour 
 to support by adducing the following facts and arguments. 
 
 fWe have here, without doubt, one of the most important of 
 Colles's observations. Up to this time the opinion that secondary 
 symptoms were not capable of communicating disease was firmly 
 believed in. John Hunter speaks very positively about it. "We may 
 observe," he says, " that even the blood of a pocky person has no power 
 of communicating and is not capable of giving the disease to another, 
 even by inoculation ; for if it were capable of irritating a sound soi'e into 
 a venereal inflammation, no person that had tliis matter circulating, 
 or had lues venerea, could escape having a venereal sore whenever he is 
 bled or receives a scratch with a pin, the part so wounded turning into a 
 chancre." Mr. Guthrie, long afterwards, is no less distinct upon this 
 point. "It is allowed," he says, "by all that the secondary ulcers of 
 syphflis, as they are called, cannot produce primary ones ; a proof that 
 the nature of the disease is changed, and that the primary and secondary 
 are two distinct things."] 
 
 Many years ago a young surgeon of my acquaintance, 
 paying his addresses to a young lady, had unfortunately at 
 the time a secondary venereal ulcer on the lower lip. The 
 lady contracted an ulcer on her lip, which was soon followed 
 by an enlarged lymphatic gland under the lower jaw; the 
 ulcer had the character of venereal so strongly marked that 
 the case was pronounced to be syphilitic, and she was directed 
 to use mercm-y ; unfortunately this medicine was employed in 
 
 * This account of venereal patients who, after long suffering, have 
 been carried off by diseases not at all akin to, or naturally attendant on, 
 SyphiUs, is partly derived from, and is materially confirmed by, tlie 
 concurrent testimony of Dr. Thos. Ferrar, now Professor of Surgery in 
 the Belfast Institution, whose zeal led him dm-ing four years, while a 
 pupil at Stevens's Hospital, to foUow many of these unhappy sufferers 
 through the various stages of their misery, to watch over them in their 
 own wretched private abodes, and to trace them through the different 
 hospitals of this city. 
 
or THE VENEBBAL DISEASE. 37 
 
 doses too powerful for her delicate constitution to bear with 
 impunity, and this joined to deep mental distress seemed to 
 induce phthisis, to which her system was strongly predisposed, 
 and she shortly died of what is vulgarly termed a galloping 
 consumption. This case, which came under my observation 
 when I was but a very young practitioner, made a deep 
 impression on my mind. 
 
 The next fact which I shall adduce is one that occurred in 
 this city twenty -five years ago; and as the circumstances 
 have been recorded by my friend Dr. Healy in Tilloch's 
 ' Philosophical Magazine,' vol. xxxix., page 90, I shall extract 
 his account, and annex to it a few further particulars which 
 came within my own observation. 
 
 " On the 23rd July, 1810, I was requested by a respectable 
 friend to see his wife, who complained of great and general 
 debility, loss of appetite, with violent pain of the head. She was 
 nursing, and the child seemed very healthy. She said she had 
 been attacked with hsemorrhoids about three weeks after her 
 lying-in, which was on the 11th May, 1810. She had had small 
 glandular swellings in her groin, which had subsided ; had taken 
 no medicine. About the 28th, reddish spots appeared on her 
 arms, and small tumours scattered over her thighs, which disabled 
 her from walking. She complained of profuse perspiration on 
 her breasts, particularly ait night. I directed the warm bath with 
 alteratives. 
 
 "August 7th. Notwithstanding the treatment, the symptoms 
 became much aggravated, and the reddish spots had spread upon 
 her face. I requested my friend to confess whether he had not 
 contracted the venereal disease ; to which he answered in the most 
 solemn manner in the negative. 
 
 " On August 14th I required a consultation, and met one of the 
 most eminent physicians in Dublin. After examining the patient, 
 he mentioned our suspicion to the mother of the lady, that 
 the disease was venereal. It was deemed advisable to have a 
 surgeon in consultation, and that we should meet the following 
 day. 
 
 "On 15th we met, and that consultation removed every doubt 
 of the nature of the disease ; and as she did not receive it from 
 her husband, I suggested to the medical gentlemen that the 
 accoucheur might have conveyed the infection by his hand. That 
 mode was deemed possible, though not very probable ; and our 
 opinion to that effect was communicated to the accoucheur. 
 
 " All that train of misery incident to supposed connubial 
 infidelity, aggravated by the sufferings of a loathsome disease, 
 must have been the fate of my patient if she and her husband had 
 
88 OK THE NATUEAL HISTOKV 
 
 not proper mutual confidence, a.nd a friendly reliance on my 
 further investigation. 
 
 " On the evening of the 14th August, I visited a patient con- 
 valescent from fever, from whom I heard that a Mrs. M — was 
 dangerously ill, not only from a disease which she had contracted 
 at the time of her lying-in, but also from a very sore mouth. On 
 enquiry, it appeared that she was attended in her accouchement by 
 the same gentleman who attended my patient. 
 
 "August 18th. I met Mrs. M — 's brother, with whom I w&s 
 acquainted ; and anxious to vindicate the character of my patient, 
 I told him my suspicions of his sister's disease, and asked him 
 whether I could with propriety mention my suspicion of the disease 
 to Mr. M — . He answered in the af&rmative, and introduced me 
 to Mr. M- — . I related to that gentleman the situation of my 
 patient, and requested to know the name of the disease his wife 
 was labouring under, and the time of her delivery. He said she 
 lay in on 22nd May, 1810, that the accoucheur was treating her 
 at present for cancer in the womb, or for a liver complaint. 
 I submitted my opinion that it was the venereal disease, and also 
 that she might have been infected at the time of her delivery, 
 the accoucheur conveying the infection by his hand. He added, 
 he suspected her disease to be venereal, and had mentioned that 
 suspicion to his wife frequently. I was introduced to the lady, 
 and after examining her I became more confident in my opinion 
 (as there were buboes in her groins). I advised Mr. M — to have 
 a conversation with the accoucheur as to the nature of the disease. 
 In consequence of this, Mr. M — called a consultation of the 
 same medical gentlemen with the accoucheur, who met on the 19th. 
 
 " The surgeon, before the consultation, called me out of the 
 room, and communicated what the accoucheur had informed him 
 of that morning ; namely, that he had contracted the venereal 
 disease in his finger, in the course of his practice, and had 
 conveyed this disease La that manner. It was deemed advisable 
 and even indispensable for the accoucheur to confess that he was 
 the cause of this severe ailment to these ladies ; which he 
 compHed with by letter, not only to these ladies, but to others who 
 had been diseased in like manner. Meaning to view the subject 
 merely as an instructive medical report, suffice it to say, that upon 
 a full and legal investigation, it was deposed on oath by a medical 
 gentleman on behalf of the accoucheur, that he had contracted the 
 disease in the course of his practice, about two years previous to 
 the preceding unfortunate event; that he had undergone a 
 complete course of mercury, and used even a larger quantity than 
 is usual, and that he conceived himself incapable of communi- 
 cating the disease ; that previous to that gentleman's attending 
 my patient, a window-sash had fallen on his finger, which 
 produced a sore; that this sore became a venereal' one, and 
 infected the ladies before he was aware of its real nature. The 
 child of the first lady was weaned on the 15th, afterwards spoonfed, 
 and continued healthy. The other child was transferred about the 
 
OF THE VENEREAL DISEASE. 39 
 
 19th to a sound healthy nurse. In a month, a rash appeared on 
 the head of the child, which in a little time spread over the body, 
 and remained anomalous for a month, but afterwards became 
 distinctly syphilitic, and yielded to the influence of mercury." 
 
 Such are the facts stated by Dr. Healy ; and if credit be 
 attached to them we must conclude that a secondary venereal 
 sore cafi produce primary ulcers. 
 
 I am happy to have it in my power, from personal know- 
 ledge and observation, to corroborate Dr. Healy's statement, 
 and thus to remove the doubts of any who might incline to be 
 sceptical respecting it. I was not myself called upon to visit 
 any of the sufferers on this melancholy occasion, nor was I 
 consulted by the accoucheur himself, who was the undesigning 
 author of their sufferings. My knowledge of the circumstances 
 occurred accidentally in the following way : — 
 
 Walking at a very early hour one morning in the month of 
 March to my hospital, I met this gentleman in a retired street. 
 He told me that he had been up all night, attending the wife 
 of a friend of mine in that neighbourhood — that he had left 
 her quite safe. He next stated that he had not been in good 
 health for some time past — that he had been afflicted with 
 severe rheumatism, for which his friend, Mr. E., had made 
 him take a great deal of James's powder and other diaphoretics ; 
 and that, by his advice, he had also used several tepid baths, 
 but all with very little benefit. However, that within the last 
 few days he had got rid, in a great measure, of the rheumatic 
 pains, by the coming out of a general rash ; at the same time 
 he drew off his glove, and showed me the palm of his right 
 Hand. My surprise was very great on beholding a most 
 unequivocally syphilitic eruption. I also noticed an ulcer on 
 each side of the nail of the index finger; these bore the 
 strongest marks of secondary venereal sores. 
 
 I did not at the time express to him my opinion of the 
 nature of the disease, but told him, in a most impressive 
 manner, that I thought he should not lose any time in showing 
 it to his friend, Mr. E., under whose advice he was acting. 
 When we parted, I could not help wondering at the readiness 
 and unconcern with which this gentleman exposed the 
 symptoms of his disease ; and I at once concluded that he 
 
40 ON THE NATURAL HISTORY 
 
 was totally ignorant of the common appearance of the 
 venereal disease. At the period of this rencontre, and even 
 for two months afterwards, no alarm, no notice of any 
 mischief done by this practitioner in midwifery had occurred 
 among his patients ; and therefore it is plain that all those 
 ladies who were contaminated by him received the infection 
 from the secondary venereal ulcer on his finger. 
 
 In a short time after the nature of this gentleman's disease 
 became publicly known, I saw him in consultation with his 
 attending surgeon, and had then an opportunity of examining 
 his symptoms at my leisure ; and I became perfectly satisfied 
 that his finger had been affected with secondary venereal 
 ulcers. 
 
 Let us for a moment reflect upon the natm-e and value of 
 this testimony. A surgeon, deservedly of the highest character 
 in Dublin, deposes on oath before a commission of legally 
 appointed arbitrators that this accoucheur had. two years 
 previously been afilicted with primary ulcer on the finger, 
 contracted in the course of his profession ; that he had 
 undergone a complete course of mercury, and used even a 
 larger quantity than usual ; and that a window-sash having 
 fallen on his finger, it produced a sore which proved also to 
 be venereal, as it infected several females before he was 
 aware of its real nature. I can feel no hesitation in saying 
 that the ulcer on each side of the finger-nail was most 
 decidedly a secondary venereal ulcer, and that the eruption 
 was as strongly-marked a syphilitic eruption as any I had 
 ever seen. The readiness with which this gentleman 
 unnecessarily exposed the symptoms of his disease to me 
 tends very much to prove that he himself was not at all aware 
 of its real nature. 
 
 When he was affected with the primary ulcer, it would seem 
 that he had not at that time done mischief to any of his 
 patients, probably because he was aware of or strongly 
 suspected the nature of his ailment, and adopted the necessary 
 precaution of covering the part ; but at the time that I saw 
 the secondary venereal ulcers on his finger he Avas certainly 
 ignorant of their real nature, and accordingly it was then 
 that he communicated the infection to a considerable number 
 
OF THE VENEEEAL DISEASE. 41 
 
 of his patients. I was totally unconnected with any of the 
 parties in this unfortunate business : chance alone made me 
 acquainted with it in the manner I have mentioned ; and I 
 have thought it j-ight to state the particulars which came 
 within my own knowledge, because the corroborating testimony 
 of a witness totally unconnected with any of the parties must 
 have soihe weight in gaining credibility to a fact which is so 
 contrary to the generally-received opinion, as to require all 
 the support that can be given to it. 
 
 In further confirmation of this conclusion, I shall next 
 adduce an article extracted from the 'Edinburgh Medical 
 Essays and Observations,' which, having been written many 
 years before the profession was at all aware of the distinction 
 between primary and secondary symptoms, is on that account 
 fully entitled to credit, as the plain statement of an eye-witness 
 to a cui-ious medical fact. 
 
 In vol. iii., Article xxi., page 297 of this work, is an account 
 of a malignant lues venera, communicated by suction, in the 
 city of Cork, in the year 1728. By Edward Barry, M.D., 
 F.E.S. :— 
 
 "A woman in this city, who was commonly employed to draw 
 the breasts of lying-in women, had, probably in the course of her 
 business, received the infection in her mouth ; which she either 
 did not suspect, or concealed, tiU she communicated the poison to 
 several persons of distinction. 
 
 " I think this affection was stiU more remarkable for its malig- 
 nity and the quick progress of the symptoms than for the 
 uncommon manner of its being received. As I had an opportunity 
 of seeing most of the unhappy persons who were thus affected, I 
 thought that a faithful account of its appearance, and the method 
 of cure which I found successful, might not be unworthy of a place 
 in your essays. 
 
 " The nipple first became shghtly inflamed, which soon produced 
 an excoriation, with a discharge of a thin hquor ; from thence red 
 spreading pustules were dispersed round it and gradually spread 
 over the breast, and, where the poison remained uncorrected, 
 produced ulcers. The pudenda soon after became inflamed, 
 with a violent itching, which terminated in chancres that were 
 attended with only a small discharge ; and in a short time after, 
 pustules were spread over the whole body. It finished this course, 
 with all these symptoms, in most persons, in the space of three 
 months. This disorder made a quick and dangerous progress 
 in such who first received it, they not being apt to suspect 
 
42 ON THE NATUIUL HISTORY 
 
 an infection of this nature in their circumstances. The husbands 
 of several had chancres, which quickly communicated the poison, 
 and produced ulcers in the mouth, and red spreading pustules on 
 the body ; but such of them escaped who had timely notice of the 
 nature of the disease before the pudenda was affected. Some 
 infants received it from theu- mothers, and to the greatest part of 
 them it was fatal. 
 
 "When I first mentioned my opinion of this disorder to the 
 midwife of a person whom I visited, she said the woman who 
 drew her breasts was a few days before, on such a suspicion, 
 examined at the request of a lady of distinction before she 
 would make use of her, and was declared free from any such 
 distemper; by which means that lady was unhappily deceived, 
 and was one of the last who received the infection. I ordered 
 the woman to be sent to me, and I observed a small ulcer at the 
 root of her tongue and a large recent cicatrix on the inward part of 
 the upper Mp. She obstinately denied that she ever had any sore 
 there, but was so much terrified when I told her she would 
 certainly rot away, that she begged I would not suffer lier to 
 perish if I suspected so much danger. While she was in a salivation 
 she owned to me and Mr. Osborne, an eminent surgeon in this 
 place, that she had had an ulcer where the cicatrix remained, 
 which she cured by two or three doses of physic and a gargle made 
 of woodbine, and some other ingredients ; and said she concealed 
 it because she imputed it only to cold, and was afraid, if known, it 
 might for ever destroy her business and character. 
 
 " The woman who communicated this infection to so many had 
 no eruptions on her body ; and by what I could find, the infection 
 never made any progress beyond the mouth. Some women, whose 
 breasts were drawn by her, had never any marks of infection ; but, 
 by what I could find, the few who escaped were such whom she 
 attended after the large ulcer on her lip was healed ; for, whUe that 
 continued, the nipple was received into a bed of cTorruption. 
 But the case of a lady was very remarkable, whose breasts were 
 drawn twice a day by her, when she communicated the infection to 
 all others who came in her way. A violent confluent small pox 
 seized this lady immediately afterwards, and she never had any 
 marks of infection. 
 
 " The activity of this poison was so great that I immediately 
 directed a mercurial sahvation to even such as were but lately 
 and lightly affected, and ordered it to be brought on by repeated 
 unctions in a small quantity, with a few grains of calomel internally, 
 and continued the salivation five or six weeks. 
 
 " I have often observed that, when the salivation easily rises 
 on the use of the small quantity of mercury, the cure is uncertain, 
 and the symptoms often return ; and that the same inconveniences 
 often attend a large sahvation, accompanied with a great inflam- 
 mation, from which many other dangerous symptoms also flow. 
 
 " The venereal disorder returned to some after a regular 
 salivation, but was entirely removed by the following method, 
 
■ OF THE VENEREAL DISEASE. 43 
 
 which I made use of to all who had this infection in a violent 
 degree." 
 
 Here follows an account of his treatment by giving the 
 patients large quantities of decoctum sarsse, and also subjecting 
 them to be sweated in a closed chair or bath : — 
 
 " When they had bathed iu this manner five or six times, 
 I ordered a strong decoction of guaiacum to be used instead of the 
 former, and a few grains of calomel to be' taken an hour before 
 they entered the bath; and in some cases I have directed two 
 grains of the turbith mineral to be mixed with the calomel, which, 
 though continued for a considerable time, seldom affected the 
 glands of the mouth, being determined with such force to the 
 surface of the body. And, if the expression may be allowed, 
 mercury thus managed produces a salivation through the pores of 
 the skin. When the salivary glands are in the least affected, the 
 use of mercurials is to be omitted till that symptom disappears. 
 I ordered the bath three times in a week ; in some cases repeated 
 it five or six times successively every day, and gradually remitted 
 the use of it." 
 
 I shall not avail myself of the charitable construction put 
 by Dr. Barry on the manner in which this woman contracted 
 the disease, viz., " that she had probably in the course of her 
 business received the infection in her mouth," as this would 
 incline us to think that the ulcer of the lip was a secondary 
 ulcer; I shall admit that it was a primary ulcer or chancre, 
 without stopping to inquire how it was contracted. It is 
 obvious then that the ulcers of the nipples must also have 
 been primary ulcers or chancres, but from these the whole 
 system became contaminated, for we find that pustules were 
 spread over the whole body ; and that these pustules, or that 
 this eruption, had also seized upon the pudenda, we have 
 proved by the statement, "that the pudenda soon after 
 became inflamed, with a violent itching, which terminated 
 in chancres that were attended with only a small discharge." 
 
 This general eruption on the surface, as well as those spots 
 of eruption which appeared about the pudenda, it must be 
 admitted were secondary symptoms. This account of the 
 general eruption having seized upon the pudenda will be 
 corroborated by the experience of every surgeon who has been 
 accustomed to treat the syphilitic complaints of females. 
 For in them we almost imiversally find that the pudenda and 
 
44 ON THE NATURAL HISTOBY 
 
 parts in their immediate vicinity are thickly beset with spots 
 of the eruption, which, however, in general differ from those 
 on the other parts of the body by being moist, yielding a 
 discharge having the appearance of an ulcerated surface. 
 By the way, it is remarkable that, while this takes place in 
 the venereal eruption of females, we find much fewer spots of 
 the eruption appear on the genitals of men than on any other 
 part of their body. From Dr. Barry's account it is plain that 
 the husbands of several of these ladies were infected by having 
 sexual intercourse with their wives, and that the disease which 
 they received was truly syphilitic, for " the husbands of 
 several had chancres which quickly communicated the poison, 
 produced ulcers in the mouth, and red spreading pustules on 
 the body." This surely is a pretty clear account of the 
 primary and secondary symptoms contracted from the wives ; 
 and I cannot conceive by what ingenuity the above facts can 
 be explained away, or how it can be asserted that the disease 
 which was communicated to the husbands was from primary 
 and not from secondary venereal symptoms. 
 
 Let it be observed that at the time when this Essay was 
 written, medical men were unacquainted with the distinction 
 between primary and secondary ulcers, and therefore when 
 Dr. Barry speaks of chancres on the pudenda of the females, 
 we are to understand merely venereal ulcers. It also deserves 
 to be noticed that at this period no question had been raised 
 as to the power of any venereal ulcer to contaminate, — this 
 was then believed to be a property possessed by aU and every 
 venereal ulcer. In my opinion, then, we have in this Essay 
 as strong traditional testimony as the case can admit of : it is 
 given by a man who had no particular theory or doctrine to 
 support, who seems to have written for the mere purpose of 
 stating facts, and recording an account of the propagation of 
 this afflicting disease in a manner which is so uncommon. 
 The only matters like theories in tliis Essay are his notions of 
 the causes why mercury fails at times to cm-e the venereal 
 disease. 
 
 A very striking instance of the power of secondary symptoms 
 to contaminate and produce the venereal disease is seen in 
 cases of infants infected with Syphilis, communicating it 
 
OF THE VENEREAL DISEASE. 45 
 
 first locally and then constitutionally to a sound nurse. I am 
 well aware that Mr. Hunter is of opinion that these cases are 
 not venereal. But I will appeal to the candour and observation 
 of every surgeon conversant with this branch of practice, and 
 who has witnessed cases of this description, and I ask him 
 whether the symptoms in the infant are not exactly such as 
 he has repeatedly observed in the adult. I am certain that 
 the answer will be in the affirmative : I put it to his candour 
 to say whether the secondary affections of the nurse differ in 
 any respect from those secondary symptoms which are the 
 consequence of genuine chancre ? Are not the features of the 
 disease precisely the same ? and are not both similarly affected 
 by mercury ? If, then, the disease of the nurse so closely 
 resemble that produced by chancre, both being preceded by a 
 local sore, and if the secondary symptoms so closely resemble 
 each other that we are not able to discover any difference ; 
 finally, if both be similarly affected by mercurial treatment, 
 how can we dispute their identity ? 
 
 I am well aware that Mr. Hunter in his work has laid hold 
 of some few particulars in which these two diseases seem to 
 differ ; but this difference, I think, may be explained without 
 involving the supposition that the disease of the infants and 
 nurse are not venereal. This I shall attempt to do when I 
 come to speak of the venereal disease in infants. 
 
46 
 CHAPTEE II. 
 
 ON THE ADMINISTRATION OF MEKCUBT. 
 
 Preparatory process necessary — Curative action of Mercury is attended 
 with Ptyalism— Eegimen to be observed during a Mercurial course. 
 
 It wiU be readily conceded that the efficacy of any remedy 
 in the treatment of disease must ia a great measure depend 
 on the accurate knowledge which the practitioner possesses as 
 to the most judicious mode of administering it ; this position, 
 which is true in respect even to the most simple and innocuous 
 medicine, will be found to apply with peculiar fitness to the 
 use of mercury, when we reflect on the astonishing powers of 
 this substance, its great superiority over every other medicine 
 in the cure of certain forms of disease, the different results it 
 is capable of producing, according to the mode in which it is 
 administered, and, above all, when we consider that in the 
 hands of the ignorant and injudicious it will not only fail to 
 remove that complaint for which it had been prescribed, 
 but may induce other diseases of a still more intractable 
 nature, and that it even may, as too often has been the case, 
 cause the sudden extinction of life. 
 
 The practitioner about to administer mercury should not 
 only be weU acquainted with the doses suited to the age 
 of his patient and with the probable effects of certain com- 
 binations on particular functions, but he should also bear this 
 fact in mind, that unless, in general, he prepare the system by 
 some preliminary attention so as to adapt or fit it to receive 
 the fuU benefit of this medicine, he will most probably be 
 foiled in his attempts to remove the disease, and he may even 
 entail upon his patient some other and more serious ailment, 
 and thus perhaps irretrievably injure a naturally good 
 constitution. Such preparative process is particidarly required 
 in those diseases, and especially in certain forms of Syphilis 
 in which we consider that a protracted course of mercury may 
 be found necessary. 
 
ON THE ADMINISTEATION OF MEECURY. 47 
 
 The older surgeons were strongly impressed -with the 
 necessity of some such preparation, and although I by no 
 means subscribe to all the details of their practice, I yet fully 
 agree in the principle. The preparative measures which were 
 adopted by them were not confined to plethoric and robust 
 individuals labouring under primary symptoms (such persons 
 were soon reduced by bleeding, purging, warm bathing, and 
 low diet), but they also very judiciously extended the principle 
 to those cases where the health appeared broken down, and 
 where the venereal disease was accompanied by some morbid 
 state of the system not necessarily arising from that disease. 
 At the time when I commenced the study of the surgical 
 profession this practice was not entirely extinct ; every vene- 
 real ijatient, on his admission into hospital, was then, as a 
 matter of course, ordered to be bled once, to be purged four 
 times, and to have the warm bath twice in the first week, and 
 not until all these directions had been complied with was the 
 use of mercury commenced. In the com'se of a httle time 
 the practice of bleeding was confined to those cases in which 
 active inflammation attended on chancre or bubo, but still 
 that of purging, warm bathing, and low living was in all 
 instances strictly adhered to. In cases of secondary symptoms, 
 in enfeebled and reduced habits, I never at any period saw any 
 sort of preparatory process adopted; at present I may say 
 preparatory treatment is considered unnecessary, for I cannot 
 consider as such that plan which is now generally pursued in 
 such cases. For example, when a consultation of surgeons is 
 held on a patient who is emaciated and hectical, with enlarged 
 lymphatic glands in the neck, &c., and that it is decided that 
 he should pursue a course of sarsapariUa and acids, with 
 country air, &c., I say that such is not a preparatory course 
 in the true sense of the word, because this plan has been 
 recommended in the hope that it may alleviate the venereal 
 symptoms, or even altogether remove them ; it has, in fact, 
 been ordered as a succedaneum for mercury, with some 
 flattering expectation that the patient may thereby be restored 
 to health, and that thus mercury may be totally dispensed 
 with ; and, therefore, not with a view of preparing the system 
 more effectually to benefit by its use, or to avoid the dangers 
 which occasionally attend its exhibition. 
 
48 ON THE ADMINISTRATION OP MERCURY. 
 
 I do not wish it to be inferred from the foregoing paragraph 
 that it is my opinion that mercury should never be prescribed 
 for a venereal patient who is much emaciated and hectical, so 
 long as this latter condition of the system shall remain ; on 
 the contrary, I shall hereafter show that many such patients 
 can and do bear a com'se of mercury, and that too with the 
 greatest advantage, provided it be conducted with proper care 
 and judgment. But all I contend for is, that if in such 
 unfortunate cases we discover any peculiar morbid state super- 
 added to, but not arising out of, the venereal disease, we 
 should then first attempt the removal of that morbid condition 
 before we venture to commence the use of mercury. If, for 
 example, we venture to administer mercury to a patient who 
 has for many days been troubled with a loose state of the 
 bowels, we run the risk of inducing such a violent and 
 obstinate diarrhoea as will be found intractable, and will 
 speedily exhaust the slender remains of strength ; or if a 
 patient, subject to habitual bronchitis, should chance to labour 
 under a fresh attack of it, great danger will attend the 
 immediate use of mercury, and, therefore, some preparatory 
 treatment is required. In fine, I am strongly of opinion that 
 the want of a due preparatory process has of late years 
 contributed to bring this valuable remedy into much disrepute, 
 and hence partly it is that execrations against mercury are 
 heard in every part of Europe ; hence has it been accused of, 
 and been condemned for, all those serious evils (and they are 
 manifold and severe), which have arisen from its indis- 
 criminate exhibition, all which ought rather to be ascribed to 
 want of judgment on the part of the surgeon, and to incautious 
 and ii-regular conduct on the part of the patient. In proof of 
 this opinion that mercury does not merit all this odium 
 I may observe that while we hear it condemned by some 
 in reference to the treatment of the venereal disease, we yet 
 daily see its wonderful powers, and hear of its superior efficacy 
 in the cure of many other diseases, over which its influence 
 has been only of late years discovered. Thus, in acute 
 inflammation of the deeper membranes of the eye, in acute 
 inflammation of the joints, and of the serous membranes 
 of the cavities, it is now lauded as a most invaluable remedy. 
 
ON THE ADMINISTRATION OP MERCUBY. 49 
 
 It is easy to explain why mercury should be generally so 
 successful in other inflammatory diseases, while it so often 
 fails in primary syphilis, which has generally a much less 
 inflammatory character. The circumstances under which it is 
 given in the two classes of cases are totally different : thus 
 in syphilis its use must be continued for a much longer time 
 than in those acute diseases ; as many weeks will be required in 
 the former as days in the latter ; again, in these acute inflam- 
 matory affections the surgeon has, perhaps unintentionally, 
 used the very best preparatory process, namely, he has 
 freely bled and pm'ged his patient, has enjoined absolute rest, 
 and has put him on the lowest diet. Contrast with this the 
 course ordinarily pursued with venereal patients. A young 
 plethoric man, who has been pursuing a dissipated course of 
 life, and pronounced by a surgeon to have a venereal ulcer 
 and bubo, is directed to commence at once the use of mercury, 
 either externally or internally : no previous measures are 
 adopted, except possibly one dose of some cathartic medicine, 
 no injunctions as to the necessity of rest and quietness and 
 confinement to the house ; no alteration in his diet — in fact, no 
 attempt to reduce the inflammatory and plethoric state of his 
 system ; but because he is young and healthy, and free from 
 any of those diseases which appear in our nosological arrange- 
 ments, he is therefore considered as in a fit state for the 
 immediate use of this powerful medicine. Could I now 
 induce such of my readers as have had practical experience to 
 recal to their recollection some of those cases of young men 
 who have been thus hurried into a course of mercury without 
 any preliminary attention to their state of health, or without 
 any particular instructions as to their mode of living ; I have 
 no doubt that every practitioner could adduce many instances 
 in which their expectations of a safe and speedy cure have 
 been disappointed; how frequently have they witnessed in 
 such cases that although the mercury acted on the salivary 
 system, the ulcer assumed not only a very unhealthy, but 
 even a very novel and peculiar appearance, one which has 
 sometimes caused them to doubt the correctness of their first 
 opinion as to its venereal character, and has induced them to 
 lay aside the further use of mercury ! Again in other cases, 
 
 E 
 
50 ON THK ADJriNISTRATION OF MERCURY. 
 
 how have they been surprised at the mefficaey of this medicine, 
 though the doses of it may have been increased from time to 
 time to a considerable amount, without producing any fcetor 
 of the breath, any swelling or ulceration of the gums, tonsils 
 or palate, or any obvious effect whatever, except an occasional 
 diarrhoea which may last for a few hours, and ocem- at 
 intervals of five or six days ! — and when, at length, the 
 accumulation of mercury in the system has become very 
 great, a train of most alarming and dangerous symptoms 
 suddenly supervened, although not one of its ordinary or 
 salutary effects have been produced. Every surgeon I have 
 no doubt must have vntnessed the misery that such patients 
 occasionally undergo even in respect to the local disease : the 
 inflammation attending then." chancre is sometimes so excessive 
 as to requu'e cold applications, and repeated and often 
 unavailing leeching ; the hxibo, too, is often attended with a 
 pecuharly severe pain of a scalding, burning or shooting kind, 
 although the swelling and the discolouration of the integuments 
 may be but to a moderate degree. When the purulent 
 collection distends the skin the suffering of the patient are 
 almost beyond endurance, and when the surgeon is forced to 
 give it vent the pain attending the act of opening it is some- 
 times so acute as to overcome even the greatest fortitude and 
 patience ; the fluid in such cases is usually thin pus, mingled 
 with the colom-ing part of the blood. Although the patient 
 may have derived some relief from the operation, yet still he 
 continues to pass sleepless nights and most uncomfortable 
 days from the continuance of pain ; even during this state, 
 however, he often possesses a good appetite and a fair share of 
 strength; but no local application succeeds in relieving the 
 local symptoms until the mercury shall have been laid aside 
 and the general health attended to ; then the suitable topical 
 means will soon succeed in improving the condition of the 
 sores, and the system will gradually recover from the several 
 effects of the precipitate and injudicious mode in which the 
 use of mercury had been commenced and continued. I feel 
 certain also that surgeons must have often seen, in cases of 
 patients affected with secondary symptoms, who have been 
 worn down and exhausted with an irritable state of the bowels, 
 
ON THE ADMINISTRATION OF MEBCURY. 61 
 
 induced perhaps, in the first instance, either by a highly 
 stimulating diet, adopted with the view of exciting appetite, 
 or, as in the poorer ranks of hfe, by ardent spirits and food of 
 an innutritious nature, that this condition of the intestinal 
 canal has been greatly increased, and even urged on to an 
 uncontrollable diarrhoea by superadding the irritation of 
 mercury during this state of the system generally, and of the 
 bowels in particular. Many of such cases have, under these 
 circumstances, sunk into a state of the most alarming and 
 even fatal weakness the moment the mercury has made an 
 impression on their irritable and enfeebled frames. 
 
 These then are some, but by no means the whole, of the 
 pernicious effects which may be, and which often are, induced 
 by the administration of mercury when due precaution has 
 not been used to prepare the system for its reception. When 
 speaking of secondary Syphilis, I shall adduce some instances 
 of its mischievous effects on many of the symptoms. 
 
 Having now, I trust, shown the necessity of some pre- 
 paratory course of treatment previous to commencing the use 
 of mercury, I ought next to speak of the mode of administering 
 it ; I wish first, however, to offer a few remarks upon the 
 curative action of this medicine. 
 
 When mercury is exhibited for the cure of any other disease, 
 as well as for Syphilis, we shall find that its sanatory impression 
 on the disease is contemporaneous with its action on the 
 salivary system, and that when the latter effect has not been 
 produced, neither will the former have occurred. Thus in 
 cases of acute inflammation of a joint, or of the dense 
 membranes of the eye, we find that the progress of the disease 
 is arrested the moment the salivary system becomes affected ; 
 and even in cases of other diseases, which cannot be considered 
 as purely inflammatory or acute, the same remark will be 
 found to hold good ; thus in cases of orthopncea depending on 
 disease of the heart, with effusion into some of the thoracic 
 cavities, and in which we commonly prescribe mercury in 
 combination with squiU and digitalis, the patient is not at 
 first sensible of any improvement, but almost invariably, as 
 soon as the gums become affected, he experiences relief, and 
 perhaps the very next morning after this occurrence he tells 
 
52 ON THE ADMINISTRATION OF MERCURY. 
 
 tells US with joy and gratitude that he is considerably better, 
 that he has passed a night of refreshing sleep, and that he 
 has been able to do what he could not have done for weeks 
 previously, namely, rest in the recumbent posture without any 
 of that distressing and alarming sense of suffocation under 
 which he had previously laboured, and which always super- 
 vened the moment he sunk into that position. It is 
 unnecessary to particularize many other diseases in which the 
 same fact occurs : indeed it may be asserted as the general 
 rule. The contrary also wUl be found equally true, that is, 
 that mercury will not prove serviceable in any disease for 
 whose cure it has been prescribed when it does not produce 
 its wonted effect on the salivary system. How often has this 
 been verified during that time when it was the fashionable 
 practice to prescribe a course of mercury in all chronic 
 affections of the liver ? It then happened over and over again 
 that slight delicate females have been subjected to this 
 treatment ; friction perhaps has first been tried, and this 
 failiag to reheve the complaint, — because it had also failed to 
 affect the salivary system, — the internal use of mercury has 
 then been substituted, or probably combined with the former ; 
 thus the medicine has been persevered in and the doses 
 increased even to an extravagant degree, but yet withal no 
 salutary effect has been induced ; on the contrary, the little 
 remnant of strength has suffered so materially that at length 
 the mercury had been lain aside, and the friends, as well as 
 the medical attendant of the patient, have had reason to 
 express not only their disappointment, but also their amaze- 
 ment at the inefficacy of the mercury, of which the patient 
 had taken fuUy as much as woidd have sufficed to salivate at 
 least half-a-dozen young and vigorous men. If, then, it be so 
 very generally found that, whenever mercury exercises a 
 salutary influence over disease, it at the same time always 
 affects the salivary organs ; and if, again, whenever it fail to 
 produce this latter effect, it be also found altogether inoperative 
 in the cure of disease, it is surely a fair and legitimate 
 conclusion to affirm that ptyaUsm marks the natural and 
 salutary operation of this mineral. 
 
 I am well aware that this doctrine has been questioned by 
 
ON THE ADMINISTRATION OF MERCURY. 53 
 
 some practical writers on Syphilis, but I trust I shall be able 
 hereafter to show that this disease does not form an exception 
 to the above general position. Let it not, however, be inferred 
 from the foregoing statement that I would wish to measure 
 the efficacy of mercury by the amount of salivation which it 
 excites ; on the contrary, the degree of ptyalism that I am 
 always anxious to attain is merely an increased secretion of 
 saliva, accompanied by swelling and superficial ulceration of 
 the gums, and sometimes also of portions of the lining 
 membrane of the cheeks and lips : this I am desirous of 
 attaining as a sort of index which denotes, first, that the 
 mercury is acting in a safe and salutary mode upon the 
 system ; and, secondly, that it displays that degree of power 
 or energy of action which will be sufficient to eradicate the 
 disease : so certain do I feel of the correctness of this view, 
 that during a course of mercury for the cure of Syphilis, 
 should this ptyalism be suffered to decline for some days, I 
 should fear that all the additional mercury which may have 
 been subsequently given in this more feeble manner would 
 prove useless, that is, unequal to cure the disease. At the 
 same time I am aware that many surgeons have exerted their 
 ingenuity to devise a mode of administering mercury whereby 
 ptyalism or any obvious effect on the salivary system might 
 be prevented; I have reason to believe, however, that the 
 precepts of such surgeons have not been very generally 
 adopted, and with most practical men have fallen into disuse. 
 Tha general regimen which patients under a mercurial 
 course should pm-sue is a subject of some importance, and one 
 of which I have not spoken as yet. In former times it was 
 the custom to have the patient covered with a thick flannel or 
 wooUen-cloth dress, and the head even covered with a sort of 
 hood, so that the face only was exposed ; he was also confined 
 to a very warm, close room, from which the external air was 
 most carefully excluded. I believe it was Mr. Hunter who 
 effected a revolution in this practice ; and this not so much by 
 any forcible argument as by simply asking a question, which 
 he prefaces by an assertion : — ■ 
 
 ' ' The manner of living under a mercurial course need not be 
 altered from the common, because mercury lias no action upon the 
 
54 ON THE ADMINISTRATION OF MERCURY. 
 
 disease which is more favoured by one way of life than another. 
 Let me ask anyone, what effect eating a hearty dinner and drinking 
 a bottle of wine can have over the action of mercury upon a 
 venereal sore, either to make it affect any part sensibly, as falling 
 upon the glands of the mouth, or prevent its effect upon the 
 venereal irritation ? In short, I do not see why mercury should 
 not cure the venereal disease under any mode whatever of regimen 
 or diet." 
 
 While I dissent from the rigid rules of discipline insisted on 
 by our ancestors during a mercurial course, I do, however, 
 believe that their system was, on the whole, productive of 
 much less mischief than what results from the laxity of 
 modern practitioners in this respect, who, I conceive, err 
 exceedingly in the contrary extreme. Thus, to permit a 
 strong plethoric young man, with primary symptoms, and 
 who has not undergone a preparatory regimen, to indulge in 
 all the pleasm-es of the table, to eat a full dinner and take 
 freely of wine, is only calculated to increase the tendency to 
 febrile action which, when at all excessive, will counteract the 
 disj)Osition to ptyalism. 
 
 With respect to the influence of exposure to the air during 
 a mercurial com-se, Ave need only refer to what has been 
 written by various authors on the benefits of free exposure of 
 the system to the fresh air in cases of merciuial Erethism, 
 and also to the assistance which the practitioner can derive 
 from it in the management of those individuals whose 
 idiosyncrasy renders them very susceptible to the effects of 
 even small quantities of mercury. 
 
 Should our patient appear debilitated after the moderate 
 and the desirable degree of ptyalism has been induced, then 
 we way safely allow him a full and generous diet, from which, 
 however, I would still exclude all stimulating food or drink ; 
 moreover, if about this period the patient's strength fail, or if 
 the local symptoms do not improve as we had expected, we 
 may then combine with great advantage bark and opium with 
 the mercury, while at the same time we should reduce the 
 doses of the latter. The experience of hospital surgeons will, 
 I have no doubt, support my opinions on this subject; for 
 they must have observed on many occasions that if the 
 symptoms of an out-patient who is using mercury should 
 
ON THE ADMINISTRATION OF MEECDRY. 55 
 
 become worse, and that he then he received into the hospital, 
 his complaints have quickly improved, and that, too, while 
 the same doses of mercury have been continued. 
 
 1 know it may be urged against this strict rule of regimen, 
 in favour of which I have expressed myself, that the daily 
 practice of some surgeons proves it to be unnecessary, 
 inasmuch as they allow their patients free exercise in the 
 open air and a liberal diet, and yet they are able to effect 
 numerous cures. While I admit this, still I think it must be 
 granted that surgeons daily meet with many untoward 
 circumstances and considerable delays in this branch of their 
 practice, that not a few of their patients pass on from one 
 stage of the venereal disease to another ; and while some of 
 them are cured in the advanced stages of the complaint, after 
 repeated disappointments and protracted sufferings, many 
 others fall victims to its sequelae, or are carried off by some of 
 those acute diseases to which the deranged state of their 
 system renders them peculiarly hable. 
 
 When I call to my recollection the results of my own 
 observations on the treatment of this disease, made thirty 
 years ago, and compare it with that of the present day, I think 
 the comparison speaks decidedly in favour of the plan which 
 was then pursued. For some years after I entered on the 
 study of the profession, a surgeon felt himself rather humbled 
 if he allowed a venereal bubo to suppurate ; and if secondary 
 symptoms appeared, he was considered to have mismanaged 
 the case, and not unfrequently lost for ever after the total 
 confidence of his patient. 
 
 [Many of the older surgeons held the same vie-w. At this time no 
 distinction had yet been recognized between infecting and non-infecting 
 venereal diseases. Mr. Solly speaks in very much the same terms in his 
 evidence before a Committee appointed to enquire into the Pathology 
 and treatment of venereal disease. "When I was a young man," he 
 says, "I was a pupil of Sir Astley Cooper and of Mr. Travers, and if a 
 man had a case of secondary syphilis then it was considered a disgrace 
 to him, and he was held accountable for it ; but at the present day, as 
 every man is in the same boat, it is not considered disgraceful if his 
 treatment of Syphilis is followed by secondary symptoms." The question 
 of how far mercurial treatment prevents secondary accidents is still 
 sub jiodice. Many of the best obsei-vers, however, agree that it does not 
 
56 ON THE ADMINISTRATION OF MERCTJEY. 
 
 prevent them, although many think that it postpones or modifies them. 
 Amongst these we may mention such distinguished names as Skey, 
 Paiker, Hutoliinson, Ericlisen, Sir WiUiam Fergusson, Longworth, &c.] 
 
 It is true that at that time mercury was often used ia 
 excessive and in dangerous doses, salivations most profuse 
 were excited, and which were attended with all thek accom- 
 panying evils ; but still on the other hand, the patient who 
 escaped these perils was generally freed at once from the 
 disease. The regimen then was as strict as the medical 
 treatment was severe. Lodging-houses were established in 
 Dublin, solely for the reception of young gentlemen who 
 required to go through a course of mercury ; and these houses 
 were always fully occupied — so seldom was it that a young 
 man could, while living among his own family, undergo the 
 severe discipline to which the surgeons of that day thought it 
 necessary to subject him. 
 
 But from the time that Mr. Hunter's work on the venereal 
 disease came to be generally read and acted upon by the 
 surgeons of this city, the discipline became not only less 
 severe, but actually as lax as Mr. Hunter himself could wish. 
 Young men, pleased at the removal of these restraints, too 
 frequently overstepped even the moderate bounds which were 
 prescribed for them ; and surgeons, finding that secondary 
 symptoms frequently appeared in eases so treated, were glad 
 to adduce Mr. Hunter's theoretical opinions of " disposition to 
 diseased action," and so forth, partly to justify themselves, 
 and partly to satisfy their patients ; so that at length from 
 this, and perhaps from other causes which I shall not now 
 consider, those cases of primary venereal disease which, under 
 the old practice, required six or seven weeks for their cure, 
 were, under the new plan of treatment, found to require as 
 many months, or even years. By the former the disease was 
 really and quickly cured ; but by the latter it is only pursued from 
 one resting-place to another, so that the patient's mind is often 
 kept in a state of suspense and anxiety for very many months, — 
 the symptoms disappearing for a few weeks, and then retui-ning ; 
 and so this scene may occur over and over again, until, by some 
 lucky chance in the treatment or in the effects of the medicine, 
 the system shall come to be finally relieved from the disease. 
 
ON THE ADMINISTRATION OF MEECUBY. 57 
 
 While I freely admit that excessive over-doses of mercury 
 have inflicted the most severe evils, yet I as confidently af&rm 
 that within the last twenty years the same medicine, when 
 employed in under-doses, or rather when it has not been 
 pushed so as to induce its legitimate action, has been 
 productive of infinitely more mischief; and I feel confident 
 that this position could be supported both by professional as 
 well as non-professional persons, were the effects of the latter 
 practice as obvious and striking as are those of the former ; 
 but they cannot be so fully appreciated by the ignorant, and 
 they have not been sufficiently attended to by the profession. 
 
 The alarm which of late years has been raised against 
 mercury, as well as the mischief to which it often gives rise 
 when it happens to disagree with the patient, have rendered 
 practitioners not only cautious, but absolutely timid and 
 nervous as to its use, — so much so, that as soon as they observe 
 the first unfavourable change in the symptoms they at once 
 suspend the further use of mercury ; some even seem not to 
 be aware that chancre and bubo almost always appear to be 
 worse on the day or two preceding the occmrrence of ptyahsm ; 
 about that time the chancre spreads somewhat, and the bubo 
 becomes more painful and uneasy. Now this is the very 
 juncture when the disease is, as it were, within the grasp of 
 the surgeon, provided he only persevere in the medicine with 
 prudence ; but if, through fear or ignorance, he lay it aside at 
 this moment, he will lose the happy opportunity of expe- 
 ditiously, and almost certainly, curing his patient ; and then 
 he assures him that the mercury is beginning to disagree, and 
 that it cannot be continued any longer with safety. A patient 
 had better not have used any mercury whatever than have 
 been treated in this way, for the constitution has been 
 disturbed, and febrile irritation has been excited to no purpose ; 
 and should the patient be of an unhealthy habit the local 
 disease may assume a very unfavourable aspect, while the 
 general health may become so much disturbed as to render it 
 unsafe to resume the use of mercury for a considerable time. 
 
 A similar mismanagement of mercury in cases of secondary 
 Syphilis will be attended with results fully as unfavourable ; 
 and the more frequently the error is repeated, so much the 
 
58 ON THE ADMINISTRATION OF MERCUBY. 
 
 more serious will be the evils consequent thereon. Under 
 such circumstances the sm-geon tells his patient that his case 
 can no longer he served bj- mercury, and therefore he consigns 
 him to the non-mercm-ial plan. In this manner, I believe, 
 a very few may be eui-ed, but many more I know have been 
 allowed to sink into an untimely grave by the slow and silent, 
 but certain operation of the venereal disease, the symptoms of 
 which have become so changed or masked that common 
 observers could not recognize the features of the original case. 
 No doubt, observation, experience, and sound judgment are 
 very requisite to enable the practitioner to decide whether 
 those changes which appear at the critical moment when 
 mercury is about to excite ptyalism be really unfavourable 
 and alarming, or whether they may be merely the natural 
 effects of the mercm'ial action : this, however, is not the only 
 instance which the practice of sm-gery presents, in which 
 accurate observation, discrimination, and judgment are 
 required to practise the profession with safety and success ; 
 these are qualifications which can only be attained by long 
 and attentive experience : no precise rules, therefore, can be 
 laid down to guide the surgeon at this critical juncture, 
 neither can any words impart to him that practical knowledge 
 without which he cannot conduct the further treatment of 
 the case with satisfaction to himself, or with true advantage 
 to his patient. 
 
59 
 
 CHAPJEE III. 
 
 ON THE ADMINISTRATION OF MERCURY. 
 
 Mode of administering Mercury — Friction — Internal administration — 
 Ordinary effects of Mercury on the system — Necessity of paying 
 close attention to tlie patient, from the time of the first impression 
 of the Mercury on the system — Cautions to be observed in the use 
 of Mercury — Eruptive diseases consequent on the use of Mercury — 
 Erethismus Merourialis. 
 
 I NOW proceed to consider the mode of administering mer- 
 cury SO as to induce its favourable action on the salivary 
 system, and at the same time its sanative effects on disease, 
 particularly on the primary symptoms of Syphilis. In order 
 to explain clearly my views upon this subject, let us suppose 
 the simple case of a young man affected with primary venereal 
 symptoms, but in other respects in perfect health. I select 
 such a case because it will require a more lengthened course 
 of mercury than most other diseases do, and therefore more 
 judicious management is necessary; and also because the 
 changes in primary venereal symptoms will often assist us in 
 deciding whether the medicine is acting in a salutary manner 
 or otherwise, and consequently whether it should be persevered 
 in or discontinued. 
 
 I shall first speak of the mode of introducing mercury into 
 the system by friction, because ia this method of administering 
 this medicine its various effects are more clearly and un- 
 equivocally exhibited. The patient should be apprised of the 
 necessity of rubbing in each dose of the ointment carefully, 
 but not violently, and this he should do in the morning rather 
 than at night, and for these reasons : first, the skin is soft in 
 the morning and will bear friction better ; and secondly, the 
 sleep will not be postponed or disturbed, as usually happens 
 when the nightly friction is employed, the patient being 
 fatigued thereby, and thrown into a state of febrile excitement 
 which is inimical to soimd repose. 
 
60 ON THE ADMINISTEATION OF MERCURY. 
 
 As to the mode of rubbing in the ointment, the patient 
 should be directed to divide the whole quantity to be used 
 into four parts, and then rub in each portion perfectly and 
 successively until all are consumed ; it is better to apply it to 
 one limb only on each day, as thus that pustular eruption, 
 which is a common consequence of mercurial friction, is less 
 likely to be excited. I prefer makiag the patient apply the 
 ointment himself, whenever his strength will admit of the 
 exertion, because the friction of his own hand is less 
 uncomfortable, and less hkely to produce irritation and 
 eruption, than that of any other person, even though protected 
 by a bladder ever so well prepared. 
 
 I do not advise the thighs to be shaved, as many surgeons 
 do, because in a few days, when the hairs grow and become 
 stiff, more irritation is produced, and thus the tendency to 
 pustular eruption is increased. 
 
 During the course of mercurial friction, the patient should 
 wear the same drawers both by day and night ; he will thus 
 have some portion of the ointment constantly applied to the 
 surface ; some of which will probably be absorbed during the 
 intervals between each friction. When the same part of the 
 body has been rubbed two or three times, it is advisable to 
 wash off the remains of the ointment with warm water and 
 soap, and this ablution should be made the night before the 
 next friction. 
 
 When we deem it necessary to emply mercurial friction 
 with a patient who is in a very weak state, or more especially 
 with one who is in a constantly feverish condition, we must 
 direct the friction to be performed by some other person, to 
 whom we should give the following instructions : — The servant 
 should be furnished with a pig's bladder, which, after having 
 been well steeped in warm water, should be turned inside out, 
 then well impregnated and softened with sweet oil or fresh 
 lard. After this preparation it is to be tied round the wrist 
 of the assistant, and the ointment rubbed by him according to 
 the directions already given. 
 
 The dose for each friction (in this supposed case) should 
 be 5SB. If we are very anxious to induce ptyalism rather 
 early, we may at the same time direct five grains of Pil. Hydr. 
 
ON THE ADMINISTEATION OF MEKCUEY. 61 
 
 to be taken every night at bed-time ; we may thuB act upon 
 the absorbents of the internal as well as upon those of the 
 external surface at one and the same time. If we use 
 mercury internally, in cases of Syphilis or other diseases 
 requiring a rather protracted use of this mineral, we may 
 employ either Pil. Hydr. in doses of five grains night and 
 morning, which is equivalent to half a drachm of Ung. Hydr. • 
 or, should we prefer Calomel, it may be given in doses of two 
 grains at bed-time, uncombined in all cases, except in such 
 as are likely to suffer by its purgative effect. For it will be 
 found to lose this effect after the second or third dose. But 
 when purging is to be avoided we should combine with it a 
 small proportion of some opiate. 
 
 In ordinary cases we seldom observe any of the usual effects 
 of the medicine until the fourth day, when, by interrogating 
 the patient, we learn that he feels a peculiar taste in his 
 mouth like that of copper or brass, or, according to some, 
 like that of iron; that this feeling is most distinct in the 
 morning, or when he has remained for some time silent, or 
 without food or drink : at this period he makes no complaint 
 as to his general health, but on particular enquiry he will 
 admit that his appetite is not quite so good, his sleep not so 
 long ; that his bowels have a tendency to costiveness, and 
 that he has a little more thirst than usual. All these 
 changes, however, are to so trifling an extent that they will 
 not be complained of, nor will they ever be mentioned unless 
 the surgeon enquire for them. About this period, too, a very 
 slight mercurial foetor of the breath may be detected, but 
 there is very little alteration in the state of the mouth. 
 
 About the sixth or seventh day ptyalism is fairly established, 
 the gams are swollen, and appear as if inclined to separate 
 from the teeth ; they also present a slight degree of ulceration 
 on their edges, especially in the intervals between the teeth ; 
 the lining membrane of the cheeks, opposite to the last 
 molares, assumes a leaden colour, and is also swollen, so as 
 to bear the impression of the teeth; the soft palate also is 
 often swollen and more red than natural, as if it were slightly 
 inflamed : the patient states that his mouth is disposed to fill 
 with water, and that during sleep some saliva had flowed so 
 
62 ON THE ADMINISTKATION OF MERCURY. 
 
 as to wet the pillow ; that he cannot chew any firm substance 
 without suffering pain in his teeth, and that a sense of aching 
 and uneasiness in the gums remains for some time after 
 taking food, even though it should be of a kind easily 
 masticated. 
 
 From the third to the seventh day, or rather from the time 
 of the first impression of the mercury on the system, until 
 the full establishment of ptyalism, we should pay very close 
 attention to the patient, for during this period he is liable to 
 much suffering and to most danger ; and it is at this period 
 that the attentive and judicious surgeon can be of essential 
 service by giving a right direction to the medicine, as well as 
 by counteracting any injurious effect it may produce. Thus, 
 during this critical period, the patient is liable to attacks of 
 griping, frequent desire to go to stool, and tenesmus ; these 
 efforts are attended with only slight evacuations, which chiefly 
 consist of mucus tinged with blood ; sickness of stomach and 
 vomiting also often supervene, the skin is hot, and the pulse 
 quick; all which phenomena are explained by the fact that 
 the specific influence of the mercury has taken effect upon the 
 alimentary canal instead of the salivary system. This 
 dysenteric affection so generally appears at this period that 
 the patient should be forewarned and prepared for it. He 
 should be directed to discontinue the use of the mercury as 
 soon as he feels this uncomfortable effect, and he should be 
 provided with draughts, containing each Tinet. Ehei 5i. 
 Tinct. Opii gutt. xx. in any appropriate vehicle ; one to be 
 taken after each dysenteric stool. An opiate enema may be 
 used instead of the draught whenever the stomach rejects the 
 latter. A gentle diaphoresis also should be encouraged by 
 the tepid bath, or by bathing the feet in warm water. In the 
 course of a day or two this febrile excitement will, under this 
 plan of treatment, have somewhat subsided, the bowels will 
 remain free from disturbance, and then we shall generally 
 find that the mouth has become a little more affected ; and 
 should we wish to have it stUl more so, we may resume the 
 use of the mercury, and continue it in such doses as the 
 circumstances of the case shall require. 
 
 It is most desirable that ptyalism should be induced without 
 
ON THE ADMINISTRATION OF MERCURY. 63 
 
 any severe constitutional disturbance, within the first seven or 
 ten days, as it estabhshes the fact that the mercury agrees 
 with the individual, and therefore it assures us that it can 
 safely be employed, and that there is every probability of its 
 accomplishing in- this case as much as mercury can do. 
 
 The young practitioner should know that sometimes the 
 influence of mercury on the system manifests itself by a 
 somewhat different state of the salivary system. Thus it will 
 occasionally happen that the patient about the usual time will 
 complain of some fcetor and some soreness of the gums, and 
 yet we do not find any increased flow of saliva after a further 
 lapse of some days. If we now carefully examine the gums 
 they will be found less soft and less swollen than in the 
 regular form of ptyalism, but their edges will be more 
 ulcerated ; indeed the ulceration of the edges appear to be the 
 only change which they have undergone. Such cases also are 
 attended with rather too much of fever. Should we persevere 
 in the present doses of mercury we shall fail in inducing 
 ptyalism ; the result will be a more severe state of ulceration 
 and a smart degree of fever. I have seen cases of this sort, 
 in which the mercury was still continued, and this state of 
 ulceration of the gums and the fever were kept up for five or 
 six weeks, until, at length, a stop was put to the further use 
 of the medicine, either by the fever rising to an alarming 
 height or by the surgeon entertaining an opinion that the 
 disease was cured, because so much mercury had been used, 
 and during so many weeks. This state of things is what the 
 lower orders in Ii'eland call a "dry course," and it is an effect 
 of mercury which a little experience will discover to be totally 
 inefficient for the cure of the disease ; 'indeed, in some such 
 cases we shall find that all the symptoms remain unmoved 
 and unaltered. This imperfect attempt at salivation may, 
 however, be converted into the full and legitimate ptyalism by 
 reducing the doses and lengthening the intervals between 
 them, and at the same time using such means as are calcu- 
 lated to reduce the rather high degree of fever which attends 
 this peculiar condition of the mouth. 
 
 In some few patients the first influence of mercury on 
 'the system is exhibited in the throat and not on the gums. 
 
64 ON THE ADMINISTEATION OP MERCURY. 
 
 Such persons about the fifth or sixth day complain that they 
 have a sore throat, which they naturally endeavour to account 
 for by saying that they had caught cold. On inspecting the 
 fauces, we discover a degree of erysipelatous blush on the 
 arches of the palate and some inflammatory thickening of the 
 velum palati; on the tonsil, and generally at its upper 
 extremity, we see a superficial ash-colom-ed slough ; one side 
 only may be thus affected, or both may be engaged in it. I 
 need hardly say that, in such a case, a further persistence in 
 the full doses of mercury would not only prove ineffectual for 
 the relief of the venereal symptoms, but would also be 
 attended with considerable danger to life, by inducing a 
 sloughing condition of the fauces. 
 
 Under such circumstances we must for a short time 
 altogether withhold the mercury, or lessen the doses of it. 
 By proper management, I have seen in some of these cases a 
 regidar ptyalism induced, but in a few others I could not 
 succeed in producing this desirable result, the renewed action 
 of mercury reproducing the same condition of the fauces; 
 such cases, however, were conducted safely through the 
 mercurial com'se by watching them closely, and taking care 
 that the inflammatory state should not be allowed to rise high. 
 
 I have been thus particular in stating at what period the 
 sm-geon should wish ptyalism to commence when using 
 mercury for the cure of primary symptoms, because I am 
 firmly convinced that he cannot count upon a cure if the 
 salivation occur at a period much different from that above- 
 mentioned ; for should it be suddenly excited, and even 
 though not very profuse, it will yet leave the disease uncured ; 
 perhaps the primary symptoms may be removed by it, — 
 oftentimes they are not ; but at all events the secondary 
 symptoms will not fail to make their appearance, sometimes 
 in fuU vigour, though often under a more subdued form. 
 This I have seen repeatedly exemplified in cases of iritis 
 treated by calomel alone, or by calomel combined wiih 
 frictions. I have also repeatedly seen mercurial fumigations 
 which were used to stop a destructive ulceration of the throat 
 produce a speedy and profuse salivation, by which the 
 ulceration has generally been stopped, but in almost every 
 
ON THE ADMINISTKATION OF MEKCUEY. 65 
 
 such instance the other venereal symptoms were only checked 
 for the moment, to return with renewed vigour. And here I 
 must remark that, after such sudden and profuse salivations, 
 I have uniformly found the symptoms very unmanageable, 
 and by no means yielding in the usual way to a subsequent 
 use of mercury. 
 
 On the other hand, if the salivation be very late in 
 appearing, not only will the patient have to lament the loss 
 of so much valuable time, but the surgeon will too frequently 
 find that the system of his patient has been so irritated by 
 this protracted, though moderate use of mercury, that the 
 ptyalism excited at this late period is not borne with the same 
 ease by the constitution, nor is it productive of the same 
 improvement in the symptoms that would have resulted from 
 it, had it come on at an early period of the treatment. 
 
 If the above statements be correct, we cannot then comply 
 with the wishes of a patient who will tell us, "I will commence 
 the use of mercury at once, although for some days I must be 
 exposed to the weather, dine out, and be out at night ; this, 
 however, cannot be any prejudice to me, as there will be but 
 little mercury in my system ; but next week I wiU make 
 arrangements to attend to all your directions." This is a 
 most injurious mode of proceeding, for the great object which 
 is sought for by the administration of mercury is to be 
 attained by due attention during the first six or eight days ; 
 it is- during this most critical period that the greatest care 
 and even nicety in the management of the case is required ; 
 and it is then that trifling cu-cumstances may divert the 
 medicine from its proper course. Whereas if the peculiar 
 action of mercury be once estabhshed, then there is but little 
 danger of its salutary course being interrupted; so that a 
 man who is under its legitimate influence may be exposed to 
 cold, or may even commit shght excess or irregularity in 
 living, with much greater impunity than one who has only 
 commenced the use of mercury, and on whose system it has 
 not yet exerted any salutary influence. If ua this latter case 
 its action be interrupted by cold or fever, or any other cause, 
 all wUl go wrong, the constitution will only suffer a certain 
 degree of irritation, and the disease will continue unsubdued ; 
 
 F 
 
66 ON THE ADMINISTRATION OF MERCURY. 
 
 much time, therefore, must be lost in allowing these 
 unfavoui-able effects to pass away, and greater care and 
 judgment must be exercised when next we resolve on resuming 
 the use of the medicine. Therefore in such cases, when the 
 patient is unable to pay the necessary attention to his health, 
 it will be more prudent to postpone the use of the mercury 
 altogether for eight or ten days rather than commence it 
 under the disadvantages of exposure to cold, or of any 
 irregularities in diet, mode of life, &c. 
 
 The remarks which I have ventm-ed to offer on the 
 administration of merem-y for the cm'e of primary symptoms 
 will enable us to adapt the use of this medicine to the 
 treatment of other diseases in which it has been found most 
 valuable. Whenever, then, we employ this medicine for the 
 cure of any other disease which is not actually threatening 
 destruction to the textm-e and functions of the parts in which 
 it is seated, or which does not endanger life, we should 
 observe the same rules and cautions as have been laid down 
 for its use in the treatment of SyphDis. Thus, in cases of 
 sciatica, of organic affection of the heart, attended with 
 orthopnoea and effusion into the chest, the ptyalism established 
 on the sixth or seventh day may be kept up without injm'y for 
 ten or fifteen days longer, if the obstinacy of the symptoms 
 should requke it ; whereas, in cases of destructive ulceration 
 of the throat or nose, or in very acute iritis, or in cases of 
 inflammation in a large joint where we dread that suppuration 
 will take place, we can only arrest these serious evils by a 
 sudden and violent action of this remedy. Here we run the 
 chance of exciting profuse salivation by the very rapid manner 
 in which we pour in the mercury. Now, in such diseases, we 
 know by experience that a protracted use of this medicine is 
 not called for, and we are well aware that the progress of 
 these dangerous diseases is at once arrested the moment that 
 the system acknowledges the full action of the mercury ; and 
 this check having been once given to the rapid and dangerous 
 progress of the symptoms, we have it in our power by other 
 means to subdue what may have been left uncured by the 
 mercury. 
 
 I am thus anxious to state my opinion as to the importance 
 
ON THE ADMINISTKATION OF MEECUBY. 67 
 
 of ptyalism, inasmuch as it is my firm conviction that the 
 most essential part of a course of mercury is to effect this 
 object with as little injury to the general health as possible. 
 Indeed, I feel satisfied that many of those failures which we 
 hear of in the treatment of Syphilis by mercury, as well as of 
 other diseases by the same remedy, are to be attributed to an 
 inattention to this very important part of a mercurial course. 
 Without a knowledge of the difficulties which he has to 
 encounter while endeavouring to excite ptyalism, the surgeon 
 will not only be unable to steer his patient with safety, 
 through the sudden and unexpected changes which occasionally 
 occur, but he will also have much less prospect of conducting 
 him to a final and a perfect cure. I have no doubt that it is 
 in consequence of the doubts and difficulties which have 
 arisen from this cause, namely, inattention to, or imperfect 
 observation of, the various early effects to which mercury 
 gives rise, and ignorance of the proper remedial means in 
 each case, that there have arisen of late years so much 
 discrepancy and vacillation in the treatment of the venereal 
 disease, and which may justify some in adding its name to 
 the list of those diseases which may be considered as an 
 opprobium to the art and science of surgery. I must add, 
 that for whatever disease, whether medical or surgical, a 
 moderate and continued action of mercury may be employed, 
 it behoves the practitioner to be as well acquainted with, and 
 as watchful of, its early effects, as he should be when he 
 employs it for the cure of the venereal disease. 
 
 When once the system has been brought under the influence 
 of mercury, there is but little difficulty in the further manage- 
 ment of the case ; and in my opinion, there is but little to 
 fear even from its protracted use, provided that mere ordinary 
 attention be paid to the general health, and that care be taken 
 not to allow the action of the medicine to pass beyond the line 
 which has been already pointed out. At the same time, if it 
 be our object to keep up a certain degree of ptyalism, we 
 should be very careful not to allow the action to subside too 
 low or too soon ; we are to be guided by the state of the gums, 
 cheeks, and fauces, rather than by the quantity of saliva 
 which is secreted, and we are not to allow the tumefaction of 
 
68 ON THE ADMINISTRATION OF MERCURY. 
 
 the former to subside very much, but should occasionally 
 renew the use of the mercury or increase the dose as soon as 
 we find that its influence begins to decline. The observation 
 of Mr. Hunter is not to be lost sight of : — 
 
 " The constitution and parts are more susceptible of mercury at 
 first than afterwards ; if the mouth is made sore and allowed to 
 recover, a much greater quantity may be thrown ia a second time 
 before the same soreness is produced; and, indeed, I have seen 
 cases where it could not be reproduced by as much mercury as 
 could possibly be thrown in. Upon a renewal of the course of 
 mercury, therefore, the same precautions are not necessary as at 
 fii-st." 
 
 The plan which I have found most successful to reproduce 
 the ptyalism when it has sunk too low is to give pretty smart 
 doses of calomel, viz., three grains, with one of capsicum, 
 two or three times a day, at the same time that the former 
 doses of the ointment are resumed. 
 
 I shall next advert to some of the untoward circumstances 
 which occasionally occur during a course of mercury, and 
 which frustrate our plans, as also those more dangerous 
 effects which often arise in the early period of its exhibition, 
 and at the same time point out the means of avoiding or of 
 removing those obstacles and dangers. 
 
 Almost every individual possesses some peculiarity of 
 constitution, or, as it is termed, some idiosyncrasy which is 
 often very remarkably exemplified in the effects of certain 
 articles of diet and of medicine, but particularly in those of 
 mercury. As such peculiarity cannot by any degree of 
 foresight be ascertained to exist, it is a judicious rule to 
 observe that, before we commence a course of mercury we 
 should inquire, had the individual ever used mercury on a 
 former occasion, and if so, whether it had produced any 
 pecuUar or dangerous effect. 
 
 In the first place, we sometimes meet with persons so 
 susceptible of the action of mercury that ptyalism will be 
 induced even by a single dose. As this almost sudden 
 influence of mercury on the system is very seldom serviceable, 
 especially in Syphilis, we should endeavour to obviate it; 
 such a patient should therefore be directed to keep very much 
 out in the open air, to take a nutritious diet, and two or three 
 
ON THE ADMINISTRATION OF MEECUBY. G9 
 
 glasses of wine daily ; the dose of the medicine also should be 
 reduced to one-fourth, and an interval of one, two, or even 
 three days left between each, and thus we should endeavour 
 to effect what Mr. Hunter calls " an accumulation of mercury 
 in the system." When we have succeeded so far, we may 
 prescribe larger doses or shorten the periods between them, 
 so as to excite ptyalism, which will then occur without any 
 unfavourable symptoms. Salivation once excited, must then 
 be directed or governed according to the judgment of the 
 surgeon, whose discretion will guide him as to the quantity of 
 mercury to be administered, as well as to the frequency of the 
 doses, and the length of time it is to be continued. 
 
 Again, we meet with cases in which a very slight effect only 
 of mercury is perceptible about the fourth day; in such it 
 will be necessary to increase the power of the medicine, 
 consequently we should increase the quantity either externally 
 or internally, or both. There can be no precise rule laid 
 down as to the extent to which the dose is to be increased ; it 
 certainly ought not to be less than by one-half, and sometimes 
 it may be doubled at once : the former proportion wUl 
 probably be the better. If the patient have been employing 
 mercury both by friction and internally, the dose of both 
 should be increased ; but if he have been using friction alone, 
 then this should be continued at an increase of one-half, and 
 he should take in addition five grains of blue pill every night. 
 If in such cases we did not early increase the doses the system 
 would become familiarised to the mercury, and at a late 
 period we should employ very large doses, and thus rxm the 
 risk of exciting a profuse and dangerous salivation. 
 
 We sometimes find in other constitutions that two or three 
 doses of mercury induce a feverish state of the system without 
 the peculiar foetor of the breath, or any of those other 
 symptoms that indicate the approach of ptyalism : the skin 
 will be hot, the pulse quick, with great general restlessness ; 
 under these circumstances, we infer that the mercury is 
 disagreeing with the system, and should we now either 
 continue its use or increase the dose, we shall only add to the 
 mischief by increasing the fever ; and if we stiU persevere, we 
 may endanger the life of the patient; in general, however, 
 
70 ON THE ADMINISTEATION OP MERCURY. 
 
 he is soon reduced to such extreme weakness, and is so 
 sensible of becoming daily worse, that he will himseK oppose 
 any further use of the medicine. Whenever this febrile state 
 of the system, unaccompanied by any sign of its acting on 
 the sahvary organs, is thus early induced, we should at once 
 desist from the further use of mercury, and endeavour to 
 allay the fever by exposure to cold air, and by the adoption of 
 such other means as may be best suited to the circumstances 
 of each case. Having accompHshed this, we must allow some 
 time for the recovery of strength before we venture to resume 
 the mercury; and when we do so, we should begin with 
 smaller doses, and these at longer intervals ; for experience 
 has shown us that the former quantities were such as 
 overpowered the system. We must also endeavour to obviate 
 any febrile action by occasional purging, by tepid bathing, 
 and by the frequent use of mild diaphoretics ; we are now to 
 proceed cautiously, increasing the strength and frequency of 
 the mercurial doses, until we gain the desired object, namely, 
 a genuine and wholesome salivation. Here I would observe 
 that this difficulty is not an uncommon consequence of 
 plunging a healthy vigorous patient into a course of mercury 
 without any previous preparation. 
 
 Not unfrequently we meet with individuals who appear to 
 evince an obstinate resistance to the effects of mercury 
 without having any fever induced. Such patients, when 
 questioned on the subject, inform us that they had a shght 
 mercm-ial fcetor on the second or third day ; that it did not 
 continue longer than for a few hours; that they do not now 
 find any effect except an increase of appetite, there is no fcetor 
 of the breath, no restlessness, no febrile excitement : in a 
 word, the medicine seems to have made not the least 
 impression on the system, excepting, perhaps, a slight 
 improvement in the appetite. The surgeon how increases the 
 dose of ointment, but without any sensible effect, and then 
 perhaps suspecting that the external absorbents are not in a 
 state of sufficient activity, endeavours to ensure the full 
 operation of the mercury by directing some favourite 
 preparation for internal use, while he still continues the 
 external application ; yet after six or eight days' trial of this 
 
ON THE ADMINISTEATION OP MERCUEt. 71 
 
 combination, he is surprised to find there is no impression 
 made on the system, except, perhaps, some slight emaciation. 
 Under these circumstances, too, it generally happens that the 
 chancre, or -whatever the original disease may have been, 
 pursues the same steady quiet course as we observe when it is 
 left entirely to itself. What is the practitioner to do in such 
 a case as this ? There is a choice between two courses only : 
 one is to relinquish the use of mercury, or at least to reduce 
 the dose ; the other is to increase the dose, from the idea that 
 those hitherto administered had been too small and too weak 
 for this patient. When the latter course has been adopted, 
 I have known two drachms, and even half an ounce of the 
 ointment, ordered to be rubbed in each night and morning, 
 and at the same time large doses of Pil. Hydrarg. Calomel or 
 Hydr. Calcinat., given internally for some days : the result of 
 this practice has been that, in some cases, it has produced 
 that general weakness and that tendency to faintness which 
 marks the approach of erethismus. The surgeon, alarmed at 
 these symptoms, decides on suspending the use of mercury ; 
 to this the patient readily assents, though at the same time 
 he expresses his disappointment at the inefficacy of the 
 practice which has been pursued, as well as his regret at the 
 time which has been lost. 
 
 In some of these cases, however, we find that these 
 alarmingly large doses of mercury do excite a ptyalism ; but 
 not that gentle, manageable kind which it is our anxious wish 
 to obtain, but rather a sudden, a violent, and an ungovernable 
 action which overwhelms the system and threatens destruction 
 to life. The day preceding the appearance of this violent 
 salivation, the patient announces its approach by informing 
 us that he was feverish and restless the precedmg night, that 
 he has great headache or tormina, or dysenteric dejections 
 from the bowels ; on the following days his cheeks and lips 
 are enormously swollen, there is a copious and incessant flow 
 of saliva, and the tongue is protruded and swollen, the speech 
 is impaired, and deglutition is so inpeded that he cannot even 
 drink without much difficulty. Haemorrhage from the gums 
 to a pretty large amount in many instances occurs repeatedly; 
 the tongue continuing swollen and protruded ; its edges, more 
 
72 ON THE ADMINISTKATION OF MEECUKIT. 
 
 particularly on their lower surface, become indented and 
 ulcerated from the pressure of the teeth. When awake he 
 hangs his head over some vessel to receive the saliva, which 
 flows copiously and incessantly; and when overcome by 
 fatigue he attempts to sleep, the sahva stUl flows, and bathes 
 his pillow with a fcetid moisture; his sleep is broken and 
 unrefi-eshing, and is frequently interrupted on a sudden by an 
 alarming sense of suffocation, induced partly by the swelling 
 of aU the sahvary and mucous structures about the mouth 
 and fauces, and partly by the accumulation of the viscid 
 saliva which he is unable to swallow. After two or three 
 weeks passed in this way with but little alteration, the saliva 
 at length becomes more thick and ropy, the sweUing of the 
 face, tongue, and fauces subsides, and the patient feels a 
 strong desire for food, but is totally unable to take any in a 
 solid form, and he suffers exquisitely in attempting to swallow 
 any, even the blandest fluid ; and thus he is harassed on the 
 one hand by a craving for food and nourishment, and on the 
 other by the apprehension of acute pain attending every 
 attempt at mastication or deglutition. At length, however, 
 the swellings subside, the ulcers of the mouth heal, and a 
 general improvement in the health occurs ; yet even then he 
 often has to lament the continuance of some of the various 
 and serious effects which the excess of mercui'ial action seldom 
 faUs to excite, such as loosening of the teeth, pain, and even 
 caries and exfoHation of the alveoli, or of the jaw bone; some- 
 times the tongue contracts adhesions to the cheeks, &c. &c. 
 It will naturally occur now to inquire, can the patient be 
 assured, as some recompense for all the sufferings he has 
 undergone, that the disease for which the mercury has been 
 administered is cm-ed ? In many cases this benefit has been 
 gained, though doubtless dearly pm-chased; but in many 
 other instances, the sui-geon as well as the patient observe 
 with regret, and even with dismay, that although the chancre 
 has nearly healed, yet dm'ing the last few days it has 
 remained stationary, and also that there is more surrounding 
 hardness than is consistent with the healthy action in the 
 part. It would be needless to comment on the judgment 
 or the feeling of that practitioner who could, imder such 
 
ON THE ADMINISTRATION OP MEECURY. 73 
 
 circumstances, recommend the patient to resume the use of 
 mercury. 
 
 It is fortunate for mankind and for the character of surgery 
 that we possess the means of avoiding many, if not all, these 
 evils, by a due attention to certaia principles; in the first 
 place, when we learn on due enquiry that the system of our 
 patient had on former occasions been nearly insensible to the 
 action of mercury, when administered in the ordinary doses, 
 we must conduct the plan of treatment according to such rules 
 as experience has proved can generally, even in such habits, 
 excite ptyalism with ease and safety, and only to such a 
 degree as can be perfectly controlled. In such habits then we 
 should employ mercury by beginning with smaller doses than 
 in ordinary, and at longer intervals, or, if we have already 
 commenced with the ordinary doses and periods of adminis- 
 tering, we should not obstinately persevere in the use of this 
 medicine, but should piu-ge the patient repeatedly, enjoin low 
 diet, and the frequent use of the tepid bath. It has sometimes 
 happened that, during the employment of these last mentioned 
 means, a safe and mild ptyalism has supervened a few days 
 after the mercury has been laid aside. This apparently 
 anomalous fact is no weak proof that the cause of our failing 
 to produce the desired effect in the first instance was owing to 
 the mercury having been administered in an injudicious, and, 
 as it were, in too forcible a manner. But if, with this 
 treatment, no signs of ptyalism should appear, we must still 
 persevere in the same constitutional means until we conceive 
 that the system is totally free from all mercurial impregnation ; 
 to induce this state may occupy twelve or fifteen days. We 
 then commence a new course of mercury, and, taught by our 
 former experience that full doses of the medicine failed to 
 produce the desired effects, we now direct it in very small 
 doses, but at the same time we persevere in the same 
 constitutional remedies as before : after a few days passed in 
 this way we are sometimes pleased to find the signs of an 
 approaching salivation gradually advancing in the very 
 manner we are so desirous to effect. It appears to me that 
 this very precept which has just been inculcated is the great 
 secret which will serve to guide us in the management of 
 
74 ON THE ADMINISTRATION OP MERCURY. 
 
 those cases which have hitherto often excited great uneasiness 
 in the mind of the surgeon ; and it is a remarkable fact that 
 this obstinate state of the system to admit of the influence of 
 mercury is not unfrequently met with in those very patients 
 who, on former occasions, had been sahvated rather too 
 quickly with the ordinary doses of mercuiy, and that, too, by 
 the very same surgeon who is now so baffled in his attempts 
 to produce the same effect. If sm-geons of much practical 
 experience will endeavour to recal to their recollection all the 
 cu-cumstances of such cases, I beheve they will find, that on 
 the latter occasions in which they had to treat such cases, 
 they were very anxious that the effects of the mercm-y should 
 be quickly established ; now, in my opinion, this very anxiety, 
 by inducing the surgeon to urge the mercury too freely, has 
 been one source of its failm-e, and of the disappointment of 
 his surgeon. 
 
 In the course of my practice I have met with eight or ten 
 individuals who appeared to be wholly exempt from the 
 influence of mercury as a sialogogue, and yet I must admit 
 that these persons were cured of their venereal complaints ; 
 and it appears a remarkable fact that their primary symptoms 
 yielded exactly in the same manner, though at later periods, 
 as in those patients whose constitutions evinced the influence 
 of mercury on the saHvary system. The greater number of 
 these ii-regularities or peculiarities to which I have alluded 
 were met with in one family of five sons, in each of whom I 
 experienced the same constitutional character or property of 
 resisting the saHvating influence of mercury; each of these 
 young men had been under treatment for venereal symptoms 
 more than once, and had been on each occasion under the 
 care of a different surgeon, so that the failure of exciting 
 sahvation, or making any impression on the salivary system, 
 coidd not be attributed to any peculiar mode of management 
 of mine, but solely to the idiosyncracy of these individuals : 
 I may add that each of these young men so far bore mercury 
 well that they did not suffer any feverish excitement, loss of 
 appetite, severe dysenteric attack, or nervous debility from its 
 use. Such constitutions, I presume, are very rare indeed. 
 
 I have not any particular remarks to offer as to the 
 
ON THE ADMIKISTEATION OF MERCURY. 75 
 
 respective merits of the various preparations of mercury. In 
 my own practice I have confined myself to a few of those 
 which I considered the least likely to distm-b the stomach and 
 bowels. I have long thought that if as much talent and 
 industry had been applied towards learning the best mode of 
 administering mercury, and of regulating its effects, as have 
 been employed in compounding new preparations of this 
 mineral, we should not at the present day be in such 
 uncertainty, and even ignorance, as to the best mode of 
 conducting the treatment of the venereal disease. 
 
 On the manner of using fumigations I shall offer merely 
 a few remarks. 
 
 In the first place, I believe it is an erroneous opinion to 
 suppose that ptyalism can be excited by mercurial fumigations, 
 applied to the sound skin only. I have frequently seen it 
 thus applied without produeing the slightest effect.* When 
 it has appeared to have excited ptyahsm, I fancy that this was 
 caused by some portion of the fumes passing into the mouth 
 and throat. When directed upon an ulcerated surface it will 
 often produce this effect ; and I need not add, that when 
 applied for an ulcer in the throat, it will generally cause a 
 pretty smart ptyalism in the course of two or three days. 
 
 [Oolles's assertion that it is an erroneous opinion to suppose that 
 ptyalism can be excited by mercurial fumigations applied to the sound 
 skin only, completely coincides with my own observations. "When a 
 student I frequently ordered, under the direction of the late Dr. Hutton, 
 
 * Amongst CoUes's manuscript notes, apparently intended to be used 
 in the second edition of this work, which, however, he did not Hve 
 to accomplish, I find the following :— " 2nd January, 1841. Sir Benjamin 
 Brodie's opinion as to the superior efBcacy of merouiy in the cure of 
 SyphiUs. Cusack having commissioned Bobert Todd to accompany his 
 patient, Mr. P., to Sir Benjamin Brodie, writes the following as the 
 opinion expressed by Sir Benjamin :— ' He thinks that effects of mercury 
 are not to be feared at all in comparison with those of Scrofula, and that 
 the syphilitic poison often excites the scrofulous action unless overcome 
 by mercury. He thinks the safest mode of administering mercury is by 
 fumigation. He subjects the whole body to the process, but finds it always 
 necessary to include the mouth, and consequently believes that it acts 
 more through inhalation than through the skin. He has no reliance on 
 any other mode of overcoming the effects of Syphilis but Mercury.' " 
 
76 ON THE ADMINISTEATION OP MEEOUEY. 
 
 calomel ointment for the treatment of psoriasis and lepra, not S3rphilitic. 
 Those who were acquainted with the practice of this eminent surgeon 
 will remember that he frequently prescribed an ointment consisting of 
 one drachm of calomel to an ounce of lard, to be frequently rubbed over the 
 surface of the body in such cases. I was struck by tlie fact that this mercurial 
 preparation, so active when given internally, never mercurialized when 
 rubbed over the skin in the form of ointment. I have known pounds of 
 it to be used, — rubbed-in in ounces daily over the entire body, — but I 
 never knew a case to be salivated by it. Later, when turning my 
 attention more to tlie subject, I found that mercuriaHzation did not 
 follow even the very frequent use of the calomel vapour-bath, — ^provided 
 the patient did not let his head into the vapour and inhale the sublimated 
 calomel. "When a patient leaves the calomel vapour-bath, if we scrape 
 the surface and examine in the microscope what has been there 
 deposited, we find the sublimated calomel in crystals — a form Ul-adapted 
 for cutaneous absorption. Doubting that it was ever absorbed in this 
 way, I made some experimental observations. Some ounces of finely- 
 levigated calomel were tied in a muslin bag. Every day, after coming 
 out of an ordinary warm bath, the patients were dusted over with the 
 calomel in the bag, from the waist down. I have myself rubbed ounces 
 of calomel over the legs, abdomen, and scrotum, leaving the patient as 
 white as a miller with it, but I have never found it salivate the patient.] 
 
 The process of fumigation may be conducted in an easy and 
 comfortable manner by directing the intended dose of cinnabar, 
 or grey oxide of mercury, to be mixed with melted wax, and 
 with a cotton wick be moulded into a small candle. This 
 may be stuck on a common plate, and then burnt under a 
 curved glass funnel, which is to be raised about an inch from 
 the plate. By conductiug the process in this way we are 
 certain that all the mercury is consumed, which is but seldom 
 effected in the ordinary mode of throwing it on heated metal ; 
 the fumes, too, are thus more gradually brought into contact 
 with the diseased surface ; and the patient, if fatigued, may 
 blow out the candle and suspend the process until he feels 
 able to resume it. 
 
 As to the general directions which the practitioner should 
 give his patient from the time the mercurial course has termi- 
 nated, until he is able to resume his usual avocations, I con- 
 sider the principal caution to impress is to avoid exposure to 
 wet or damp, to cold, or to night air; the bowels should 
 be attended to, and an occasional tepid bath may be enjoined, 
 more particularly as this advice usually accords with the 
 
ON THE ADMINISTRATION OF MEECURY. 77 
 
 patient's feelings, there being a vulgar, but a very general, 
 impression that it is useful in taking the mercury out of the 
 system. Patients, after mercury, are often delicate, and more 
 subject to cold ; hence a great liability to rheumatic pains, 
 and hence, I believe, to guard against exposure to cold is the 
 best advice can be given to those who are recovering from a 
 mercm'ial course. It is a matter of common observation that 
 persons, after a mercurial course, not only recover their flesh 
 very quickly, but even manifest a great tendency to corpulency. 
 
 Of late years surgeons have become very well acquainted 
 mth a peculiar eruption which is occasionally induced by the 
 use of mercury ; this affection is named Erythema mercuriale. 
 
 It was, I believe, first described by Dra. Alley and Moriarty, 
 of this city, and more lately and fully by Mr. John Pearson. 
 Of this affection I shall in the first place remark that we may 
 observe some slight indication of an approaching ptyalism at 
 the very time that this rash appears. It is therefore to be 
 looked for in the early periods of the mercurial course. Some- 
 times it scarcely attracts the attention of the patient for the 
 first two days, and not until the uneasy sense of itching, which 
 it excites, shall have deprived him of a night's rest, and then, 
 when he complains first of it, it may be found widely spread 
 over the limbs and body. During the earlier period of a 
 mercurial course, therefore, we should frequently examine the 
 surface of the body, more particularly the angular fold at 
 either groin, as also those between the scrotum and each 
 thigh ; for it is in these situations that this eruption usually 
 makes its first appearance, in whatever form mercury be used. 
 On the slightest symptoms denoting the approach of this 
 affection the surgeon should instantly discontinue the mercury, 
 purge the patient, and, should the disease advance farther, he 
 should expose him to the open air as freely as the state of the 
 weather will permit. 
 
 The degree and kind of fever which attends this eruption is 
 very various, and seems to be influenced partly by the previous 
 habit and constitution of the patient, but still more by the 
 severity and duration of the eruption. I could not find that 
 any particular type of fever necessarily or even generally 
 accompanied it. Indeed, unless the disease be severe, we 
 
78 ON THE ADMINISTEATION OF MEKCXIBY. 
 
 take no note of the fever, so very slight is it, and so little 
 different from that which attends the ordinary action of 
 mercury v?hen inducing ptyalism : and here I would remark 
 that instances of a severe case of this disease are so rare 
 that I have not met with more than one continuing beyond 
 eight days diu-ing the last three years. In a word, it seems 
 to me that the severity of this disease has been owing to the 
 eruption having escaped notice, and to the use of mercury 
 having been continued for two or three days after the rash had 
 appeared, rather than to any peculiarity of constitution. 
 However, we must expect now and then to meet vnth a rare 
 instance of a severe case. The treatment of the fever in such 
 cases must be regulated by the existing symptoms. 
 
 With respect to local treatment, I believe that dusting the 
 excoriated parts with any of the mild drying powders will be 
 found to afford as much relief as any other application. 
 Sometimes the application of cloths, wetted with black wash, 
 has procured rehef, and has appeared to promote the forma- 
 tion of cuticle. In a very severe case it will be necessary to 
 have the sheets, in which the patient is laid, prepared so as to 
 prevent them from sticking to the skin ; I think that this is 
 very effectually done by a mild ointment of rather a stiff con- 
 sistence. The common one, made of equal parts of suet and 
 bees'-wax, spread as thin as it can be spread by holding the 
 spatula on its edge, wUl answer extremely well. I do not 
 pretend to say that some other composition may not be 
 discovered which will better promote the healing of the 
 excoriated surface, but whatever it be, I should recommend it 
 to be made of a firm consistence, for the softer ointments, by 
 the heat of the body, are found to run quickly through the 
 sheets, and consequently to leave the surface which is applied 
 to the body nearly dry. 
 
 I may next remark that an obvious amendment takes place 
 in the symptoms of the venereal disease on the first appearance 
 of this eruption, and that in a degree more striking than that 
 which attends so slight a degree of ptyalism. 
 
 What is most worthy of remark is this, that we never find 
 this eruption to make its appearance while the system is 
 under the influence of ptyalism. So that, after we have 
 
ON THE ADMINISTRATION OF MERCURY. 79 
 
 ptyalism fully established, we may dismiss all our fears 
 on account of this rash. But let us not be lulled into a false 
 security merely because this symptom may not appear in the 
 early part of a mercurial course ; for in some instances it 
 does not appear until the mercury has been used for a con- 
 siderable time. 
 
 I recollect the case of a young woman affected with an 
 induration of one of her breasts, for which I had directed 
 small doses of Pil. Hydr. combined with Extr. Conii. No 
 sensible mercurial effect having been produced at the end of 
 three weeks, I increased the dose of the pills ; the result was 
 very speedily a slight degree of ptyalism, and with it very full 
 eruption of mercurial erythema, which proved tedious, obsti- 
 nate, and alarming. 
 
 In this case it is obvious that the eruption attended that 
 slight febrile excitement of the system which mercury so 
 generally occasions when it is just about to act on the consti- 
 tution. During the first three weeks of its use the mercury 
 had not produced any sensible effect, and therefore had not 
 excited this eruption. We may, in fact, declare that at what- 
 ever period of a course of mercury the mercurial fever is first 
 suddenly excited, there is danger of the erythema. Hence it 
 should be a rule with those who are conducting a course of 
 mercury to watch carefully the earliest effects of each increase 
 in the doses of the medicine, and to question the patient 
 minutely, that he may get the earliest notice of the presence 
 of this affection. When once the first burst of mercurial 
 fever is over, and ptyalism has been fairly established, then 
 the surgeon may carry on the mercurial process to any length 
 of time necessary (provided he do not allow the action of 
 the mercury to subside), and yet be under no apprehension of 
 an attack of this rash. The following case is well deserving 
 of attention : — 
 
 Oct. 22, 1807. — Burrows, a dragoon, was admitted with a 
 chancre on the frsenum : on this and the succeeding night he 
 rubbed in half a drachm of mercurial ointment, and on the 
 morning of the 24th he was found affected with mercurial ery- 
 thema ; this attack quickly subsided without the use of any other 
 medicine than the Mistura Salina Diaphoretica of the hospital. 
 
80 ON THE ADMINISTBATION OF MERCURY. 
 
 On Not. 4th he was ordered Calomel gr. ij sing. noct. ; this 
 he continued until Dec. 4th, when he was directed to take the 
 same quantity mane et nocte. On Dec. 5th mercurial 
 erythema again appeared; the mercury was laid aside and 
 resumed on Dec. 19th. Calomel gr. ij omn. nocte, which 
 dose he continued until Dec. 26th, when he was discharged 
 cured. 
 
 I need not point out how smaU the quantity of mercury was 
 which excited the first attack of the disease in this case ; but 
 it is worthy of notice that when the dose of calomel was 
 doubled, on Dec. 2nd, it produced another attack of this 
 affection, although his system had been for twenty-eight days 
 accustomed to the simple dose ; hence I infer that the attack 
 of this eruption is produced, and is to be looked for whenever 
 the mercurial impetus or fever is expected, whether at the 
 commencement of the mercurial course or at a late period, in 
 a protracted use of mercury whenever the dose is quickly 
 increased. 
 
 It may not be amiss to observe that on the declining of the 
 first rash the chancre unproved ; that it remained stationary, 
 or nearly so, during the entire period of his taking the single 
 dose of calomel, and that it healed very rapidly as the second 
 rash began to subside. This case also proves that the in- 
 ternal, as well as the external, use of mercury will excite this 
 affection. 
 
 There are some persons whose skin wiU become affected 
 with this eruption by an inconceivably small quantity of 
 mercury, such as a single blue pill, or a few grains of mercurial 
 ointment which may have been used perhaps for the mere 
 purposes of cleanliness. It may be asked, how are we to 
 manage the case of such an individual when affected with 
 Syphilis, for we are told that this cutaneous disease is worse 
 than that for the cure of which the mercury is required : it 
 happens, however, fortunately that this peculiarity of con- 
 stitution is very rare, and it is a stiU more fortunate circum- 
 stance that we have it in our power to bring such a system 
 into a state which wUl bear whatever quantity of mercury 
 may be required for the cure of even the most obstinate form 
 of venereal disease. The plan to pursue in such cases is 
 
* ON THE ADMINISTEATION OF MEBCURY. 81 
 
 this : in addition to purging and warm bathing which have 
 been alluded to before as a judicious preparatory course, we 
 should enjoin the patient to wear lighter clothing than usual, 
 to exercise in the open air during the greater part of the day, 
 to keep the windows of his sitting-room pretty constantly open, 
 to keep on light covering at night, to live abstemiously, and 
 on food of the least stimulating quality. The mercury should 
 be administered at first in extremely small doses, and at long 
 intervals ; by degrees the former may be increased and the 
 latter shortened, in proportion as we find the medicine to 
 agree with the system. By this sort of management I have 
 treated some such individuals, both for primary and secondary 
 symptoms, and have at length brought them to bear the fullest 
 doses of mercury. No doubt this plan or process is very 
 tedious, 'but it is a certain mode of curing the disease, and 
 is free from the risk of inducing this cutaneous affection, 
 which is certainly among the most formidable effects of 
 mercurial action. 
 
 The remarks which I have offered on the mercurial erythema 
 will apply only to the generality of individuals who are 
 subject to it, and by no means to those (fortunately) very 
 rare cases in which the susceptibility of this disease is so very 
 great that it is constantly excited by the smallest portion of 
 mercurial medicines. Let us take the following as an 
 example : — 
 
 Mr. E. applied to me, 12th August, 1813, for the cure of a 
 chancre. I had treated him in 1810 for a similar disease, and 
 was then made fully acquainted with his extreme tendency to 
 mercurial erythema. Having premised a tepid bath and some 
 active purging medicine, I commenced by directing a pill of 
 Hydr. Acet. gr. ss. and Pulv. Antim. gr. ij. to be taken every 
 night. On the second day a slight rash appeared on the 
 inside of his thighs ; of course the mercury was withheld for 
 a day. No improvement in the chancre attended this eruption. 
 The pills were continued sometimes every day, sometimes 
 every second day (according to the appearance of the rash) 
 until the middle of September, when the chancre took an 
 unfavourable turn, and showed a tendency to slough. Then 
 
82 ON THE ADMINISTEATION OF MERCURY. 
 
 the mercurial medicines were entirely discontinued. The rash 
 having disappeared for four days, the state of the ulcer 
 induced me to recommend the ordinary hlack wash (Calomel 
 and Aq. Calcis). This had been apphed for one day only, 
 when the rash reappeared, and with increased severity. On 
 resuming the mercury, on Oct. 3rd, I directed Hydr. Acet. 
 gr. ss., and Extr. Cicutse gr. i. No rash appearing, the dose of 
 the pills was doubled : the rash reappeared on 11th October. 
 After this the dose was cautiously increased to three, and 
 ultimately to four pills per diem. The chancre was very slow 
 in healing, but was completely healed on the 1st of November. 
 The mercury was continued some days longer, although a 
 shght return of the rash again obliged us to desist for a day 
 occasionally. During this lengthened course of mercury 
 Mr. E.'s general health continued good. No pty^thsm was 
 induced; the gums were not made sore, but the inside of 
 the cheeks assumed a leaden colour, and became a good deal 
 swollen during the last fortnight of the treatment. 
 
 Mr. E. gave me the following account of the effects of 
 mercury on his system : — Previously to the year 1806 he had 
 used mercury for cure of a chancre, and did not then 
 experience any but the ordinary effects from the use of this 
 medicine. In 1806 he again had occasion to use it for cure of 
 a chancre, and then he employed it, both internally and 
 externally, in very large doses. On this occasion it did not 
 affect his mouth ; but immediately after he had laid aside the 
 medicine he was attacked with mercurial erythema, which 
 affected him in a very severe and dangerous degree. Since 
 that period (and never before) he has experienced an .extreme 
 susceptibility to the action of mercm'y in producing this rash ; 
 for example, a very small portion of mercurial ointment 
 rubbed on the pubes, for the purposes of cleanliness, has 
 more than once produced it. A grain of calomel combined 
 with purgatives has had the same effect. 
 
 In this case I would remark that the venereal symptom did 
 not improve on the appearance of the rash as it does in less 
 susceptible constitutions. The mercury had not the effect of 
 producing ptyalism, though used for such a length of time. 
 The effects of the topical application of black wash affords 
 
ON THE ADMINISTEATION OF MEECUEY. 83 
 
 the strongest proof of the great susceptibility of this in- 
 dividual. 
 
 We should carefully distinguish between erythema mercuriale 
 and another, but more partial, eruption arising from the use 
 of mercury. They both come on under similar circumstances ; 
 both seem to be excited by the first impression of mercury on 
 the general system. Our attention is attracted to this latter 
 eruption by our patient informing us that he fears he has got 
 the itch — that he could scarcely get a wink of sleep for one or 
 more nights preceding. He then exhibits on his hands and 
 wrists an eruption beginning with small but very distinct red 
 papulae, some of which, in a more advanced stage, have 
 vesicles on their apices : they chiefly occupy the anterior 
 surface of each wrist, and of the fore-arm half way up to' the 
 elbow ; the backs of the hands and fingers are also thickly 
 beset with them. On first view this eruption closely resembles 
 a form of itch, in which the vesicles are small ; but on more 
 careful examination you discover that the clefts between the 
 fingers are altogether free from the former, while they are 
 known to be the principal seat of the latter. This eruption is 
 accompanied by a slight degree of fever, and generally by 
 marks of commencing ptyalism. 
 
 I cannot say what changes or effects on this eruption would 
 be produced by persevering in the use of mercury, because all 
 the patients in whom I witnessed this symptom were also 
 affected with a smart degree of fever, and complained so 
 bitterly of the itching and of the restlessness caused by it 
 that I felt afraid to go on with the mercury until the irritation 
 of this eruption had subsided. A few days' use of the anti- 
 phlogistic regimen, and abstinence from mercury at the same 
 time, were sufficient for the desquamation of the pustules, and 
 the removal of this rare effect of the mineral. 
 
 I need hardly observe that this eruption differs from the 
 mercurial erythema by the early appearance of the vesicles, 
 by the eruption being much more distinct and less thickly set 
 in the skin, by the parts of the body which it affects, and, we 
 may add, by its not extending to the other parts of the body, 
 and not seizing on the angles of flexion in the limbs, where 
 two skins occasionally lie in contact with each other. I 
 
84 ON THE ADIIINISTEATION OF MEBCURY. 
 
 suspect this effect of mercury is observed only in cases where 
 the patient is using mercurial frictions. Here, as weU as in 
 mercurial erj'thema, we observe a decided improvement in the 
 primary symptoms imiformly to occm-. 
 
 Having for some time noticed this eruption only among the 
 soldiers under my care ia the hospital, I at first suspected 
 that it was produced in a great degree by the oatmeal diet, to 
 which they are so much accustomed ; but subsequent observa- 
 tion has removed this error, and convinced me that it is 
 attributable solely to the use of mercury. Of course the use 
 of mercury must be resumed as soon as the itching has ceased 
 and the eruption begins to desquamate. 
 
 Another effect of mercury, allied perhaps to the foregoing, 
 which the sm-geon should watch for, is an excoriation of the 
 skill on the corresponding surfaces of the scrotum and thighs. 
 If this be discovered in its commencement it will be seen as 
 an excoriation in the very angle between the thigh and scrotum ; 
 from this it spreads over the entire extent of the opposed 
 integument of these parts, and a profuse discharge of a very 
 fcetid nature takes place. 
 
 We cannot well imagine a more distressing state than that 
 of a patient labouring under this affection ; at least no persons 
 more pathetically lament their condition. Not only are they 
 deprived of sleep by day and by night, but they cannot 
 attempt the slightest movement in the bed without inducing 
 severe pain and agony, and they most earnestly solicit some 
 reUef even of a temporary nature. It should also be carefully 
 remembered that in some instances, in addition to the parts 
 already mentioned, this disease wiU also affect the skin in the 
 vicinity of the anus, where the integuments of the nates lie 
 in contact with each other. Occasionally, too, we meet with 
 instances where this disease affects only the skin in the vicinity 
 of the anus, whUe the scrotum and adjacent skin of the thigh 
 remain perfectly free. 
 
 The degree of fever and suffering attendant on this excoria- 
 tion is so very severe that we must at once relinquish the use 
 of mercury. If the patient, through downright stupidity, or 
 from an anxiety not to disturb the course of treatment, should 
 conceal his sufferings from the surgeon for one or two days, 
 
ON THE ADMINISTRATION OF MERCURY. 85 
 
 the continued use of mercury will have the effect of 
 aggravating very considerably both his fever and his local 
 sufferings, hut it does not seem to make the excoriation spread 
 to other parts. 
 
 When this excoriation takes place we do not find that the 
 venereal symptoms are improved; they sometimes remain 
 stationary, but more frequently they become in a slight degree 
 worse, and they improve in proportion as the excoriation goes 
 on to heal. 
 
 The duration of this affection varies from eight to fifteen or 
 twenty days. For the relief of all these sufferings we find 
 opium unavailing ; it fails to procure any continued sleep. 
 The antiphlogistic regimen scarcely moderates the fever. The 
 most immediate and most effectual relief is procured by local 
 means, the most efficient of which is dusting the excoriated 
 parts with equal parts of lapis calaminaris and starch, very 
 finely levigated : this is to be laid on pretty thickly, and then 
 a fold of old linen interposed between the two adjacent skins. 
 Another application, which often procures immediate ease, 
 is the black wash of Aq. Calcis and Calomel ; the affected parts 
 are to be kept asunder by lint constantly moistened with this 
 lotion. 
 
 The following case affords an example of this effect of 
 mercury : — 
 
 Dennis Dempsey, set. ann. 20, admitted Dec. 13th into 
 Stevens's Hospital, No. 11 Ward. The penis and scrotum 
 are much swollen, red, and excoriated; the prepuce is par- 
 ticularly engaged in this swelling, causing a very great 
 enlargement of the anterior extremity of the penis. On the 
 lower surface of the prepuce are several superficial ulcers ; a 
 number of similar ulcers occupy the skin covering the body 
 of the penis. Excoriations also exist between the scrotum 
 and thighs, obviously caused by want of cleanliness. He is 
 pale, weak, and emaciated : has had ulcers within the prepuce 
 for some weeks past. 
 
 Prom 13th to 30th December he used black wash, tepid 
 bathing, and Pulv. Antimon. The inflammation and excoria- 
 tion having been then quite removed, he was ordered Ungt. 
 Hydr. Fort. 5 ss. om. n. and Pil. Hydr. gr. v. om. n. ; 
 
86 ON THE ADMINISTRATION OF MERCUKt. 
 
 by these his mouth was made sore in six days. On the 7th 
 the mercury was laid aside because his mouth was sufficiently 
 affected, and more especially because he complained of sore- 
 ness about the anus. On examination the surface of the skin 
 of the nates on each side of the anus, and from this along the 
 periaseum, appeared raw, wet, and red ; and yet it could not 
 be said to be excoriated, as there was no appearance of the 
 want of cuticle. On 20th January, this affection of the skin 
 having entirely ceased, I again put him on the use of mercury, 
 in the same doses and of the same preparations as before ; 
 and on 31st January (in eleven days) his mouth again became 
 very sore, with considerable ptyalism; indeed the action of 
 the mercury proved more severe than I had wished. Yet on 
 this latter occasion there was not the least sign of a return of 
 the excoriation and discharge. He was dismissed cured on 
 21st February. 
 
 I have never seen this effect of mercury in any patient, 
 except when I thought the action of the mercury was too 
 high. I do not pretend to say that too high an operation of 
 mercury is always attended by this effect; I only mean to 
 call the attention of the profession to this as one of the 
 marks by which they may know that mercury has made 
 too severe an impression on the system. It is satisfactory to 
 observe that a repetition of the same forms and doses of 
 mercm-y may be resorted to without producing the same 
 unpleasant effects. 
 
 The occurrence of each of these eruptions points out to us 
 the necessity for suspending the use of mercury ; but because 
 the patient has already suffered in this manner we should 
 watch with more anxiety the earliest opportunity for resuming 
 its use. Should we wait- untU all the constitutional tumult 
 raised by the mercury has entirely subsided, we shall not 
 only require a greater length of time and a larger quantity of 
 mercury to reproduce it, but by too long delay we may run 
 the risk of having our efforts to effect a cure again interrupted 
 by a recurrence of the very same symptoms. I have more 
 than once witnessed the ill effects of this mismanagement. 
 I have known cases of mercurial erythema produced by the 
 first three or four doses of mercury ; the surgeon then delays 
 
ON THE ADMINISTRATION OF MBRCUET. 87 
 
 to resume the use of mercury too long after the fever has 
 ceased ; at length he begins it by employing small doses, and, 
 through fear of reproducing the same state, contiuues these 
 small doses too long, until both he and his patient, being tii"ed 
 of the delay, he finds it necessary to venture on larger, per- 
 haps on double, doses; and the new impetus of mercury 
 occasioned by its exhibition in these quantities on the system 
 produces a renewed attack of erythema. 
 
 Let us, then, bear in mind these facts — that each and all 
 of these untoward effects of mercury are owing to the first 
 impression of the medicine on the system ; that on the 
 subsidence of this state the mercury may be used as freely 
 and as long as can be required for the treatment of any 
 venereal symptom (or indeed for the cure of any disease 
 curable by mercury) without the danger of reproducing the 
 same condition. Let us, then, during the early period of 
 a mercurial course, — say from the second to the twelfth day, — 
 anxiously watch and guard against these untoward occur- 
 rences ; but as soon as we have brought the system once 
 fairly under the influence of this medicine, let us dismiss all 
 fears and anxiety on this head, and now direct our whole 
 attention to the changes in the venereal symptoms, to the 
 degree of salivation, and to the strength and general health 
 of our patients. The salivation once fairly established we 
 may consider ourselves as having escaped the chief dangers of 
 a mercurial course, and as now being on the high road 
 to a certain cure. We now may be confident that the mercury 
 will not act (as it too often does) as a poison, instead of 
 its proving one of the most active and beneficial remedies in 
 the materia medica. 
 
 Of all the dangerous effects which may result from the use 
 of mercury, on the occurrence of ptyalism, the most alarming 
 is that which has been so well described by Mr. Pearson, 
 under the name of Mercurial Erethismus. 
 
 " This state is characterised by great depression of strength, a 
 sense of anxiety about the prfficordia, irregular action of the heart, 
 frequent sighing, trembling, partial or universal, a small, quick, 
 and sometimes an intermitting pulse, occasional vomiting, a pale 
 contracted countenance, a sense of coldness ; but the tongue is 
 
88 ON THE ADMINISTRATION OF MERCURY. 
 
 seldom furred, nor are the vital or natural functions much dis- 
 ordered." 
 
 Again he adds (page 158) : — 
 
 " The gradual approach of this diseased state is commonly 
 indicated by paleness of the countenance, a state of general 
 inquietude, and frequent sighing. The respiration becomes more 
 frequent, sometimes accompanied ■with a sense of constriction 
 across the thorax ; the pulse is small, frequent, and often inter- 
 mittiag, and there is a sense of fluttering about the prsecordium. 
 When these, or the greater part of these symptoms are present, a 
 sudden and violent exertion of the animal powers will sometimes 
 prove fatal ; for instance, walking hastily across the ward, rising 
 up suddenly in the bed to take food or drink, or slightly strugghng 
 with some of their fellow-patients, are among the circumstances 
 that have commonly preceded the sudden death of those afflicted 
 with the mercurial erethismus." 
 
 I imagine that, in general, this dangerous effect of mercury 
 comes on suddenly, and is actually estabhshed before the 
 surgeon has due notice of its approach. It may, however, be 
 useful to observe that I have very frequently remarked this 
 affection to have been accompanied with an intense desire for 
 some acidulated di'iak; and although the patient remarks 
 that a sUght exertion induces palpitation, yet his countenance 
 remains unaltered, or it may perhaps be somewhat paler than 
 usual. 
 
 Although palpitation of the heart is the prominent symptom 
 in this disease, we are to consider it only as one of a series of 
 those effects which mercury produces when it acts as a poison, 
 and not as owing to any pecuhar tendency to injure that vital 
 organ ; for when mercury acts favourably on the system it is 
 80 far from producing any specific bad effect on the heart 
 that in diseases of this organ, attended with anasarca, 
 orthopntea, and effusion into the chest, it affords considerable 
 relief ; so much so that the patient himself acknowledges its 
 utnity, as soon as the gums become affected, by joyfully 
 announcing to us the glad tidings that he is now enabled to 
 he down, and even to enjoy sound sleep. Erethismus, then, is 
 caused by merem-y acting in the manner of a poison on the 
 constitution. I never knew an example of its occurring 
 after ptyalism was fully established : if a patient once have 
 
ON THE ADMINISTEATION OF MEKCUEY. 89 
 
 a regular sore mouth we may continue the use of mercury to 
 an indefinite period, and in any doses, without the risk of 
 producing mercurial erethismus. When I say this I speak of 
 what accords with my own observation of this affection ; for 
 I am aware that Mr. John Pearson says the subjects were men 
 who had nearly, and sometimes entirely, completed their 
 mercurial course. Now, according to my observation, 
 this affection comes on at a late period of a mercurial course 
 only in those cases where an increased dose has at length 
 been employed with a view of inducing ptyahsm, or where the 
 ptyalism was slow in coming on ; or where that which had 
 been first excited has been allowed to subside, and that we are 
 endeavouring to renew it, or rather to reproduce it. I have 
 never seen any instance of its affecting a patient who had 
 entirely completed his mercurial course. Indeed, I feel per- 
 fectly confident that it will not affect any person while he is in 
 a state of moderate salivation. I am aware that now and 
 then instances have occurred where mercury has appeared to 
 lie dormant and inactive in the system for two or three weeks 
 after it has been altogether laid aside, and that after this 
 internal ptyalism has come on. I imagine that when mercurial 
 erethismus attacks men who had entirely completed their 
 mercurial course, it must have been in some one of these very 
 rare instances. 
 
 The treatment to be pursued in a case of this formidable 
 disease should be as follows : — First, at once discontinue the 
 use of mercury, and charge the patient to change his dress, 
 and to lay aside every article of it which can be in any way 
 impregnated with that mineral; also, caution him to avoid 
 any, even the slightest exertion, such as getting out of bed 
 without assistance ; for we know by experience that, under 
 these circumstances, a patient may sometimes expire on 
 making any slight muscular effort ; in the next place we 
 shoidd exhibit cordials in small, but frequent doses ; but above 
 aU we should expose him, in the horizontal posture, to the 
 free, open air, both during day and night ; we need entertain 
 no apprehension of any of those injurious effects which 
 exposure to cold so commonly induces ; it would appear as if 
 the present febrile state of the system suspended the ordinary 
 
90 OM IHE ADMINISTRATION OF MERCUEY. 
 
 effects of exposure to cold, or at least enabled the system to 
 resist them. 
 
 If this treatment have proved successful in rescuing our 
 patient from the imminent danger in which he was involved, 
 we must be careful not to resume the use of mercury for two 
 or three weeks at least, and not even then unless his health 
 and strength are perfectly restored ; and when we have deter- 
 mined to have recourse to it anew, we should obsei-ve the 
 following precautions : — We should use the medicine in smaller 
 doses than those which were used when the erethismus 
 appeared ; we should interpose occasional purging, allow the 
 patient occasionally to take mild exercise in the open air, and 
 use every effort suitable in his state to direct the action of the 
 mercm-y to the sahvary system, so as to induce i^tyahsm. 
 
91 
 
 CHAPTEE IV. 
 
 ON CHANCRE. 
 
 Although every surgeon must admit that Mr. Hunter's 
 description of a chancre is correct and drawn from nature, 
 still I believe few will confine this term, or that of primary 
 venereal sore, to those ulcers only which answer to his 
 description. We sometimes, though rarely, meet with ulcers 
 which possess all the characters of the Hunterian chancre, 
 and yet prove to be not venereal. The only distinction which 
 I can discover between these and the venereal chancre is that 
 the former are of a very diminutive size, and although they 
 heal like the Hunterian ulcer, they do not even approach it in 
 point of size. As the result of long, attentive, and anxious 
 observation, I should say that primary venereal ulcers present 
 an almost endless variety of character. I would define a 
 primary venereal ulcer to be " one which is remarkably slow 
 in yielding to ordinary, mild, local treatment, but which is 
 curable by mercury, and which, if not so cured, is Ukely to be 
 followed in two or three months by secondary symptoms, 
 which again also are cm-able by mercury." If then there be, 
 as I affirm there is, an almost endless variety in chancres, 
 how can we decide on the nature of primary ulcers so as to 
 pronounce some to be syphilitic, and others to be mere 
 common sores, or simple excoriations ? I reply, that we are 
 to be guided in our decision by observing, first, that many of 
 these suspicious ulcerations cannot be referred to any class of 
 common ulcers, as they strikingly differ from them; and, 
 secondly, by attending to the course which these take, when 
 not interfered with by any stimulant or caustic application, 
 and when treated only with some mild ointment or cold 
 water. If under these circumstances we find that after eight 
 or ten days such ulcers show no disposition to heal, and if at 
 the same time there be a total absence of any cause, such as 
 defect in the general health, to account for this obstinate 
 
92 
 
 ON CHANCRE. 
 
 condition of the local disease, we may then pronounce them 
 to he syphUitic. But I repeat that the local applications 
 must have been of the mildest kind, for almost any primary 
 venereal ulcer may be made to heal by the use of stimulating 
 appHcations, applied even for so short a time as one or two 
 days. 
 
 It often happens that young men affected with primary 
 sores will first treat them for one or two days with stimulant 
 washes, and then apply to a surgeon ; he directs the mildest 
 applications, and finding the ulcers to heal under this 
 treatment without any hardness remaining, concludes that 
 they were not venereal; the appearance of secondary 
 symptoms, however, in a few weeks afterwards, proves the 
 error of that opinion. I have known a few such cases, in 
 which the surgeon has felt so confident in this opinion that he 
 has allowed the patient to marry in a short time after the 
 healing of the sores. I need not attempt to describe the 
 state of his feelings when called on to treat the wife for 
 primary venereal sores ! ! I am therefore anxious to impress 
 this as a very important rule, not to pronounce any ulcer on 
 the genitals as of an innocuous nature which may have 
 healed under the mildest applications, if at any time, even 
 during the short space of one or two days, it have been treated 
 with stimulant applications. 
 
 We shall now consider the proper treatment for a case of 
 true venereal ulcer, the Hunterian chancre : — The local 
 treatment should, in my opinion, be confined to the most 
 bland and mild applications, such as caimot in any manner 
 alter the features of the ulcer, for I am certain that many 
 useful indications which may serve to guide us in the 
 administration of mercury are to be derived from observing 
 the changes which these ulcers undergo through the agency of 
 that medicine; these changes, and their corresponding 
 indications, I shaU hereafter advert to. I am further 
 confirmed in this opinion from having observed that little 
 or no benefit is to be derived from a country practice ; thus, 
 I have known a chancre completely cut out on the first or 
 second day after its appearance, yet the occurrence of 
 secondary symptoms was not prevented; I have also, in 
 
ON CHANCEE. 93 
 
 numerous instances, known various caustics and stimulating 
 applications employed, but I hG,ve not seen that such cases 
 were rendered thereby more manageable, or that the patient 
 was secured from those untoward changes which too frequently 
 occur in the chancre itself before it is finally healed ; nor were 
 such cases less liable to secondary symptoms. 
 
 But before we can appreciate the effects of, or draw 
 indications from, the various changes induced in a chancre 
 by mercury, we should first be well acquainted with the 
 wholesome or natural effects of this medicine on such an 
 ulcer. If it be asked how soon may we expect to find the 
 condition of the ulcer in any manner influenced by the 
 mercury ? I would say, in ordinary cases, we can observe it 
 from the third to the seventh day. I cannot agree with 
 Mr. Hunter as to the time in which he says a chancre 
 becomes affected by mercury. Page 833, octavo edition : — 
 
 " Probably from the before-mentioned circumstances (the varia- 
 tions produced by certain peculiarities of the constitution at the 
 time) it is that a chancre is, in common, longer in healing tha.n 
 most of the local effects from the constitutional disease, or 
 lues venerea ; at least longer than those in the first order of 
 parts'; and this is found to be the case, notwithstanding that the 
 cure of a chancre may be attempted both constitutionally and 
 locally, while the lues venerea can, in common, only be cured 
 constitutionally. It is commonly some time before a chancre 
 appears to be affected by the medicine. The circulation shall 
 be loaded with mercury for three, four, or more weeks, before 
 a chancre shall begin to separate its discharge from its surface, 
 so as to look red and show the living surface ; but when once 
 it does change, its progress towards healing is more rapid. A 
 lues venerea shall, in many cases, be perfectly cured before 
 chancres have made the least change." 
 
 Now, I think it may be affirmed that, in ordinary, the 
 constitution is brought under the influence of mercury 
 between the third and the seventh or eighth day ; and I feel 
 no hesitation in saying that, as soon as this takes place, we 
 shall observe a striking change in the appearance of the ulcer. 
 The first remarkable change is that the chancre appears a 
 little larger, but, at the same time, less deep. This increase 
 in the size of the ulcer is not very considerable, nor is it 
 attended with an increase of sui'rounding inflammation or 
 
94 ON CHANCBE. 
 
 swelling. The first demonstration of the influence of mercury 
 on the ulcer will be eagerly Jooked for by a surgeon who is 
 acquainted with its effects ; and yet it would create uneasiness 
 in the mind of a practitioner who was unacquainted with it. 
 Indeed I strongly suspect that this first change in the ulcer 
 has, in many instances, deterred the surgeon from its further 
 use, and has impressed him strongly with an opinion that, in 
 in such cases, the mercm-y disagreeing with the ulcer proved 
 that it was not venereal. And thus the patient was debarred, 
 for the present, from the benefit of this medicine, and was so 
 prejudiced against its use that he could not be prevailed on to 
 employ it in any subsequent stage of the disease, until 
 convinced, by long and sad experience, of the inefiicacy of 
 other modes of treatment. While an experienced surgeon will 
 not be deterred, by this slight change in the ulcer, from 
 persevering in the mercm-ial treatment, he will also be well 
 aware that a sudden and considerable enlargement of the 
 ulcer, especially if accompanied with an increase of surrounding 
 inflammation and swelling, would denote a very unfavourable 
 change. We next find that the surrounding hardness declines, 
 that granulations begin to arise, that the discharge becomes 
 purulent, and that the entire surface of the ulcer becomes 
 clean and red. In a few days more the ulcer contracts, a thin 
 cuticle forms on its edges, and this daily increases until the 
 ulcer is finally healed. Some degree of hardness, however, 
 remains for four or five days after the healing of the ulcer, 
 but this also disappears, and leaves the part possessed of its 
 natural softness. Such is the progress of this symptom from 
 the time it comes under the salutary influence of mercury 
 until it is finally cured, in these cases where the mercury 
 agrees well with the patient, and where it has been used with 
 judgment. I shall only add that, in general, it wiU be 
 prudent to continue the use of mercury not only until aU 
 hardness be removed, but even for a few days longer. I think 
 we may lay it down as a general rule that the course of 
 mercury, even when it has been well conducted and has 
 agreed well with the patient, should be continued for not less 
 than one month. I know that some cases have been perfectly 
 cured in three weeks ; but I have too frequently seen relapses 
 
ON CHANCKE. 95 
 
 follow such short courses of mercury when employed for the 
 cure of primary symptoms. 
 
 I believe it is scarcely necessary for me to add that I should 
 wish a moderate ptyalism to be kept up from the time the 
 mercury comes to act on the system until it be finally 
 discontinued. The doses in which the mercury should be 
 administered, and the circumstances which require it to be 
 from time to time discontinued and again resumed, must be 
 left to the judgment of the practitioner, and will of com'se 
 vary in different cases. 
 
 From some expressions in Mr. Hunter's work I have known 
 some young men led to suppose that, when a chancre had lost 
 its venereal characters and had got into the state of a 
 granulating ulcer, it was devoid of all venereal virus, and 
 therefore incapable of conveying infection. In the early part 
 of my professional life I have known more instances than one 
 which proved the fallacy of this notion. I had once an 
 opportunity of learning that a chancre, even when recently 
 healed, was stiU capable of communicating the venereal 
 disease if the cuticle chanced to be rubbed off. A young man, 
 whom I was treating for a chancre, had the imprudence 
 to marry privately in a day or two after his chancre had 
 healed ; the cuticle was rubbed off, and I was called upon, in 
 a fortnight after, to treat his wife for a chancre and bubo. 
 
 The progress of an Hunterian chancre towards healing 
 often deviates from the description just now given. I shall 
 here notice a few of those interruptions which deserve 
 attention, as they show a necessity for some alteration either 
 in the local or constitutional treatment ; and I may here add, 
 that the other forms of primary venereal ulcers are liable to 
 the same interruptions. 
 
 First. The ulcer, though its surface may be clean and 
 florid, may yet show no disposition to cicatrize, but will 
 remain stationary for many days, although the mercury seem 
 to agree well with the system. When we see this indisposition 
 to heal attending the full and healthy action of mercury, we 
 have only to apply a single touch of argentum nitratum ; this 
 wUl induce a rapid cicatrization. 
 
 Secondly. After the ulcer has spread a little under the 
 
96 ON CHANCEE. 
 
 influence of mercury, it will sometimes throw up a whitish 
 fungus, and continue to enlarge more than we should expect 
 in a healthy chancre : this condition is most apt to occur in 
 those cases in which the mercury has been late in beginning 
 to act on the system, and in which it does not act very kindly. 
 In such a case the most judicious treatment is either to 
 suspend the use of mercury for a few days, or at least to allow 
 longer intervals between the different doses ; and at the same 
 time to give the patient bark joined with small doses of opium, 
 and to apply the wash of calomel and lime-water to the part. 
 This plan will in a few days bring the system more 
 satisfactorily under the influence of mercm-y, and put the 
 ulcer into a healthy granulating state. 
 
 Thirdly. The mercury, in some cases, will most unex- 
 pectedly take a sudden and severe hold of the system, inducing 
 profuse ptyalism within the first three or four days, and, as a 
 consequence, the almost instantaneous healing of the chancre ; 
 such a healing of the chancre, however, is not a cure of the 
 venereal disease. For we shall find that a bubo wDl now 
 make its appearance, perhaps at the very time that the 
 chancre has thus suddenly healed; this bubo will proceed 
 with unusual rapidity to suppuration if we do not at once 
 desist from mercury. I have not tried by experiment whether 
 such bubo absolutely requires a farther use of mercury, I can 
 only say that I have always acted on the supposition of its 
 being required, and as soon as the salivation had subsided 
 I have resumed the use of mercm-y in such a manner as to 
 affect the mouth again, but more slowly and more gently. 
 
 Fourthly. When, during the heahng of the first chancre, 
 one or two new ulcers arise, possessing all the obvious 
 characters of chancre, I think that we are not called upon to 
 make any change in our treatment, for I have generally 
 observed that these new ulcers pass through the different 
 processes which lead to the healing of a chancre, but with 
 greater rapidity than the original chancre had done, so that 
 they are perfectly healed at the time that we should have 
 desisted from mercury for the cure of the original ulcer, if 
 these secondary chancres had not appeared ; I do not recollect 
 having seen one of these accessory ulcers ever undergo an 
 unfavom-able change. 
 
ON CHANCEE. 97 
 
 Fifthly. After a chancre has been healed, even without 
 the assistance of active topical treatment, the hardness will 
 sometimes continue too long. When this occurs in those 
 chancres which had been seated on a flat surface, we can 
 generally refer the induration which remains to a late or to an 
 unsatisfactory action of mercury : under such circumstances 
 we must therefore be cautious not to lay it aside too soon, and 
 we should at the same time rub the cicatrix twice a day with 
 mercurial or iodine ointment. But when the chancre has 
 occupied the very edge of the prepuce, the hardness, which 
 will then very generally remain, is merely owing to the 
 peculiar loose structure of the part, and the adhesion 
 produced by the inflammation in the interposed cellular 
 substance now preventing the outer from moving on the inner 
 skin. The hardness, in such a case, must be left to the slow 
 operation of time, and its removal may be expedited by 
 repeated frictions of the part. Here I would observe that the 
 opening of the prepuce sometimes becomes so much contracted 
 bj^ the cicatrix of one or two chancres which had been seated 
 on its edge as so require the operation for phymosis : the 
 division of the skin in this case should be made in a line with 
 and close to the frsenum, by which we shall sufficiently 
 enlarge the prepuce, and leave less deformity or inconvenience 
 than if the division had been made along the dorsum or sides 
 of the penis. Mr. Wilmot long since suggested to me a 
 practice in this operation, which I consider a material 
 imjjrovement, namely, to pass two stitches of interrupted 
 suture in each lip of the wound, so as to keep the cut edges of 
 the skin and mucous membrane on either side in apposition 
 with each other, and thus effect the healing of each lip of the 
 incision by the first intention, leaving the angle to heal by 
 granulation. 
 
 When chancres become inflamed and paraphymosis takes 
 place, the usual operation for dividing the stricture should be 
 performed. 
 
 Sixthly. Although I have repeatedly stated that when 
 ptyalism has been established the further use of mercury 
 becomes comparatively safe, yet it may happen, either from 
 the mercury being continued too long or too largely in a 
 
98 ON CHANCRE. 
 
 weakly system, or fi-om a state of fever induced by other 
 causes, that a chancre which has made some progress towards 
 healing will take an unfavourable tru'n, and assume a 
 phagedsenic or a sloughing disposition. From whatever cause 
 this change may aiise, it is plain that the mercm-y should be 
 instantly laid aside, and 'every means adopted to remove the 
 febrile condition, while the local treatment must be varied as 
 the state of the ulcer shall requii-e. In cases where, fi'om 
 peculiar ii-ritability or delicacy of the patient's habit, such 
 unfavom"able changes might be apprehended,, we may guai'd 
 against such a change by giving bark and other tonics as soon 
 as the ptyahsm is established. 
 
 Lastly. The other changes which chancres occasionally 
 undergo are trifliag when compared with those which are 
 produced by the supervention of a high degree of inflammation, 
 ^Ye occasionally meet with cases iu which a chancre has 
 existed for many days, without any remarkable degree of pain 
 or swelling of the paris — yet on a sudden it is attended with a 
 high and dangerous degree of inflammation. This we can 
 generally trace to intemperance, to excessive exercise, or to 
 neglect on the part of the patient. In such cases we find the 
 enth'e penis becomes much swollen, the integuments are of a 
 bright or purplish red, and there is considerable discharge 
 fi-om the prepuce. These local symptoms will be attended 
 with more or less of fever, the type of which may vary from 
 that of the high inflammatory down to the low asthenic or 
 typhus. If in such a case we press the prepuce aU around, 
 we shall detect one spot with an extraordinary thickening and 
 hai'dness, and herethe patient will feel a tenderness beyond 
 even that of all the rest of the prepuce. Should the inflam- 
 mation continue and increase, we may at lengih observe a 
 black spot in the prepuce, on its dorsum or one of its sideSj 
 the effect of gangrene ; this soon opens, the opening from day 
 to day grows larger, until at length the glans appears 
 protruding through it ; as soon as this has occm-red we shall 
 observe that a considerable remission of pain takes place, the 
 aspect of the ulcerated opening improves, the discharge 
 declines and soon ceases, but the glans continues protruded, 
 and what remains of the prepuce forms such a thickened 
 
ON CHANCEB. 99 
 
 mass, that to enable the patient to have sexual intercourse 
 all the projecting skin must be removed by the knife. How 
 should such a case be treated before the gangrene of the skin 
 has begun? I believe the safest line of conduct is to 
 endeavour to subdue the attendant fever ; and therefore we 
 must employ the antiphlogistic regimen to such an extent as 
 may be required ; nauseating doses of tartar emetic appear of 
 the greatest service in all cases which do not require 
 venesection, or where this evacuation has been previously 
 made. Warm or cold applications may be employed, 
 according as either is found to suit best the feelings of 
 the patient ; but on no account should we neglect to make 
 him use the black wash very freely : this can be applied most 
 effectually by means of a syringe with a long pipe, introduced 
 between the glans and prepuce, while the orifice of the latter 
 is closely pressed around the pipe, so as not to allow any of 
 the fluid to escape until the prepuce has been fully distended. 
 This partial gangrene of the prepuce must be looked upon as 
 rather a favourable consequence of this very high inflam- 
 mation ; for in many instances it threatens to destroy the 
 whole of the prepuce, and even to involve the penis itself in a 
 similar fate. Under these circumstances I have repeatedly 
 found that the destructive process was at once arrested by 
 washing the diseased surface with the strong white muriate of 
 antimony, and sometimes with the nitric acid; the former, 
 however, I much prefer. This application very generally 
 arrests the further progress of the unhealthy action, reheves 
 the patient from pain so that he can enjoy sleep, and assuages 
 his constitutional fever : however, until this favourable change 
 takes place, we cannot lay aside our fears for the safety of 
 more or less of the penis. In a few cases the process of 
 destruction ceases not until it has destroyed this organ to a 
 level with the pubes; in such melancholy instances, even 
 after the ulcer is healed, the patient is tormented by the 
 manner in which the urine passes out of the distorted and 
 contracted opening of the remnant of the urethra ; for it rises 
 so much upwards that the unhappy patient is obliged to direct 
 the stream forward by holding his hand above the pubes. 
 About twenty years ago, when I had charge of a large 
 
]00 ON CHANCRE. 
 
 number of soldiers labouring under the venereal disease, who 
 were received into the attic wards of Stevens's hospital, I 
 attempted the treatment of such cases by throwing in mercm-y 
 largely and suddenly ; but whether it was owing to the want 
 of a judicious plan of using mercury, or to the bad habits of 
 the men, induced by intemperance and dissipation, I know 
 not ; but I freely admit that, with many, this practice was not 
 successful. However, the success of the two plans, that by 
 mercury and that by the antiphlogistic regimen, was so 
 evenly balanced at the time the military hospital was broken 
 up, that I was quite undecided which to prefer. About this 
 time I learned the use of the black wash, which has rendered 
 such essential service in the early periods of this condition 
 that I have not since repeated the experiment of administering 
 mercm-y through the constitution. Many of the cases treated 
 with mercury were cm-ed without the slightest destruction of 
 any part, but this was purchased by the certain and severe 
 sufferings of a violent salivation. Some escaped with the loss 
 of part of the glans, and some few had the penis destroyed 
 down to a level with the pubes. Possibly -the mercurial 
 treatment would have been more frequently successful, had I 
 more constantly used venesection and other evacuations as a 
 process preparatory to the use of mercury. There is one 
 condition of the sloughing penis which I look upon with total 
 despair of being able to afford any means of arresting its 
 progress untU it has destroyed the entire penis down to the 
 pubes : I mean that condition in which the sloughing part is 
 so soft as to resemble melted tallow when beginning to form 
 into a solid. I have never yet seen the progress of this 
 arrested, even for a moment, by any local or constitutional 
 means hitherto employed. 
 
 When, in addition to the inflamed and painful condition we 
 have just now alluded to, we find haemorrhage to supervene, 
 we must carefully watch the effects of the evacuation. In 
 some fortunate cases the patient informs us that the pain is 
 much mitigated since the bleeding ; here we may hope for a 
 favourable issue, the inflammatory swelling of the prepuce 
 wih begin to decline, as also the pain and fever. Possibly 
 another hasmorrhage may take place in three or four days 
 
ON OHANCEE. 101 
 
 subsequently, which will be followed by a still more marked 
 decrease of inflammation and fever. But in other less 
 fortunate instances the first haemorrhage is not followed by 
 any mitigation of inflammation or fever, and a succession of 
 bleedings may take place at intervals of twelve, twenty-four, 
 or thirty-six hours. The type of the fever then becomes 
 changed; it is no longer of the inflammatory, but merges 
 towards the typhoid form, in all its characters strongly 
 representing what some have called an irritative fever. The 
 patient gets no sleep, he looks pale and haggard, is rapidly 
 emaciating, complains of the unceasing and severe pain of the 
 diseased parts, and is in constant dread of a fresh hsemorrhage ; 
 the discharge becomes more copious and extremely foetid, and 
 so acrimonious as to excoriate the neighbouring parts over 
 which it runs. In order to afford effectual relief in this 
 miserable state, we must slit up the prepuce, taking care to 
 carry our incision so as to run near to the chancre, and 
 having thus exposed the sloughy surface, we must apply to 
 the bleeding point a dossil of lint soaked in spirits of 
 turpentine, and then apply moderate compression. The 
 turpentine seems to serve such cases not only by arresting 
 the bleeding, but also by exciting in the ulcerated surface a 
 more healthy action, which soon induces the parts to heal. 
 We should be careful not to have the dossils of lint so wet as 
 to allow the turpentine to trickle along the adjoining parts, as 
 this wUl be found to scald them very much, and thus add 
 unnecessarily and severely to the inflammation of the penis, 
 and to the sufferings of the patient. I have seldom seen the 
 ligature succeed in preventing a return of the hsemorrhage, as 
 the coats of the arteries appear to slough again almost 
 immediately under the' ligature. 
 
 In some cases of sloughing of the prepuce the process 
 spontaneously stops, after having completely removed the 
 entire prepuce, leaving the patient as if he had undergone the 
 operation of circumcision. By some practitioners we are 
 recommended to consider this as a perfect and permanent 
 cure of the disease, and not requiring the further use of 
 mercury. I have certainly known some cases which would 
 tend to confirm this opinion, especially when the sloughing 
 
102 
 
 ON CHANCBE. 
 
 began at the early period of the chancre ; but in other 
 instances secondary symptoms ha've supervened ; and therefore 
 I should consider it prudent to subject to a course of mercury 
 aU those in whom the sloughing had taken place at a late 
 period. 
 
 Having offered these few remarks on the accidents to which 
 primary venereal ulcers are subject, I shall make some observa- 
 tions on chancrous excoriation. 
 
 This excoriation does not at first present any distinctive or 
 specific characters ; after ten or twelve days, however, it 
 presents new features ; sometimes a great part of the excoriated 
 surface heals, and leaves one or two spots unhealed: these 
 are usually of a circular form, and rest on a hardened base, 
 although up to this period no induration had been perceptible. 
 Another striking feature, often met with in chancrous excoria- 
 tion, is that while it generally presents a red surface, it looks 
 as if it were dry, or is like an excoriation which has been for 
 some time exposed to the air, and this even although it be 
 dressed with lint soaked in water. 
 
 As a proof that such excoriations are primary venereal 
 ulcers, we shall find that their morbid characters will begin to 
 improve as soon as the system feels the salutary action of 
 mercury; and that they will heal, and the hardness be 
 dispersed, in the same time and manner as the true Hunterian 
 chancre. We shall al^o find that if mercury be used in an 
 injudicious or ineffectual manner these excoriations will, like 
 ordinary chancres, undergo various unfavourable changes, and 
 will be followed by the usual secondary venereal symptoms. 
 
 A few instances will suffice to show the changes which 
 excoriations may undergo before they assume the venereal 
 characters ; and to show that this form of primary venereal 
 symptom requires an attentive and lengthened course of 
 observation before we venture to decide on its nature. 
 
 July 31st. Mr. W — , six days since, immediately after con- 
 nexion, perceived two excoriations, to which he appUed dry 
 lint : one of them has healed ; the other shows no disposition 
 to heal. This latter is situated on the inside of the prepuce, 
 at the root of the frsenum, and is equal in circumference 
 to that of the flat surface of a split pea ; is very superficial, 
 
ON CHANCEE. lOS 
 
 with a smooth surface, and edges not at all raised ; it appears 
 to yield very little discharge, and is seated on a very 
 hard base, the hardness extending a little beyond the 
 limits of the excoriation. Sumat Pil. Hyd. gr. v. mane 
 nocteque. 
 
 Aug. 3rd. The excoriated spot presents more the characters 
 of a secondary than of a primary ulcer ; it is enlarged, and 
 now has a white centre, surrounded with an orange-coloured, 
 or reddish circle ; the hardness is unaltered. Sumat Pil. Hyd. 
 gr. V. ter. in die. 
 
 Aug. 6th. Inner gums of lower incisors are slightly affected : 
 ulcer yields a purulent discharge in suf&cient quantity : the 
 white part in the centre is much reduced in extent, as if the 
 orange circle had encroached on it ; hardness not at all 
 reduced ; an incipient bubo in right groin, which is slightly 
 painful when he sits down or gets up, but not when he is 
 walking. Pergat. 
 
 Aug. 9th. Mercurial action more discernible ; ulcer has its 
 central part of a less deep colour, and of less intense white- 
 ness ; the outer edge of the orange border has healed ; orange 
 colour is less deep ; the hardness of the base is also less. 
 Pergat. 
 
 Aug. 12th. Ulcer is all healed, except a line in the centre, 
 which is quite red and healthy ; the groin is easy ; mouth as 
 on 9th instant. Pergat. 
 
 Aug. 16th. Ulcer perfectly healed, glands of groin quite free 
 from all pain, mouth not more affected. Sumat Pil. Hyd. gr. 
 X. ter in die. 
 
 Aug. 20th. Mouth not more affected. E. Calomelanos 5 ss. 
 Ext.' Opii gr. v. Ft . Pil. x. Sumat i. ter in die. 
 
 Aug. 22nd. Sumat Pil. unam omni mane. Ungt. Hyd. Fort. 
 5 ss. omni noete. 
 
 Sept. 14th. During last three days mouth has been a good 
 deal affected. 
 
 Sept. 17th. Mouth rather less affected. Sumat Pil. j bis in 
 die. Eept. Ungt. Hyd. 0. n. 
 
 Sept. 21st. Mouth a little more affected. 
 
 Sept. 24th. Omitt. Med. 
 
 Mr. B — applied to me ten days ago on account of a small 
 
104 ON CHANCRE. 
 
 circular excoriation on the inner sm-face of the prepuce ; this 
 was so purely an excoriation, of such a healthy red colour, so 
 free from hardness and from every venereal or suspicious 
 appearance, that I did not at that time look on it as venereal, 
 and accordingly advised him to apply only lint and cold water. 
 In the course of six days the appearances began to change ; 
 and on the tenth day I observed that the centre of the excoria- 
 tion had assumed a dirty yellow colour, while a pretty wide 
 margin retained its healthy red appearance. On the thirteenth 
 day the surface was as on the tenth, but the entire ulcer now 
 rested on a base of considerable hardness ; judging this to be 
 venereal I then put Mr. B. on- the use of Pil. Hyd. ; this did 
 not agree very well with him, and the ulcer did not proceed 
 on kindly towards healing ; on the contrary, at one period its 
 central part assumed a blackish tinge, and showed a disposi- 
 tion to slough, whilst the margin remained of a pretty healthy 
 red colour. 
 
 At the expiration of six weeks (the ulcer not being yet 
 healed) he was affected with venereal eruption and sore throat. 
 These symptoms yielded, and the ulcer healed, under a rather 
 protracted course of Pil. Hydr. gr. iii. and Sulph. Quininse gr. 
 ii., the doses of which did not at any time exceed three in 
 the day. 
 
 Towards the conclusion of this course, being anxious to 
 finish the treatment by a more decided action of mercury on 
 the system, I added to the above Ungt. Hydr. Fort. 5 ss. omni 
 nocte, for eight nights. But this proved to be too much for his 
 system, as was evinced by an attack of mercurial excoriation 
 about the anus ; on the appearance of this of course the 
 mercury was laid aside, and since that period Mr. B. has not 
 had any return of venereal symptoms. 
 
 Feb. 17th. Mr. P^ — had been exposed to the danger of 
 infection fourteen days ago, three days after which he applied 
 to me with a pretty large excoriation of the prepuce behind 
 the glands ; this was attended with scarcely any hardness, 
 and it healed in the course of eleven days under the appli- 
 cation of spermaceti ointment. At present the surface, 
 though healed, looks unhealthy, and this spot resembles a 
 venereal tubercle ; there is considerable hardness, fully as great 
 
ON CHANCRE. 105 
 
 as that which attends the true Hunterian chancre : Pil. Hyd. 
 gr. V. mane et noote. 
 
 Feb. 20th. Surface is again ulcerated, or rather excoriated, 
 with a purulent discharge, and considerable hardness of base. 
 Sumat Pil. Hydr. gr. x. omni nocte, et gr. v. omni mane. 
 
 Feb. 26th. Sumat Pil. Hydr. gr. x. nocte maneque. 
 
 March 3rd. Yesterday had an attack of mercurial dysentery ; 
 mouth is now sufficiently sore ; for the two or three last days 
 has taken only three pills a day : ulcer is much smaller, and 
 almost free from hardness. He himself remarks that it differs 
 from every other chancre he has had, or has seen, in its never 
 having gone deep. 
 
 March 9th. Mouth still sore ; ulcer is perfectly healed, not 
 leaving the slightest degree of hardness. N.B. — He left town 
 the following day, with directions to keep his mouth slightly 
 sore for a fortnight longer. He has since enjoyed good 
 health, and has had no appearance of secondary venereal 
 symptoms. 
 
 [It is to be regretted that in two of the foregoing cases the dates are 
 not given up to which the patients continued in the enjoyment of good 
 health, and free from venereal s3rmptoms.] 
 
 A chancre on the skin of the penis, or external surface of 
 prepuce, is quickly covered by a scab. Perhaps the best mode 
 of treatment (at least the most comfortable to the patient) is 
 to let the scab remain, and whenever it is accidentally rubbed 
 off to expose the part to the air, and cause a fresh scab 
 to form. The drying in of the scab, its gradual contraction, 
 and its less intimate adhesion to the surface of the ulcer, will 
 point out the gradual improvement in the concealed ulcer, 
 and enable us to judge of the favourable action of the mercury ; 
 while the contrary changes in the scab will indicate that the 
 mercury is not acting in a salutary manner. 
 
 I deem it right here to notice an appearance in chancres 
 healed by local means only, which we occasionally meet with 
 in cases where mercury has been injudiciously employed — an 
 appearance which I have never, except in one instance, seen. 
 The appearance I allude to is a remarkably hard lump, as 
 large as a filbert, situated on the prepuce in the site of the 
 
106 ON CHANCRE. 
 
 original chancre ; the skin which covers it is of a pecuKar 
 purple colour. In one instance, that of a young gentleman, 
 whose chancre had been healed for three or four weeks, this 
 appearance was attended with most alarming symptoms, viz., 
 extreme emaciation, thirst, loss of appetite, and profuse night 
 sweats. The suddenness with which he had been reduced to 
 this state from a tolerably full habit of body, and from 
 apparently excellent health, excited in my mind great appre- 
 hensions for his safety, especially as some of his family had 
 died of hcemoptysis succeeded by phthisis. I never saw any 
 case in which the venereal virus acted in a manner so like to 
 what we might fancy should be the effect of a slow poison on 
 the system. Yet by means of a mercurial course gradually 
 raised from very small doses, and continued for a longer 
 period than usual, the hardness and discoloration were 
 removed, and he was soon restored to good health, which he 
 still enjoys. This case occurred many years since, at the time 
 when the non-mercurial treatment was first introduced into 
 Dublin. In all the other instances of this large purple 
 tumour, where it has formed after the healing of a chancre 
 by local means only, I have seen secondary symptoms follow 
 in the same time, and pursue much the same course, as 
 when these have succeeded to chancres which have been 
 only imperfectly cured by the injudicious administration of 
 mercury. 
 
 I shall next consider some of the peculiarities of chancres, 
 depending on the peculiar structure of the part in which they 
 are situated. It is scarcely necessary to say that the quantity 
 of hardness is much less in chancres situated on the glans 
 than in those on the prepuce ; but stiU a degree of hard- 
 ness sufficient to guide us in the treatment attends even the 
 former. 
 
 There is a form of venereal chancre on the edge of the 
 prepuce, of which I do not recollect ever to have read any 
 description. The account we receive from the patient is that 
 he thinks he tore himself in the act of connection ; we see 
 that the lacerated part shows no disposition to heal, but is not 
 painful or swollen, and appears in the form of a fissure. 
 When the prepuce is partly retracted this fissure appears as 
 
ON CHANCEE. 107 
 
 if it had been divided by a long ineisioh ; ths edges are hard 
 and deep, not swollen or inflamed, and yielding scarcely any 
 discharge ; it is not at all painful, unless when an attempt be 
 made to retract the prepuce. This is certainly a primary 
 venereal ulcer : its peculiar characters may probably depend 
 on the infection being ingrafted on the torn surface ; it requnes 
 the use of mercury to the same extent as does the circular 
 Hunterian chancre ; nor does it need any peculiar local treat- 
 ment. I cannot recollect any instance in which this form of 
 ulcer took an unfavourable turn, although I have known some 
 patients who did not apply for assistance for three weeks after 
 connection, being lulled into a feeling of security by observing 
 that this ulcer was unattended with swelling, inflammation, 
 pain, or hardness. 
 
 [No doubt we have here a period of about three weeks' incubation, as 
 it would now be designated, during which time, if any sore at aU 
 existed, it was so far " unattended with swelling, inflammation, pain, or 
 hardness," that it escaped the patient's notice.] 
 
 We sometimes see the edge of the prepuce beset with five or 
 six circular ulcers; these, if left to themselves, will first 
 granulate, then become fimgous, and finally will heal spon- 
 taneously. The form, as well as the slow and indolent 
 character of these ulcers, might dispose us to conceive that 
 they were syphilitic ; the appearance, however, of several of 
 these at once along the margin of the prepuce, and their 
 being destitute of any hardness, will serve as a criterion 
 whereby we may make the distinction. These ulcers may 
 always be cured by suitable local treatment alone : I have 
 never seen them take an unfavourable turn. Sometimes there 
 may also be present, in conjunction with these, others of a 
 true venereal character, and for which mercury must be 
 administeied ; we shall then have an opportunity of remarking 
 that this medicine exerts no influence on the ulcers at the 
 extremity of the prepuce. Sometimes this circle of ulcers is 
 accompanied by a single one of the same character far within 
 the prepuce. 
 
 [It appears clear from the observations made in the foregoing para- 
 graph that CoUes had caught hold of the fact, that besides the Hunterian 
 chancre there exists another variety of venereal sore, occurring on the 
 
108 ON CHANCRE. 
 
 genital organs. Wlisn he speaks of five or six circular ulcers, granulating, 
 then becoming fungous, destitute of hardness, and always capable of 
 cure by local treatment alone, he in fact gives most of the symptoms 
 regarded at the present day as characteristic of the sore now described 
 under the following names by different authors, viz., soft chancre, simple 
 chancre, non-infecting or suppurating chancre, chancroid, chancrelle, 
 false syphilis or local syphihs. When he says that we can have an 
 opportunity, in cases where the true infecting chancre co-exists with 
 those local sores, of observing that mercury exerts no infltience on the 
 latter, he forestalls the assertion of Lancereaux, who mentions this as 
 one of the distinguishing features between true and pseudo-syphilis, 
 viz., that the former is " susceptible of being influenced by certain agents, 
 as proto-iodide of mercury and iodide of potassium," the latter (soft 
 chancre) "being entirely unaffected by alteratives, if not aggravated by 
 the administration of them."] 
 
 When a chancre is seated close to either side of the frsenum 
 we find it invariably happens that the ulceration passes 
 through this process of integument, at first making an open- 
 ing through it, and in a few instances the ulcer has healed, 
 leaving this hole ; but in the majority of cases the ulceration 
 goes on until it has divided the frsenum entirely, then each 
 side of the ulcer heals separately, the part on the glans 
 showing a tendency to advance slowly, making a superficial 
 groove in the anterior part of the glans. The only direction 
 to attend to in the management of these chancres is to cut 
 through the frsenum as soon as the ulcer has once perforated 
 it ; for we shall generally find when this has not been sub- 
 mitted to that the sore will not assume the granulating state 
 until the ulceration has completely divided the frsenum. The 
 posterior part of the ulcer having generally the larger part of 
 the frsenum will require repeated touches of caustic to prevent 
 it from healing vrith a large knob, while the anterior part will 
 be benefited by the black wash or some other gentle stimulant. 
 Sometimes the frsenum (having been divided by the surgeon 
 or by ulceration) presents a furrow, showing that the part is 
 composed of two layers of cuticle ; this may be a little more 
 tedious in healing. 
 
 A chancre sometimes, though rarely, is seated at the very 
 orifice of the urethra ; in this situation it is always slow in 
 going through the different stages preparatory to healing, and 
 it too often assumes an eating disposition, passing all round 
 
ON CHANCRE. 109 
 
 the orifice ; there is one very serious ill consequence which 
 always results from this, namely, that in some time, perhaps 
 in one or two years, the patient will suffer severely from 
 symptoms of stricture. In treating such a case we should 
 use every effort to prevent the extension of the ulceration to 
 the entire circle of the orifice, for unless it entirely encircle the 
 orifice contraction will not follow ; this can with certainty be 
 accomplished by touching the ulcer, as soon as it begins 
 to extend, with the colourless muriate of antimony, or with 
 nitric acid : these applications are no doubt severe, but the 
 evil they avert is one of great magnitude ; for I will venture 
 to assert that of all forms of stricture this is one most apt to 
 reciir ; indeed, it does not in any instance admit of a cure by 
 the ordinary treatment of strictures. 
 
 I am happy to say that I have lately discovered a mode of 
 treating this stricture which has proved eminently successful 
 in the few cases in which I adopted it. This plan of treat- 
 ment consists in this simple operation : — Having detached the 
 skin from the end of the urethra, to which it is generally 
 intimately adherent, I divide the urethra below to the length 
 of more than half an inch. I raise the mucous membrane 
 from each lip of the incision, then cut away a portion of the 
 bared corpus spongiosum to such an extent as will allow the 
 raised mucous membrane to cover the cut edge. I stitch 
 down this membrane upon the corpus spongiosum, and thus, 
 having covered each lip of the wormd with mucous membrane, 
 I have effectually guarded against the possibility of reunion of 
 the lips of the wound, or subsequent contraction of the opening. 
 The opening of the urethra thus produced is of course of a 
 size larger than natm'al. 
 
 Of late years, notwithstanding what Mr. Hunter asserts to 
 the contrary, I am confident that I have seen cases of chancre 
 seated altogether within the urethra ; such cases have been 
 frequently mistaken for mild gonorrhoea, and have for weeks 
 together been treated as such : in some of these cases the 
 surgeon has not been apprised of his mistake until the 
 ulceration has actually laid open the fore-part of the urethra, 
 or has extended forwards to its orifice, so as to become visible. 
 A very little attention will enable us to discover the real nature 
 
110 ON CHANCEE. 
 
 of this case, even in its earliest stages, for we can externally 
 feel a hardness in that spot of the urethra where the chancre 
 is seated, and the symptoms of gonorrhoea are so slight that 
 this alone should excite our suspicion, and induce us to search 
 for a chancre in the ui'ethra. 
 
 [It was probably a case of urethral cbancre from wbich Jobn Hunter 
 took the virus for his experimental inoculation, the result of which 
 induced him to beheve the gonorrhoeal and syphilitic poison to be one 
 and the same, and which led to such unfortunate results in consequence 
 of his strongly maintaining this view. It is not impossible that the 
 experimental inoculation made by Hunter (and stated by H. Lee to have 
 been pei-formed upon himself) may have been made with matter fi-om a 
 urethral chancre mistaken by Hunter for gonorrhoea. Lee, in his turn, 
 adopts a different hypothesis ; he believes that in a syphihtic subject 
 " the irritated and inflamed mucous membrane of the urethra may 
 furnish at the same time a secretion resembling that of a simple 
 gonorrhoea,, and also the poison which may give rise to an infecting 
 chancre." Such he supposes to have been the " venereal matter from a 
 gonorrhoea " in which John Hunter dipped the lancet for his experiment. 
 The absolute truth must remain for ever in obscurity. All that is certain 
 is that the experiment led Hunter to conclude that the virus of gonorrhoea 
 and syphilis was identical, and that it required many years of obsei'vation 
 and experiment to prove that he had been in error.] 
 
 I shall not attempt any further description of the various 
 primary venereal ulcers which are daily to be met with ; much 
 less shall I undertake any classification of their endless 
 varieties, or of the course which each peculiar form has been 
 supposed to run. They will he found to differ so constantly 
 that very rarely shall we find any two of them to correspond 
 accurately with each other ; not merely at their commence- 
 ment do they present such dissimilar characters, but in their 
 different stages towards healing they will he also found to 
 deviate most strangely from each other, more particularly so 
 when they have been treated by mercury. One remark, 
 however, as to their treatment deserves notice, viz., that 
 patients affected with these irregular ulcers have been found 
 in general very difficult to salivate. This cannot be ascribed 
 to the medicine having been used too sparingly, for in 
 the reported cases we find the doses were rather too full than 
 the reverse. Some have said that it was owing to a degree 
 of febrile excitement in the system, which the irritable state 
 
ON CHANCKE. Ill 
 
 of the ulcer had induced and maintained. But this remark 
 can truly aj)ply only to a few of these cases, for the majority 
 of them will be found to possess rather an indolent character. 
 The explanation which I would offer on this subject is, that 
 the general health of such patients has not been in a good 
 condition at the time these ulcers have made their appearance, 
 and on that account mercury was more likely to disagree and 
 to exert its poisonous than its salutary operation on their 
 system, especially if used in full doses. Inattention then to 
 the existing derangements of the system, ignorance of the means 
 to remedy these, and probably, in most instances, the exhibition 
 of mercury in too high doses, have all conspired to bring into 
 discredit the plan of treating such ulcers by mercury. 
 
 There are some, I know, who assert that mercury is an 
 unfit remedy, "because it disagrees with the ulcers;" but 
 such persons altogether overlook its influence on the system, 
 and imagine that mercury disagrees with such ulcers only 
 because the latter have been derived from a peculiar kind of 
 virus, to which they suppose mercury is inimical. That it is 
 not with the ulcers, however, but with the constitution that 
 mercm-y disagrees, we may learn from this fact ; that when 
 treating a patient affected with any other irregular and 
 obstinate ulcers, and who may chance to be regularly salivated 
 by the mercury, the ulcer is not found to be injured by this 
 medicine ; moreover, such an opinion is against all experience 
 of the effects of mercury upon almost every other description 
 of ulcer. For my own part I cannot recollect an instance 
 where mercury, when it produced a healthy ptyalism for the 
 cure of other diseases, had disagreed with a fresh wound, or 
 with an ulcer of any ordinary class ; on the contrary, I am 
 sure that every surgeon has at times been agreeably surprised 
 on finding that a salivation, excited for the cure of some acute 
 or chronic disease, had at the same time, most unexpectedly, 
 caused an obstinate ulcer to heal. This fact has been so often 
 forced on my observation that I have in some instances of very 
 obstinate ulcers subjected the patients to a com-se of merciiry 
 solely for the purpose of healing these ulcers. I shall adduce 
 some instances of the success of this practice, when treating 
 of diseases not venereal, which are curable by mercury. 
 
112 
 
 CHAPTEE V. 
 
 ON BUBO. 
 
 To Mr. Hunter is the profession indebted for correct notions 
 respecting the natui-e of bubo, which he has properly classed 
 among the primary symptoms of the venereal disease. It is 
 not a little sm'prismg that the most extensive opportunities 
 have not as yet furnished practitioners with a single instance 
 in which this symptom can be traced to a secondary venereal 
 ulcer ; and yet buboes cannot always be attributed to an 
 inflammatory condition of the chancre, as they more gene- 
 rally arise when the inflammation in the latter has subsided, 
 or when it does not exceed that which usually attends the 
 secondary venereal ulcer : hence it would ajjpear, in the 
 latter case, as if the venereal virus had undergone some 
 change which tends to assimilate it to the human solids and 
 fluids. 
 
 The period at which bubo occurs after the appearance 
 of chancre is not confined to any definite .time, nor is it 
 a necessary attendant on all chancres, many chancres being 
 cured which had never at any time been followed by bubo ; 
 nay, it sometimes happens that chancres are cured without 
 the use of mercury, and secondary symptoms supervene, and 
 yet the passage of the venereal virus into the system had not 
 been delayed or aimoimced by the formation of bubo, or by 
 any tendency to it. The venereal virus, therefore, can pass 
 unaltered into the system, although in this course it must 
 have passed through one or more lymphatic glands. 
 
 Wlien chancre and incipient bubo co-exist, it is admitted 
 that the treatment by mercury should be precisely the same as 
 if the chancre alone were present ; and accordingly we find 
 that as the latter improves so the swelling and tenderness in 
 the former subside : even should the bubo, in consequence of 
 neglect, have acquired great size, and have advanced so far 
 toward suppuration that the integuments shall have become 
 
BUBO. 113 
 
 red, still the treatment should be the same as for the chancre 
 alone. When the ptyalism is commencing the inflammatory 
 condition of the bubo wiU for a day appear rather aggravated ; 
 but when the ptyalism is established, then the inflammation 
 obviously begins to subside. Some advise the use of mercury 
 to be postponed until the gland has suppurated, and the 
 inflammation has been reduced by letting out the matter ; I 
 do not think this delay is necessary, though I admit we should 
 first adopt antiphlogistic means to subdue or mitigate the 
 febrile symptoms which have been excited by the inflamed 
 condition of the bubo ; this being accomplished there is no 
 reason why we should longer defer the use of mercury. But 
 should we meet a case in which, while the chancre is improving 
 (ptyalism being established), the bubo becomes larger, and is 
 attended with an increase of inflammatory redness, and a 
 painful sensation like that of scalding, we are then to infer 
 that the mercury is disagreeing; we should, under such 
 circumstances, discontinue it for a few days, direct brisk 
 purgatives, and the most strict quietness, also the horizontal 
 posture. The amendment in the bubo will assure us that 
 such a line of practice was most judicious, and we may then 
 resume the mercury as soon as we observe its effects on the 
 system beginning to decline, using it perhaps in less powerful 
 doses. 
 
 It happens in some few individuals that mercury, when 
 rubbed upon the thigh for the cure of chancre, ■will excite 
 a slight swelling of the inguinal glands. In such cases it is 
 prudent to desist from the use of mercury on that side for a 
 few days; during this time the swelHng will subside, and 
 on resuming the mercury there wiU be no return of this 
 inconvenience. 
 
 When we come to speak of secondary symptoms we shall 
 find that the cervical glands sometimes swell on the approach 
 of ptyahsm ; but this swelling will also subside on discon- 
 tinuing the mercury, and on allowing the salivary system 
 a few days to unload itself. Thus it appears that mercury 
 may cause a sweUing even of those lymphatic glands which 
 are remote from the route the mercury takes to reach the 
 circulating system ; or it may be that the lymphatic cervical 
 
114 BUBO. 
 
 glands are only sympathetically affected in consequence of the 
 excited state of the saUvary organs. 
 
 If mercury, administered for the cure of a chancre, should 
 chance suddenly to produce profuse ptyahsm, we shall find the 
 chancre will heal almost iastantaneously, while at the same 
 time a bubo will begin to show itself. The state of the 
 mouth in such instances prevents us from falling into the 
 error of giving more mercury. Purging, and such other 
 evacuations as may be employed, with the view of reducing 
 the ptyahsm, will also tend to produce a resolution of the 
 inflamed gland. 
 
 Should we meet with a ease in which no traces of a bubo 
 are discoverable at the commencement of the mercurial com-se, 
 but in which it may arise after the mercury has fairly affected 
 the system, in such a case also we should for a time discon- 
 tinue the use of mercury. 
 
 In aU the above cases we should, in addition to pm-gatives, 
 endeavom- to restore the system to a healthy state by giving 
 bark or opium, or such other medicines as we may judge 
 necessary. Sometimes carriage exercise will be fotind highly 
 advantageous. 
 
 If, notwithstanding om- endeavours to the contrary, the 
 bubo shall have suppurated, are we to allow it to open spon- 
 taneously, or when, and how, ought we to open it ? The 
 opening of the bubo should be delayed until the- tumour has 
 pointed and the skin has become very thin : an earlier 
 opening wiU induce an increase of pain and fi-esh inflammation 
 which will not subside in less than three or fom- days; by 
 delay, also, there is a chance that the matter may be absorbed, 
 and the patient be thus saved from all the annoyance 
 attendant on an ulcer in the groin. 
 
 In most cases I advise the opening to be made in the 
 thinnest part of the integuments, and only large enough to 
 admit of the easy escape of the matter. 
 
 There is one particular form of bubo in which a very 
 different rule for opening it must be adopted ; I allude to that 
 which has acquired a larger size, in which the tumour does 
 not point or become conical, but assumes a flat sxu'face, the 
 whole of the integument becoming very thin and discoloured : 
 
BUBO. 115 
 
 in such a case we should cut through the entire length of this 
 thin covering of the abscess. Were we only to make a small 
 opening, we should find that the discharge would continue 
 very long, that it would be thin and of bad quality, and that 
 at the end of five or six weeks there would be no prospect of 
 healing ; for the integuments will have lost so much of their 
 vitality that they wiU either be removed by ulcerative 
 absorption or wiU have curled and turned in, and then the 
 surgeon wiU be compelled to apply the caustic or the knife 
 for their removal. Formerly, surgeons were in the custom of 
 using a large curved scissors to cut away all this loose skin, 
 and thus leave a very large ulcerated surface : such an 
 operation would be considered at the present day not only 
 useless, but injurious and cruel. When a quantity of loose, 
 thickened, and corrugated skin forms the sides of a deep ulcer, 
 we should rub these flaps, or their edges, with the kah pm-um ; 
 thus a portion of this superfluous skin will be removed, and a 
 vigorous healing action will be excited in the remainder, and 
 the healing will be much promoted by pressure applied over 
 the entire ulcer. 
 
 Should a bubo become phagedaenic, and threaten to open 
 the femoral artery, or should it give rise to constitutional 
 fever and irritation, its further progress can often be almost 
 instantaneously arrested by brushing over the edges with the 
 strong muriate of antimony ; and however large the surface, 
 it will begin to heal, even if the edges alone have been touched. 
 The pain from this application must be severe, but it does not 
 last in general more than from half an hour to an hour ; and 
 the patient then often finds great relief, and falls into a sound 
 refreshing sleep of some houtrs' duration ; although, perhaps, 
 for many nights previously, he had been unable to procure 
 rest, even with the assistance of large doses of opium. 
 
 After a bubo has opened spontaneously, we sometimes find 
 that one of the lymphatic glands rises up from it, and 
 protrudes beyond the surface of the surrounding skin, the 
 loose edges of which overhang its base. This, though formid- 
 able in appearance, is not very painful : it gradually subsides, 
 and becomes covered by skin in the process of cicatrization, 
 like the rest of the ulcer, and yields as certainly, though not 
 
116 BUBO. 
 
 as quickly, as the other primary symptoms when once ptyalism 
 is fairly established. Some have advised the destruction of 
 the protruded gland by caustics and other means ; but I have 
 never seen a case in which any such severe measures were 
 necessary. 
 
 We sometimes meet with the following condition of a bubo, 
 — a large, indm-ated, indolent mass, the integuments but 
 little or not at all discolom-ed, with sometimes a slight 
 tendency to inflammation and suppuration, and yet the 
 patient has used mercury so as to ailect his system : in such 
 a case I think blisters will be found most efficacious ; they 
 should be applied repeatedly, but not retained longer on the 
 part than five or six hours. Some advise us, if we feel a 
 softened spot in the centre or in any part of this tumour, to 
 apply the kali purum, with the hope not only of letting out 
 the matter, but also of exciting a healthy inflammation in the 
 part : this practice, however, entails the additional incon- 
 venience of an open ulcer without accelerating the dispersion 
 of the bubo as efficaciously as blisters do. Many cases of this 
 sort are ascribable to an injudicious use of mercury, and 
 therefore we must at the same time apply ourselves to restore 
 the system to a more healthy state. 
 
 A bubo not unfrequently leads to another tedious local 
 affection, that is, a sinus commencing at the pubic corner of 
 the ulcer, and descending in the angle between the scrotum 
 and the thigh ; we observe the skm in this situation to be red 
 and raised ; by pressing on this we force out a little matter 
 into the ulcer; from day to day we can see this sinus 
 increasing in length. This disease teases the patient for a 
 long time, as it continues even after the accompanying chancre 
 has healed under the influence of mercury. Pressure has no 
 influence in arresting the progress, or in effecting the cure of 
 this sinus. The treatment to be pursued in this case is either 
 to leave it to the restorative powers of the system, or, if these 
 prove inefficient, we may divide it in its entire length, or make 
 a small opening into it inferiorly, and daily inject some 
 stimulant fluid. 
 
 Another, and a still more troublesome consequence of bubo, 
 is a superficial spreading of the ulceration along the inside of 
 
BUBO. 117 
 
 the thigh, in some cases even to the anus ; in others it extends 
 upwards on the abdomen, and in some it occupies both 
 situations; one edge of this ulcer is deeply and slowly 
 increasing or eating away, while the opposite is thin and may 
 be healing : this is what has been described as the horseshoe 
 ulcer ; it is often very sensitive. Mercury in general does not 
 serve this symptom, it sometimes even seems to excite its 
 rapid extension : lotions of different kinds, especially the black 
 wash,, appear to me to agree with it better than any other 
 applications, yet in some cases very minute doses of mercury 
 will be found most useful in disposing the ulcer to heal. Let 
 the following serve as a striking, but not an unparalleled, 
 instance of the extent to which this kind of ulcer sometimes 
 spreads, of the great length of time during which it may 
 continue, and of the difficulty with which it is at length 
 brought to heal. 
 
 October 13th, 1826. Mr. H — , aged 30 years, contracted a 
 chancre on the frsenum three years since. Argentum nitratum 
 was rubbed on the ulcer, and he used mercm-ial ointment 
 under the care of a physician who made him repeatedly 
 suspend the use of mercury the moment his mouth became 
 ever so slightly affected. Before he had ceased the course of 
 frictions, a bubo appeared in his groin — this was punctured 
 with a lancet. In five months after the appearance of the 
 chancre he consulted an eminent surgeon in Cork, who 
 prescribed some form of mercurial pills which slightly 
 salivated him : he used only twelve of these. This surgeon 
 then told him he should not use any more mercury, and 
 advised sarsaparilla, lotions, and ointments of various kinds. 
 Twelve months from the commencement of the disease he 
 again consulted the same surgeon in consultation with 
 Mr. Evans, the author of the ' Treatise on Ulcerations of the 
 Genital Organs.' Eepeated venesections and low diet (the 
 results of their deliberations), he states, induced great 
 weakness, and nearly brought him to death's door. 
 
 When recovered from the debilitating effects of this plan, he 
 repaired to London, where he remained for one month under 
 the care of the late Mr. Abernethy. Blue pill every second 
 night, and a sort of blue wash, constituted the plan of treatment. 
 
118 BUBO. 
 
 He next applied to another very eminent surgeon in London, 
 wlio tried blue pill for a short time, but laid it aside because 
 he thought it caused erysipelatous inflammation, and he 
 cautioned him never again to use mercury. Under this 
 gentleman's care he remained for two months, trying a great 
 variety of external applications, never employing the same 
 beyond four or five days. He also used a variety of internal 
 remedies, among which were acids, bark, and arsenic. 
 
 He next applied to the late Mr. John Pearson, and during 
 six weeks that he remained under his care he took sarsapariUa- 
 syrup, and used a variety of local applications, of which he 
 can only name carrot poultice. 
 
 In the summer of that year he drank the Harrogate waters 
 for one month, having been told that the sores were prevented 
 from healing by a scorbutic state of his blood. He derived no 
 benefit from these waters. 
 
 During the last year he had gone through long courses of 
 sarsaparHla, and repeatedly. 
 
 At present he has an ulcer, the size of a shilling, on the left 
 outer ancle : this does not possess the character of a secondary 
 venereal ulcer. In the left groin is a cicatrix, which, beginning 
 about the anterior spine of the iUum, is continued down the 
 groin and passes to the back of the thigh, where it joins a 
 prodigiously extensive ulcer ; this ulcer reaches from the anus 
 down along one-third of the back of the thigh ; below the fold 
 of the buttock it covers the entire breadth of the posterior part 
 of the thigh ; above the fold of the buttock it is less wide, 
 being in one place as narrow as one inch and a half. It is 
 surrounded by a very deep edging of skin, which is cut very 
 irregularly into knobs. The surface of this extensive ulcer is 
 everywhere devoid of granulations, and presents three spots of 
 deeper ulceration in parts remote from each other. The 
 entire of this ulcer is exquisitely sensitive and sore. Another 
 branch of the cicatrix extends along the front of the thigh, 
 and, having traversed the upper third of the limb, it there 
 ends in an irregular deep ulcer, the size of half-a-crown. The 
 skin of the forehead near the roots of the hair is a deep red or 
 copper colour, and the scalp is in a very scruffy condition. 
 The general health is apparently very good. For three years 
 
BUBO. 119 
 
 he has been prevented by this disease from attending to any 
 business. 
 
 October 13th, 1826. Ordered Ung. Hydr. Port. gr. x. omni 
 nocte femoribus infricanda. '^i Aq. Calcis, gviij. Hydr. Oxym. 
 gr. ij. M., ft. lotio ulceribus apphcanda. 
 
 23rd. Eepet. Ung. et Lotio. — Ung. Hydr. Nitr. 5i. Ung. 
 Zinci, §i. ft. ung. quo curentur ulcera omni nocte. 
 
 28th. No sensible effect on the mouth ; bowels costive. 
 Ung. Hydr. Fort. 9 i. o. n. Lotio Acet. cupri ulceribus ; Pill. 
 Purg. pro re nata. 
 
 November 6th. Mouth slightly affected, which induced him 
 to omit the mercurial ointment the last three nights. Anterior 
 ulcer of the thigh had been covered with Hydr. PrsBC. Eub., 
 which has acted too severely, having carried off everything 
 like granulation. 
 
 7th. 9i. Ung. Hyd. Fort, alt noct. — 5. Ung. c. Lapid. 
 Calam. gi. Ung. Mvag. Mxia 5ij. fiant ung. — quo curentur 
 ulcera omni nocte. 
 
 18th. Ulcers are all healing, but without throwing up 
 granulations. In the ulcer in front, as also in that behind, 
 some new ground has been broken up. Ung. Hyd. Fort. 9 i. 
 alt. nocte. 
 
 16th. Mouth not affected ; ulcers improving. Ung. Hyd. 9 i. 
 omni nocte. 
 
 22nd. Mouth slightly affected; ulcers are all improved ; 
 that on the outer ancle is not larger than the surface of a 
 split pea; that on the front of the thigh is not as large as a 
 sixpenny piece, but not granulating. The ulcer on the back 
 of the thigh has the greater part of its surface covered with 
 very small granulations, and altogether shows a strong 
 disposition to contract and heal. In one part it is only half 
 an inch across, and in a narrow neck only one-quarter broad. 
 There is still too great a thickness of the scales in the scalp. 
 Eepetatur Ung. 9i. o. n. Sumat. Sulph. Quinse. gr. ij. ter 
 in die. 
 
 26th. Mouth not more affected : ulcers are all slowly but 
 steadily improving ; the large one is obviously healing, more 
 by contracting its surface than by granulations. Eepetatur 
 Ung. 9 i. 0. n. et Sulph. Quinae. 
 
120 BUBO. 
 
 December 1st. Mouth more affected : the small ulcer on 
 the front of the thigh is nearly healed ; since 26th ult. it has 
 healed much more rapidly than I had expected; the large 
 ulcer is also contracting rapidly, its edges are much less 
 raised. Pergat. 
 
 7th. He has now rubbed for twenty-four successive nights 
 Ung. Hyd. Fori. 9i., by which his mouth is affected, but this 
 affection does not increase according to the increased number 
 of rubbings. The two small ulcers have scabbed ; the large 
 ulcer is very much reduced in extent, is much less irritable, and 
 its edges are very healthy. Omitt. Ung. — repet. Sulph. Quinse. 
 
 13th. Mouth is more affected since he left off the rubbings. 
 The large ulcer is diminishing rapidly, its edges are much 
 thinner, its surface is more healthy, being red and covered 
 with very minute granulations. 
 
 28th. General health is very good ; the scab has dropped 
 off the ulcer on the ancle ; that on fore part of the thigh is 
 very small. The large idcer is healing fast by contraction, 
 and is not skinning from the edges, although the edges are 
 thin and the entire surface is covered with small fii'm 
 granulations ; no bad spot appears on its surface ; the 
 greatest length, which is along the internal edge, is four 
 inches and a quarter, and the greatest breadth from angle to 
 angle is three inches. Ung. Hyd. Fort. 9 ss. o. n. — omitt. 
 Sulph. Quinse. 
 
 January 14th, 1827. Greatest breadth of the ulcer is two 
 inches and three-quarters ; greatest length, three inches and a 
 half. The surface of the ulcer is not ^uite so healthy ; it shows 
 more of a yellowish surface. The gums of the lower incisors 
 are sHghtly affected hj the mercury. General health is good. 
 Eepet. Ung. 9ss. o. n. — I^. Ung. Cerse Flavae §1. Hyd. Praec. 
 Eub. 5i. Fiat. Ung. omitt. lotio. 
 
 10th. The ulcer is not contracting; it has become more 
 irritable ; in different spots the granulations have been swept 
 away ; no sloughing. Ung. Hyd. Fort. 9 i. o. n. 
 
 19th. Mouth very slightly affected ; ulcer is rather more 
 unhealthy than on 10th instant. Und. c. Lapid. Calam. gi. 
 Ung. ^rug. iEris 5ij. fiat ung. Omitt. Ung. Hyd. Sumat. 
 Sulph. Quinse gr. ij. ter die. 
 
BUBO. 121 
 
 23rd. Ulcer much contracted ; surface much more healthy, 
 with only one or two spots of a yellow colour ; the edges are 
 remarkably diminished in height. 
 
 February 1st. The ulcer is three inches in length and two 
 inches iu breadth ; its edges are perfectly flat and level with 
 the granulations. The ointment does not smart it ; he dresses 
 it twice a day. Eepet. Sulph. Quinas. 
 
 21st. The ulcer is one inch and a quarter in its greatest 
 length ; the edges and the surface are perfectly healthy, except 
 in the centre ; here it is of a dirty dark green colour, bleeding 
 on the slighest friction. He has laid aside the quinine. 
 
 March 2nd. Ulcer has now assumed a circular form, and 
 is less than half an inch in diameter ; the edges are not at all 
 raised ; the granulations are very healthy. It will be healed 
 perfectly in six or eight days. He returns to the country 
 to-morrow. 
 
 Although a period of four months and a half might, at first 
 sight, appear very long for the healing of an ulcer, yet when 
 all the circumstances of the case are considered a different 
 conclusion will probably be drawn. When we take into 
 account the very great extent of ulcerated smrface, and the 
 increased difficulty of healing any sort of very large ulcer; 
 when we recollect the very obstinate nature of this, which had 
 proved so intractable in the hands of so many eminent 
 surgeons, some of whom had devoted themselves very much 
 to the treatment of the venereal disease and its sequelae ; and 
 also when we consider the great variety of local and constitu- 
 tional remedies which had been so ineffectually employed, it 
 must be admitted that this was an ulcer difficult to heal. It 
 is pretty plain also that sarsaparilla had not the power of 
 inducing it to do so, for in addition to the use of it under the 
 late Mr. John Pearson's care the patient himself had employed 
 it repeatedly during one year. Without presuming to say 
 that this ulcer could not have been healed without the use of 
 mercury, this much is pretty clear, that it had resisted a vast 
 variety of other modes of treatment. When I undertook to 
 employ mercury in this case I proposed to myself to 
 treat it as I would one of those cases of secondary venereal 
 ulcers which require a very sparing use of mercury, and of 
 
122 BUBO. 
 
 which 1 shall speak -when treating of secondary venereal 
 symptoms. 
 
 In Mr. H's ease the system resisted the action of mercury 
 very strongly, as his mouth was not in any degree affected 
 until the 5th November, and did not at any time exhibit 
 symptoms of ptyalism. Yet as soon as the system acknow- 
 ledged the action of mercmy, then have we the first account 
 of improvement in the ulcers. On December 7th the mercury 
 was omitted because I feared to persevere longer ia its use, 
 seeing that the soreness of the mouth did not increase with 
 the increased rubbings, and fearing that this mineral would 
 soon begin to act as a poison. The mercury was resumed on 
 28th December, but it now appeared to disagree, for on 
 January 10th, in different spots, the granulations had been 
 carried off. On 19th January, the ulcer receiving a still more 
 unfavom-able aspect, the mercury was relinquished, and in a 
 few days the ulcer put on a favom'able appearance, and 
 proceeded slowly, yet without interruption, to a final healing. 
 
 I am fully convinced that had the mercury been employed 
 in the ordinary manner of beginning with 5ss. or 5i., and 
 afterwards increased, it would have had a deleterious effect on 
 the ulcer, and have caused it to spread and to slough ; so 
 mainly is the benefit of mercmy dependent on our apportioning 
 the doses to the state of the system, and to the pecuhar 
 condition of the existing symptoms. 
 
 Now, although this ulcer had not the characters of secondary 
 venereal ulcer, and although it was not attended with any 
 other venereal symptom, if we except the suspicious state of 
 the forehead, yet I am disposed to think that it had been kept 
 for two years from healing by some infusion of the venereal 
 poison ; this, however slight, the constitution was not able to 
 subdue or expel, even though assisted by various reputed 
 antivenereal medicines, until mercury was tried and persevered 
 in, in the manner I have detailed. 
 
 I beg it may not be inferred that I would recommend the 
 use of mercm-y in all cases of this horseshoe ulcer, the 
 consequence of ulcerated bubo ; or that I conceive that such 
 ulcers cannot be cured without the use of merciu-y. On the 
 contrary, I have often Been them yield, though slowly, to 
 
BXIBO. 123 
 
 other treatment, and I have even known some to have heen 
 made worse by the use of mercury. But surely when other 
 means have been tried fully, and without good effect, we 
 should not refuse our patient the chance of being benefited by 
 mercury, especially as we can protect him against any of its 
 mischievous effects by using it in very small doses, and by 
 carefully watching its influence on the system and on the 
 ulcer. In the case I have just stated, I preferred the ointment 
 to any internal preparation of mercury, as I was certain that 
 this would agree with his system fuUy as well as any other 
 form of the medicine, and especially as the last internal 
 preparation which he used seemed to have disagreed with him 
 so much as to have made his surgeon caution him against 
 ever using mercury again. 
 
 The history of bubo would be incomplete were we not to 
 mention that this symptom occasionally, but rarely, precedes 
 by a few days the appearance of chancre : such cases require 
 great caution on the part of the surgeon ; he should be slow 
 to pronounce them venereal, and he should not commence a 
 mercurial course until the chancre has appeared : this delay 
 cannot be productive of any bad consequence, but on the 
 contrary will encourage both patient and surgeon to enter 
 on the mercurial course with greater confidence as to its 
 propriety. 
 
 [The form of bubo above alluded to is that recognised by French 
 writers as "Bubon d'emblee." Hunter admitted its existence; but in 
 more recent times, Lagneau, Vidal de Cassis, and Castelnau have more 
 particularly discussed the bubo at 'the first onset. There can be little 
 reasonable doubt that true venereal buboes may exist either without 
 preliminary chancre, or where the chancre has existed in so sUght and 
 transient a form as to escape the notice of the patient, and have healed 
 before advice is sought ; it is, however, also probable that buboes at the 
 first onset may be instances of simple adenitis connected with excessive 
 coition. 
 
 Between the virulent adenitis of soft chancre and the multiple, 
 indolent, indurated, non-suppurating glandular engorgements of true 
 syphilitic bubo, CoUes makes no distinction. The chronic form of bubo 
 next mentioned and particularly dwelt upon in Chapter XII. of this work 
 belongs to a later period of the disease.] 
 
 There is a chronic form of bubo which sometimes appears. 
 
124 BUBO. 
 
 in connexion with secondary venereal symptoms, the con- 
 sideration of which we shall reserve until we come to speak of 
 the secondary symptoms of syphilis. 
 
 The lymphatic vessels of the penis are sometimes affected 
 not only with inflammation along their comrse, but in a few 
 cases this iuflammatiou will in some one part of the vessel go 
 on to cu'cumscribed suppuration, forming what has been, 
 termed lymphatic bubo. In a few instances we may find two 
 of these buboes in the same individual. 
 
 In an hospital patient, in September, 1833, one of these 
 buboes took place a Httle anterior to the pubes, and another 
 iu the central line of the pubes, a little above the penis. 
 These arose from rather a large chancre on the external 
 surface of the prepuce, near to its orifice, and on its dorsal 
 aspect. 
 
 In a private patient I lately saw one small bubo a little 
 anterior to the pubes, and another between the pubes and left 
 groia. So that there is no determined point at which these 
 must occur. It is cui-ious that, although one of these buboes 
 may go on to suppuration, especially when mercury disagrees 
 with the system, yet we rarely, if ever, see the second run into 
 this state — it slowly retires. 
 
125 
 
 CHAPTEE Vi. 
 
 ON A DISEASE OP THE LYMPHATIC GLANDS OF THE GEOIN, 
 ATTENDED WITH PECULIAE SYMPTOMS. 
 
 The following account was published in the Dublin Hospital 
 Keports in the year 1818 : I have thought it advisable to 
 introduce it here, in reference to the subject of the preceding 
 chapter. 
 
 One of the lymphatic glands of the lower or femoral range 
 is generally the seat of this disease. Sometimes, however, it 
 is seated in one of those of the upper or inguinal row. I have 
 never had an opportunity of seeing the disease in its incipient 
 state, the patients not having applied to me until the swelling 
 had attained the size of a walnut. At this period the 
 integuments are not in the slightest degree discoloured, nor is 
 the surface shining. The inconvenience of which the patient 
 coihplaias is a slight pain which he experiences in walking or 
 in making any considerable exertion with the lower limbs. 
 The progress of the tumour to suppuration is uniform, though 
 slow ; the integuments become red, but not pointed ; and the 
 matter is spontaneously discharged at a period varying from 
 the fifth to the eighth week. The cavity of the abscess is 
 small in proportion to the extent and hardness of the tumour. 
 The matter is in general of a tolerably good consistence : not 
 unfrequently a second, and sometimes even a third, collection 
 of matter forms in the neighbourhood of the first, the tumours 
 exhibiting the same indolent character. The openings by 
 which the matter escapes are narrow, and spread not to a 
 large size, preserving rather the appearance of fistulous 
 orifices than degenerating into broad ulcers. In general they 
 heal spontaneously in the course of two or three months from 
 the period of ulceration ; but I have met with some few cases 
 in which they became complete fistulous ulcers, and remained 
 open for the space of even twelve months, the patients having 
 refused to submit to the surgical treatment which fistulous 
 
126 DISEASE OF THE LYMPHATIC 
 
 ulcers require. A very striking feature of this disease is the 
 trifling degree of pain which attends it : the patient suffers so 
 very little as to be capable of ■walking about without any 
 perceptible lameness. I have known some of them, in the 
 situation of merchants' clerks, continue to lead a very active 
 Ufe under this complaint, doing the out-business of the house, 
 as they term it, during the entire progress of the disease. In 
 fact, the patients generally complain more of the bulk than of 
 the pain of the swelling. One case only occurred to me where 
 the pain was such as to require the abscess to be opened with 
 the point of the lancet ; and in this instance, for three or four 
 days after the opening had been made, the patient experienced 
 the most unaccountable soreness and pain from this very 
 trifling operation- In some few cases, while the tumour is 
 approaching to suppuration in one groin, the glands of the 
 other begin to swell, and in a rare instance, now and then, the 
 tumour having arrived at suppuration, remains for a time 
 stationary, the matter is then gradually absorbed, and the 
 swelling at length slowly removed. 
 
 This disease usually occurs in men between the ages of 
 twenty and forty, but in general nearer to the former than to 
 the latter period of life. I have met with only one instance of 
 it in a female, who was about thirty years of age. 
 
 From the very earliest period at which I have had an 
 opporttmity of observing this disease, the constitution is found 
 to be engaged. The patient is affected with headache, which 
 is more severe in the morning, and which is increased by 
 stooping : he also admits, when questioned, that he feels more 
 fatigue than usual from long- continued or violent exertions; 
 his pulse is quick, being in no case, when he is out of bed, 
 under 100, and generally beating 120 in the minute. This 
 quickness of pulse appears the more extraordinary, as it is 
 obviously not produced by a high degree of pain, nor is it 
 accompanied by a discoverable derangement of any other of 
 the functions ; on the contrary, the countenance is natural, 
 respiration easy, skin of temperate heat and not very dry, 
 tongue clean, appetite as good as usual, and scarcely ever 
 nocturnal sweats : the patient, however, feels himself more 
 comfortable in the open aii- than when confined to the house. 
 
GLANDS OF THE GEOIN. 127 
 
 I have had an opportunity of examining one patient only 
 while lying in bed in the morning. His pulse was then only 
 72, but on his rising and dressing himself it rose to 110. 
 The tumour at this time was as large as half a hen's egg, and 
 the integuments were not discoloured. 
 
 The patients generally conceived that their health was 
 improved by this disease ; for, before the final healing of the 
 ulcerated opening, they have informed me that they felt 
 themselves in better health than they had enjoyed for some 
 months previous to the attack. 
 
 In the treatment I have confined myself to those means 
 which I have conceived to be calculated to mitigate the 
 severity of the symptoms, and to promote suppuration, which 
 in general indeed seemed an unavoidable and always a 
 salutary termination of the disease. The headache appeared 
 to be alleviated by no class of medicines but by purgatives. 
 These were repeated every day, or every other day, until the 
 symptoms were completely removed. Very large doses were 
 often required to produce the desired effect. The removal of 
 the headache was not attended with a diminished frequency of 
 the pulse. Poultices, warm fomentations, and gum plaisters 
 were the only topical applications to which I had recourse. 
 Leeches had been applied in two instances before I saw the 
 patients, but apparently without any salutary effect. Cold, 
 and as they are termed repellent applications, when used for 
 a few days in the earlier stages of the disease, did not appear 
 to produce either benefit or injury. 
 
 A knowledge of this disease may probably assist us at some 
 future day in developing the pathology of the lymphatic 
 system, which remains still involved in considerable obscurity, 
 and will at all events be of some use, I trust, in practice. 
 
 I cannot say from observation what consequences would 
 result from the exhibition of mercury in this complaint. 
 But I apprehend that we have everything to fear from 
 administering that medicine to patients affected with such an 
 extraordinary quickness of pulse. Indeed, the very appre- 
 hension of the evils that might thence result has deterred me 
 from ever putting the matter to the test of an experiment. 
 
 We should be careful to distinguish cases of this disease 
 
128 DISEASE OF THE LYMPHATIC GLANDS OF THE GROIN. 
 
 from examples, no doubt very rare, of truly venereal enlarge- 
 ment of those glands wherein the sweUmg of the gland 
 precedes, for some days, the appearance of the chancre. By 
 attending to the constitutional symptoms, so characteristic of 
 the disease here described, we shall with certainty avoid this 
 error. 
 
 I may here observe that, in some instances, when an 
 enlargement of the inguinal gland arises from the di-ying up a 
 venereal chancre without the use of mercury, the patient will, 
 as in this complaint, be affected with severe headache and 
 quickness of pulse. Such cases, however, will scarcely be 
 confounded with the disease here described ; for the previous 
 ulceration of the genitals in the one case, and the absence of 
 that symptom in the other, are sufficiently characteristic, and 
 though the quickness of the pulse and the severity of the 
 headache be common to both, yet these constitute almost the 
 only constitutional symptoms in the one case, while in the 
 other they form but part of a series of alarming derangements 
 of the system, such as remarkable prostration of strength, 
 loss of appetite, and profuse night sweats. In short, the one 
 case presents us with a striking picture of general disease and 
 debihty; while the other exhibits every character of general 
 health, except the affection of the head and the extraordinary 
 quickness of the pulse. 
 
 Since the preceding observations first appeared I have had 
 many opportunities of treating this disease, and I have met 
 with fom- or five cases in which the patient was reduced to a 
 state of extreme weakness, emaciation, and hectic, by 
 repeated suppm-ations and profuse discharges ; and I am 
 happy to say that I found a certain and rather speedy remedy 
 for all this alarming extent of disease in sea air and tepid salt- 
 water baths. Of course tonic remedies formed a part of the 
 treatment, but in my opinion the credit of the cures must 
 chiefly be ascribed to the sea air. 
 
129 
 
 CHAPTER VII. 
 
 ON SECONDAKY SYMPTOMS. 
 
 When a primary symptom has been long neglected, or 
 when treated injudiciously or carelessly, it may happen that 
 the first series of secondary symptoms shall make their 
 appearance before it has been removed, and thus the patient 
 may labour under both primary and secondary disease at the 
 same time. In some cases the condition of the primary 
 symptoms does not appear to undergo any change in 
 consequence of this accession of disease; but in other 
 instances we find it to be materially affected. It is not very 
 uncommon for the surgeon, in treating a chancre of an old 
 date, or an ulcerated bubo, when he has brought them into a 
 healthy state to find his hopes disappointed for the present, 
 and to see this ulcer most unaccountably change its apppear- 
 ance and take an unfavourable turn, either by sloughing or 
 assuming the phagedssnic character ; and this unfavourable 
 change will, in spite of the most judicious treatment, continue 
 for eight or ten days, until the secondary symptoms are fully 
 established. 
 
 Nor yet is it very common for a primary symptom which 
 has been obstinate, and has for many days undergone a very 
 imfavourable change, suddenly and unaccountably to assume 
 a healthy aspect, and for a few days make rapid advances to 
 healing; this progressive improvement, however, is checked 
 as soon as the secondary symptoms are fuUy developed. 
 I freely confess that I am unable to explain why such 
 different and opposite effects should result from the same 
 cause, viz., the development of the secondary symptoms. 
 This is a point which deserves close and attentive observation; 
 the discovery of it may lead to some useful hints to guide our 
 treatment of obstinate primary symptoms. 
 
 When this combination of primary and secondary symptoms 
 is treated by mercury we shall observe that both forms of the 
 
 E 
 
130 ON SECONDAR-Y SYMPTOMS. 
 
 disease will come under the influence of its action at the same 
 time. No doubt some secondary symptoms, viz., eruption 
 and sore throat, are apparentlj'^ much more early affected by 
 it ; thus an eruption will have sensibly declined before the 
 chancre or ulcerated bubo will have assumed the aspect of a 
 granulating ulcer. But if we closely watch the primary ulcer 
 we shall see as early, though not as signal, an impression 
 made upon it. The assertion that the secondary are cured 
 sooner than the co-existent primary symptoms appears to me 
 to be derived from a hasty and superficial view of the subject, 
 from mistaking the great amendment in the former for a 
 cure, and that only in two sj'mptoms — sore throat and 
 eruption. For if we chance to meet with the rarer case in 
 which primary and secondary ulcers in other situations co-exist, 
 we shall surely see the primary healed some time before the 
 secondary ulcer, and that too in eases where both are nearly 
 of equal size. 
 
 In treating of the history of the venereal disease I expressed 
 my regret that Mr. Hunter had not followed ou.t the course of 
 the disease beyond the appearance of secondary symptoms, 
 omitting all those constitutional changes and diseases which 
 intervene between this period and the fatal termination. 
 Again we have to regret that he has described the secondary 
 symptoms in such a manner as to give only a single description 
 for each class. Thus, in speaking of venereal sore throat, he 
 has described only one form of ulcer ; no doubt he has hinted 
 at one or two varieties under which the venereal eruption 
 appears, but he has glanced at these in such a manner as can 
 convey very little information on this subject to an in- 
 experienced person ; while on the subject of venereal sore 
 throat he has not even once alluded to the vast variety of 
 features which this class of secondary symptoms presents, 
 according to the modifications which the disease may have 
 undergone from peculiarity of constitution, or from the 
 influence which previous courses of mercurial or other treat- 
 ment may have induced. 
 
 It is remarkable that Mr. Hunter has given only one form 
 of each symptom, whether primary or secondary, — e.g., one 
 form of chancre, one of venereal sore throat, the same of 
 
ON SECONDAET SYMPTOMS. 131 
 
 venereal eruption ; and on the subject of nodes he is equally 
 limited. Perhaps he intended only to sketch the great 
 outlines of the symptoms, reserviag for a subsequent oppor- 
 tunity his observations on the varieties which each order of 
 symptoms occasionally presents. 
 
 Every person, however, who has paid even moderate 
 attention to the secondary forms of the venereal disease, will 
 admit the accuracy with which Mr. Hunter has described the 
 order of parts successively attacked. No doubt, as he has 
 remarked, we occasionally meet with exceptions to this rule, 
 and some of the parts second in order will be affected before 
 those which are generally the first. He has not attempted to 
 account for this phenomenon : from a good deal of observation 
 I am disposed to ascribe it, in some cases, to the maladminis- 
 tration, and in others to the excessive use, of mercury, by 
 which both the healthy and morbid actions in the system have 
 been disturbed and deranged. 
 
 When we inquire into the time at which the secondary 
 disease has succeeded to the first inoculation, we ahall find it 
 to differ in different individuals, and we shall also find that it 
 is influenced by the previous treatment of the primary 
 symptoms. Where these have been treated on the non- 
 mercurial plan we generally observe that the secondary 
 symptoms are later in appearing, and that they are also 
 preceded by less previous disturbance of the system; but 
 when mercury has been used for a short time only, or has 
 been discontinued as soon as the chancre had healed, we shall 
 find in such cases that the secondary symptoms will appear 
 more early. It is generally admitted that if febrile action be 
 excited by ordinary causes, this very action will eliminate the 
 virus and make secondary symptoms display themselves at 
 an earlier period. In some persons, however, secondary 
 symptoms do not occur until after a very long interval of 
 time, perhaps six months. 
 
 [The question of how far the secondary disease is influenced as to the 
 time at which it succeeds to the first inoculation, first by the individual 
 differences of the patients, secondly by the previous treatment of the 
 primary symptoms, is one still open to careful observation. CoUes had 
 reason to believe that secondary symptoms are later in appearing in cases 
 
132 ON SECONDARY SYMPTOMS. 
 
 treated on the non-mercurial plan, and that when mercury has been used 
 for a short time only that secondary symptoms will appear more early. 
 Some excellent observers, as Langston Parker, Hardie, Comrie, Gas- 
 ooyne, Longmore, &c., take a different view: they beheve that those 
 symptoms are postponed and modified by mercurial treatment. Among 
 many of the most reliable practitioners of the present day the opinion 
 prevails that secondary symptoms cannot be prevented by mercurial 
 treatment of the primary disease. Among these may be mentioned 
 Marston, Longmore, Peny (Boyal Artillery), Comrie, Nelson, Sir W. 
 Fergusson, Langston Parker, De Merio, and others. Mr. Jonathan 
 Hutchinson says after mercurial treatment " the secondary symptoms, I 
 think, are rather Mghter, but I feel certain that it does not prevent their 
 occurrence : they come out just about the same time, I think." Mr. Skey 
 says: — " I think it is clear that the primary sore treated by mercury is 
 as likely to be followed by secondary disease as the primary sore not 
 treated by mercury." * CoUes's opinion, as stated at pages 55 and 56, is 
 exactly the reverse of this. " Hunter," says Bicord (and precisely the 
 same may be said of OoUes), "had observed that the chancre was on 
 certain subjects a pui-ely local affection. He affirmed that infection 
 might he prevented by early and well-directed therapeutical means. But 
 that which he attributed to the influence of medicine I attribute to the 
 special form of the primitive ulceration. Without doubt there are 
 chancres which infect the economy, whilst there are others which do not 
 infect it, and that, let it be understood, independently of every therapeutic 
 influence. Many practitioners adopt in good faith the mercurial treat- 
 ment for the simple non-infecting chancre. How many honest and 
 upiight individuals believe they have cured Syphilis which in reality 
 never existed."] 
 
 For some days before the secondary symptoms appear the 
 patient feels himself out of order, is languid in the evening, 
 unwilling to use either mental or bodily exercise, and often 
 complains of pains in the shoulders or legs; these do not 
 remain fixed, but at different times they affect different parts ; 
 his sleep is unrefreshiag. These fugitive pains all cease as 
 soon as the eruption or sore throat appears. 
 
 The latter affection is at first attended with slight uneasiness 
 in swallowing ; in the coiu-se of a few days this amounts to 
 pain ; a dryness is also felt in the throat when the patient 
 awakes at night, and his efforts to swallow saliva are productive 
 
 *See evidence and " Eeport of the Committee appointed to enquire 
 into the Pathology and Treatment of the Venereal Disease with the 
 view to diminish its Injurious Effects on the Men of the Army and Navy," 
 18C7. 
 
 r 
 
ON SECONDAEY SYMPTOMS. 133 
 
 of more pain than his attempts to swallow food or drink ; a 
 slight external tenderness and swelling are now discoverable 
 in the site of the tonsil. On inspecting the throat we observe 
 one tonsil or both swollen, with increased redness, and we 
 readily discover an ulcer which Mr. Hunter describes as 
 " a fair loss of substance, part being dug out, as it were, from 
 the body of the tonsil, with undermined edges : this is 
 commonly very foul, having white thick matter adhering to it 
 like a slough, which cannot be washed away." The patient 
 complains of pain running upwards in front of the ear and 
 occasionally down the side of the neck, even to the point of 
 the shoulder. 
 
 This form of venereal ulceration of the throat may be 
 looked upon as the type of the genuine venereal sore throat. 
 However strongly the characters of the ulcer may be marked, 
 still we must not rely solely on the present appearances ; we 
 should trace back the history of the previous disease, look to 
 the interval which has elapsed, inquire into the premonitory 
 symptoms, as also into the treatment which had been employed 
 for the cure of the primary disease. 
 
 Having satisfied ourselves of the nature of the disease, we 
 next enter upon the treatment, which must be conducted 
 according to the rules already laid down for the treatment of 
 secondary symptoms. I need not repeat the admonition 
 of taking care to excite the mercurial action in the manner 
 most likely to insure its sanatory operation, to produce the 
 least possible injury to the constitution, and yet to excite 
 and keep up such a mercurial action as we know is most 
 likely to effect a permanent cure of the venereal disease. 
 This action, I need scarcely say, will require, in general, to be 
 kept up for eight or ten weeks. In this, as in primary 
 chancre, I would abstain from local applications to the ulcer, 
 as the changes which the latter undergoes will, in various 
 instances, assist us in discovering when mercury is beginning 
 to disagree with the system ; besides, we must be guided in our 
 opinion as to the proper duration of the mercurial course by 
 a reference to the period of the healing of the ulcer in 
 the throat. Should we be so unfortunate as to have merely 
 caused the ulcer to heal without at the same time thoroughly 
 
134 ON SECONDAEY SYMPTOMS. 
 
 eradicating the disease, we shall find that the ulcer wUl 
 return, in the same or the other tonsil, and with precisely the 
 same characters as the first ulcer in the throat had done. 
 
 The perfect em-e of the disease is not at all times enough 
 to satisfy the patient ; for we are often called upon hy a 
 patient whom we have cured of a venereal sore throat, but 
 who is in great alarm, and states that he is not cured ; that 
 he feels his throat as bad as ever ; that he has the very same 
 pain in swallowing, and the very same uneasy sensations 
 which accompanied the former ulceration ; yet, on inspection, 
 every pai-t of the throat appears m a healthy state. On the 
 closest examination we cannot discover anything morbid, 
 except occasionally some vei-y slight appearances of inflam- 
 mation. Now all this alarm is groundless ; it arises from the 
 facility with which morbid sensations are renewed. "We some- 
 times trace this alarm to a local excitement caused by a fi-esh 
 cold, sometiaies to a derangement of the stomach or bowels, 
 and in some few cases .it is the ofl^spring of slight hypochon- 
 driasis. I think the practice of washing and rubbiag the 
 throat externally will prove the best means of preventtag or 
 removing this disquietude. Country air and sea-bathing are 
 also of the greatest service. 
 
 The venereal ulcer of the throat, though generally seated in 
 the tonsil, wdl yet in some instances fix itself in a part where 
 it is very much concealed from view ; and therefore we should 
 be prepared to search for it when the sensations of the patient 
 lead us to apprehend the existence of such an ulcer. In one 
 or other of the following spots we shall discover these concealed 
 ulcers. Sometimes we meet with a patient who complains of 
 very severe pain whenever he attempts to swallow, and which 
 occasionally is so constant as to deprive him of sleep ; yet on 
 inspecting the fauces we are sm-prised to find that all within 
 our view appears in a healthy state ; no ulcer can be seen, nor 
 even any appearance of inflammation ui any part. This first 
 view, however, should not satisfy us ; we should consider in 
 what points an ulcer may exist and lie concealed. The most 
 common place for such to occur is on the back pai't of the 
 pharynx, and there it may be concealed by the interposition of 
 the velum palati. We should therefore desire the patient to 
 
ON secoMdaky symptoms. 135 
 
 inspire as fully as he can ; in attempting this he raises the 
 velum, and if we then look into the pharynx we shall 
 generally discover the lower part of an ulcer : this, of course, 
 leads us to make a more full examination ; to effect this we 
 must depress the tongue, and with a curved probe raise up the 
 velum. 
 
 The ulcer, which now becomes more fully exposed to view, 
 is of a circular form, is sunk deep in the substance of 
 the pharynx ; the surface is rather foul, but not at all sloughy ; 
 the surrounding inflammation extends a very short distance 
 beyond the margin of the ulcer. The present sufferings of the 
 patient loudly call for speedy relief, as he is not only deprived 
 of the power of taking nutriment, but he is sometimes kept 
 in a high state of irritative fever. Here we must use topical 
 applications, although by so doing we lose the opportunity of 
 watching the progress of the ulcer towards healing. We 
 should rub the entire surface of the ulcer with muriate of 
 antimony ; the pain which this occasions is no doubt severe, 
 but it is of very short duration, and the patient will soon 
 enjoy sleep, and swallow without any suffering. 
 
 The best mode of applying the mmriate of antimony is 
 by means of a little lint rolled pretty firmly on the eye-end of 
 an aneurism-needle, and dipped in the liquid. We should 
 take great care that the application be confined to the ulcer, 
 for should any of this fluid trickle down towards the larynx 
 it will cause a most distressing sense of suffocation, one which 
 sometimes alarms the surgeon as well as the patient and his 
 friends. 
 
 All the misery attendant on ulceration of the throat will 
 sometimes be found to proceed from an ulcer of the pharynx, 
 situated below the level of the base of the tongue, and there- 
 fore, when we cannot discover any ulceration of the tonsils, or 
 back of the pharynx, high up, we should carefully look for it 
 in the lower part of the latter ; indeed we should be doubly 
 solicitous to discover it, as an ulcer situated so low down may 
 creep still lower, and spread to the sides and top of the 
 larynx, producing there such mischief as must lead to a 
 certain, though often a slow, death. 
 
 The ulcer low down in the back of the pharynx generally 
 
136 ON SECONDARY SYMPTOMS. 
 
 presents a foul, and sometimes a sloughy surface, seldom 
 assuming the venereal characters described by Hunter, and has 
 this remarkable featm-e, — that its lower edge is very sharp, 
 whUe the upper part of the ulcer is superficial. A pretty 
 constant symptom complained of by the patient is that when 
 he attempts to take any food the morsel stops at a certain 
 point, and can only be got down by his taking after it a sup of 
 liquid : in proportion as the ulcer improves the power of 
 swaUowing solids improves also. 
 
 The ulcer once discovered should be very well rubbed with 
 muriate of antimony ; taking very great care, however, to 
 prevent it trickling down to the larynx. 
 
 Another position in which we sometimes find a venereal 
 ulcer, which causes not only pain in swaUowing, but also pain 
 shooting up one side of the head and face, is close to 
 the insertion of the anterior j)alatine arch into the tongue. 
 If the latter sj'mptom be absent the ulcer wiU be found about 
 the central part of the base of the tongue. In making an 
 examination of the throat in such a case we are frequently 
 warned of the existence of the ulcer by the severe pain which 
 we cause to the patient, when, in attempting to depress 
 the tongue by the spatula, in order to search the throat as low 
 down as possible, we chance to lay the instrument on the ulcer. 
 
 The ulcer wiU be found deep and foul, but not at aU sloughy ; 
 and whether it be seated on the dorsum or near the edge of 
 this fold, its exquisite sensibility should be immediately de- 
 stroyed by touching the surface with strong solution of nitrate 
 of silver, or with muriate of antimony. 
 
 In a few instances we observe that the voice of the patient 
 is rendered very nasal, and this sometimes even on the fii'st 
 appearance of the venereal sore throat and eruption ; and yet 
 neither the situation nor the condition of ulcer visible in 
 the fauces will enable us to account for this symptom. In 
 this form of the disease we find that the patient not only 
 suffers severe pain in any attempt to swallow, but he is also 
 teased by frequent desire to draw down the mucus from the 
 back of the nares ; and this secretion, when coughed out, 
 is often found slightly tinged with blood. A smart degree of 
 fever also generally attends. 
 
ON SECONDARY SYMPTOMS. 137 
 
 The ulcer in this case is seated behind the velum, high up 
 in the angle between the upper and back part of the pharynx, 
 or at the juncture of its occipital and vertebral portions. 
 
 In this case we should endeavour to aUay these sufferings as 
 soon as possible ; no benefit whatever can result from our 
 waiting in the expectation of its being healed during the 
 mercurial action ; and as the ulcer is out of sight we cannot 
 derive from it any information to guide us in the administra- 
 tion of the mercury. 
 
 The patient wiU be materially benefited by our rubbing to 
 the ulcer some liquid caustic, such as a strong solution of 
 Argentum nitratum, 9j. ad §j., by means of lint wrapped 
 round the end of a silver aneurism-needle. Here let me 
 caution those who adopt this practice against the danger 
 of this lint slipping off, and remaining behind the uvula when 
 the aneurism-needle is withdrawn. Should this occur the 
 patient will be perfectly miserable as long as it remains there ; 
 and yet such is his impatience that he will not, or cannot, 
 submit to the ordinary means in use for dislodging it. To 
 avoid such an accident we have only to pass one end of 
 the lint through the eye of the needle, and then wrap the 
 remainder about it. 
 
 When the ulcer is seated on the posterior surface of the 
 velum^rather an uncommon case — we are not only directed 
 to its exact seat by an appearance of thickening, together 
 with a blush of redness on the anterior surface of the velum, 
 which appearance corresponds to the seat of the ulcer ; but 
 we can gain a positive knowledge of its situation by carrying 
 behind the veluni an aneurism-needle armed with lint, and 
 rubbing it to the suspected spot ; if there be an ulcer the lint 
 will be covered with the discharge from it. Here also the 
 immediate application of liquid caustics to the ulcer is 
 indispensable. 
 
 Although I have spoken of these as pure original venereal 
 ulcers of the throat, yet I am doubtful whether this arrange- 
 ment be strictly correct. For although I can recollect instances 
 in which the original ulcer first fixed itself in some of those 
 concealed situations, yet I cannot speak with certainty of 
 them all ; and I freely admit that in the relapsed sore throat 
 
138 ON SECONDARY SYMPTOMS. 
 
 the ulcer will frequently be discovered in some of the above 
 positions. 
 
 There is an affection of the throat of which those who suffer 
 from it complain repeatedly. It is by no means»confined to 
 those who labom-, or have previously laboured, under venereal 
 disease, and is occasionally met with in females of most 
 unblemished characters ; still, when it occurs in a patient who 
 has recently been afflicted with Syphilis, it is apt to create 
 much mental uneasiness. I allude to that condition of the 
 mucous membrane of the back of the pharynx in which it 
 is seen to be covered with an imiform thin crust of whitish or 
 yellow hardened mucus : this, of course, is more troublesome 
 in the morning, when it is found to be perfectly dry and 
 hardened than it is in the after part of the day, when it has 
 been broken into detached pieces, some of which have been 
 removed in the act of deglutition. 
 
 This affection, as far as my observation goes, is very 
 obstinate and very tedious. I have known it continue not 
 only for months, but for years. However, though very 
 obstinate, it does not prove dangerous ; for at the end of some 
 years we find the parts in precisely the same state as that in 
 which we saw them when the case first came under our notice. 
 The nature of this disease is very readily ascertained; it. 
 is only required to rub off the mucous crust gently with 
 the probe wrapped round with lint, and then we shall see the 
 membrane perfectly free from ulceration, and in no way 
 morbid, except that it may be a little more muscular, rough, 
 and dry on the surface than it is found to be in a healthy state. 
 The diagnosis, of course, is then easy, but the means of cm-e 
 are by no means either easy or certain. I have known some 
 cases much relieved by gargling the throat with sea-water, and 
 others to be, for the time at least, apparently cured by sea- 
 bathing ; but I have known both fail in many instances. I 
 have, however, never known any case in which the disease 
 degenerated into a worse condition, although I have watched 
 some for ten or twelve years. 
 
 I have ah-eady said that ulcerated venereal throat is often 
 materially changed in its characters by an unsuitable line of 
 treatment : this assertion will be found to be strongly corrobo- 
 
ON SECONDARY SYMPTOMS. 139 
 
 rated by the appearance which the parts present even when 
 healed. How frequently may surgeons observe, on lookmg into 
 a throat which has suffered severely or repeatedly by venereal 
 ulcers, that these now exhibit that smooth, shining, silvery 
 surface which we always see in those spontaneous ulcers 
 occurring in young people, and which are by many called 
 scrophulous ulcers of the throat ; whereas those venereal sore 
 throats which heal kindly, and which have not undergone any 
 very bad change in their course, will be seen to present a 
 healthy surface, similar to that of the rest of the mouth, with 
 only occasionally a slight depression at the part. 
 
 For practical purposes we shall find it of much advantage 
 to attend to these appearances. Suppose, for example, that a 
 patient comes to us complaining of a relapse of his sore 
 throat, and that we discover an ulcer in a fresh part, while the 
 silvery cicatrix is seen in the site of some former ulcer, we 
 are at once led to suspect that this patient's system must have 
 been a good deal broken down by the previous treatment ; and 
 we are warned to avoid the dangers of precipitating him again 
 into a similar state by employing mercury in a manner suited 
 only to an unbroken system. Before, however, we come to 
 any positive determination in such a case we should make 
 particular inquiries as to what had been the local treatment of 
 the ulcers, for the application of a very strong caustic to an 
 ulcer of the throat will be followed by a silvery cicatrix of 
 such ulcer. 
 
 The patient who is labom-ing under venereal sore throat has 
 not only to complain of the pain which he suffers, but is also 
 sometimes afiSicted with a flow of saliva, which pours almost 
 incessantly from his mouth by day, and which, falling back on 
 the larynx when he lies down, threatens instant suffocation, 
 and altogether deprives him of sleep. I know not why it is 
 that this incessant flow of saliva attends some cases and is 
 absent in others. I think this symptom does not depend on 
 any particular situation, or any particular form of the ulcer. 
 I need scarcely say that the diminution of this discharge is 
 one of the first signs of amendment. 
 
 Another distressing symptom, which occasionally attends on 
 venereal sore throat, is the regui'gitation of the patient's drink 
 
140 ON SECONDABY SYMPTOMS. 
 
 through the nose. This alarms the patient excessively ; we 
 can, however, relieve his anxiety by assuring him that this wUl 
 cease when the ulcers have healed. Indeed it is surprising to 
 see how very well many of those unfortunate persons can ulti- 
 mately swallow, even though they have lost a considerable portion 
 oi the soft parts about the palate and fauces. The powers of 
 deglutition in these persons often become wonderfully restored, 
 partly from the contraction which occurs, during the healing 
 process, in all the surrounding parts, and partly from the 
 power which the muscles possess, either of accomodating 
 themselves to their altered condition or of acquiring some new 
 or peculiar mode of action. 
 
 Perhaps in the wide range of surgical diseases we cannot 
 find any one so liable to be materially changed as secondary 
 SyphUis ; I shall not say in its nature, but certainly in 
 its appearance, and in the course of its symptoms, as also in 
 the line of treatment suited to its cm-e. These extraordinary 
 changes some authors have endeavoured to account for by 
 referring them to a scrophulous, or to some other cachectic 
 state of the system of the individual. In my opinion too 
 much stress has been laid upon this explanation ; for if we 
 confine ourselves to those cases in which, from ignorance on 
 the part of the patient, the disease (suppose a venereal ulcer 
 of the arm) has been undisturbed by any active measure, and 
 has been treated only by purgatives, poultices, and mild 
 ointments, — in such instances we do not observe that the 
 genuine characters of the venereal sore have been modified or 
 altered by the state of the general system ; that is, it stiU 
 remains a venereal ulcer. 
 
 I would merely ask a surgeon, who entertains this opinion 
 of the influence of the habit in modifying secondary venereal 
 ulcers, whether he would undertake, by examining a secondary 
 venereal ulcer in any patient, to pronounce from the appear- 
 ances there exhibited that this individual is of a scrophulous 
 habit. 
 
 In my judgment the great varieties in the appearances and 
 nature of venereal sore throats are occasioned by the manner 
 in which mercury has been used, either for the cm'e of 
 primary or for the treatment of the secondary symptoms. No 
 
ON SECONDARY SYMPTOMS. 141 
 
 doubt when mercury is used injudiciously, and in a manner 
 unsuited to the general health and condition of the patient 
 we shall find that it causes more mischief, and produces more 
 strange changes in the venereal ulcers of the throat, if the 
 patient be of a highly scrophulous or of a very delicate habit, 
 than if he be of a vigorous and healthy constitution. 
 
 Among the secondary symptoms of Syphilis we cannot find 
 any which are more strikingly influenced by injudicious 
 treatment (conjoined with peculiar states of the general 
 system) than ulcer of the throat. To describe all the varieties 
 of these, which are thus produced, would be a useless and 
 almost an endless task; but I think it may not be without 
 benefit to say a few words in particular on one which is the 
 most commonly met with, differing, however, in its site and in 
 its extent, in different instances ; as also briefly to notice one 
 or two other varieties. 
 
 In a case where a genuine syphilitic ulcer of the throat has 
 been treated by an irregular or excessive course of mercury, 
 and has healed under this treatment, we shall often find the 
 patient suffer what he terms a relapse of sore throat. The 
 new ulcer, whether it appears in the site of the former one, or 
 whether it occupy some new position, will be found to differ 
 most strikingly from the original ulcer. This appearance, 
 which may be very frequently observed, is that of a superficial 
 ulceration of rather a whitish colour, with a good deal of 
 surrounding redness and some slight degree of swelliag; in 
 fact, it presents many of those characters which might lead 
 some to call it an aphthous ulcer. If we watch the course of 
 this ulcer we shall frequently see that it creeps along from 
 place to place; that unless it be seized by phagadaena, or 
 sloughing, it appears to be rather indolent in its nature and 
 mUd in its character; thus it admits of being healed, or 
 almost healed, by. various topical means, assisted, perhaps, by 
 some tonic or alterative internal medicines. 
 
 A vast variety of ulcerated throats wUl be seen between this 
 well-marked type of the Hunterian sore throat and this 
 aphthous-like ulcer. To describe each of these would be both 
 a vain and a useless task, for the judgment of the surgeon 
 alone must direct the treatment, and suit it to each particular 
 
142 ON SECONDARY SYMPTOMS. 
 
 ease according to the existing circumstances in each. Thus 
 an aphthous ulcer of this kind, in the person of a robust man 
 not labouring under ii-ritative fever, will require and will bear 
 such a course of mercury as would exasperate a similar ulcer 
 in a patient whose system was affected with a high degree of 
 this fever ; nay, the misapplication of this treatment might 
 even endanger the life of the patient. I need not add, that 
 the state of the ulcer itself should also influence our line of 
 treatment ; for, if phagedsena or sloughing should seize upon 
 it, we must prescribe for, or according to, these altered 
 conditions of the ulcer, instead of prescribing according to 
 the name of the disease, a " relapsed venereal sore throat." 
 
 One of the most alarming aspects which venereal sore 
 throat exhibits is the following : — On inspecting the fauces we 
 find the entii'e of the velum and both tonsils in a state of 
 sloughy ulceration, and the back of the pharynx appears 
 converted, as it were, into a soft pultaceous mass; indeed, 
 sometimes we see all parts of the throat covered with this 
 soft slough : by rubbing these parts with lint wrapped round 
 the end of a probe we ascertain that this covering adheres 
 tenaciously to the surface. The patient is scarcely able to 
 swallow even a sup of the most bland fluid ; by day a constant 
 flow of ropy saliva issues from his mouth, and he complains 
 that by night he is not only deprived of sleep by the pain of 
 his throat, but that he is prevented from lying down, for in 
 that position he is in danger of being suffocated by the viscid 
 saliva passing down his throat. His general health is 
 completely broken up, he is emaciated to an extreme degree, 
 his strength is quite prostrate, pulse extremelj' quick, and 
 skin hot ; in fact he is in a very high state of fever which is 
 of the hectic type. In a word, I do not think that a more 
 pitiable and alarming combination of symptoms is scarcely 
 ever presented to the notice of the surgeon. 
 
 When we inquire into the history of such a case, we learn 
 that this unfortunate man had undergone repeated slight 
 courses of mercury, or one or two very severe ones, for the 
 cure of the venereal disease ; that these, for a time, relieved 
 the symptoms, but that on desisting from the use of mercury 
 the disease of the throat had relapsed, and had assumed the 
 
ON SECONDARY SYMPTOMS. 143 
 
 present appearances. I believe that the usual mode of 
 treating such cases is to give sarsaparilla in decoction or in 
 broth,* and at the same time to endeavour to arrest the 
 ulceration of the throat by various topical applications : under 
 such treatment many recover, but with no inconsiderable 
 mischief done to the throat, and after tedious and severe 
 sufferings. 
 
 Now this is precisely one of those cases in which very small 
 doses of mercury will be found of the most signal service ; 
 although I make no doubt but many surgeons will be startled 
 by the mere proposal of using mercury under such dis- 
 couraging circumstances. 
 
 I shall adduce the following as one instance out of many, to 
 prove the safety and the benefit of this line of treatment : — 
 
 James Johnson, ast. 40, 12th ward, admitted January 10th, 
 1836. A number of ulcers with dark brown scabs, but not of 
 a conical or rupia form ; these scabs are of an oval figure, 
 are surrounded by a red defined zone, between which and the 
 edge of the scab runs a yellow ring containing pus. One of 
 these ulcers is on the left side of the nose, one on each 
 eyebrow, two on the forehead, one on the chin, one on the left 
 shoulder, one on the sternum, and one on the left leg. The 
 arches of the palate, uvula, and tonsils are deeply ulcerated ; 
 the entire surface of the pharynx is converted into, or covered 
 over by, a soft slough, like half-boiled flummery. Has great 
 pain and difficulty in swallowing ; there is a constant copious 
 flow of thin saliva ; he complains of pains of shoulders ; sleeps 
 very badly. P. 144. He is very much emaciated and very 
 weak. He states that thirty weeks ago he first perceived a 
 bubo in his left groin ; at this time he had neither ulcer on 
 penis nor discharge from urethra. He took pills, by which 
 his mouth was made sore ; the bubo having spontaneously 
 opened in three weeks. After this he remained well for about 
 seventeen weeks, when he felt his throat sore. For this he 
 
 * To three ounces of sarsaparilla sliced, add three pints of water ; let 
 them simmer on a slow fire until reduced to two pints ; take out the 
 wood, and bruise it in a stone mortar; return it into the hquor, with half 
 a chicken, or half a pound of raw beef without fat, Boil slowly for an 
 hour, and pour off the liquor. 
 
144 ON SECONDARY SYMPTOMS. 
 
 was treated in the infirmary at Liverpool, using pills, by 
 which his mouth was made slightly sore, and his throat was 
 cm-ed. In ten weeks after leaving the hospital, his throat 
 again became sore, and again healed under a more severe 
 salivation. Throat remained well for three weeks only. The 
 ulcers began to appear six weeks ago. 
 
 January 10th, Throat to be brushed every second day with 
 Solut. Arg. Nit. Decoct. Sarsae Bb i. Acid Nit. Dil. 5!. indie. 
 
 January 16th. Throat rather better; is scarcely able to 
 swallow the decoction. Scabs stationary. Pergat. 
 
 January 26th. Two ulcers, one on each eyebrow, show the 
 pointed foitn of rupia. Two others of the ulcers, which have 
 been dressed with ointment, exhibit a flabby surface very 
 different from ordinary secondary venereal ulcer, and are 
 devoid of the yellow ulcerated margin of such ulcers ; the flow 
 of saliva continues unaltered. The throat as on admission. 
 Eepet. Decoct. Sarsae et Garg. Chi. Sodae. Ung. Hyd. Fort, 
 gr. X. 0. n. 
 
 January 30th. Mouth is sore from the mercury. Com- 
 plains of weakness; can swallow fluids only. Ulceration of 
 throat less sloughy; scabs on the face appear as if of less 
 extent; those which had assumed the rupia shape have 
 dropped off. Eepet. Decoct. Sarsae, Garg., et Ung. Hyd. 
 Porter Ibi. indies. 
 
 February 6th. Throat now presents one clean ulcerated 
 surface; left tonsil seems to have been entirely removed; 
 scabs drying and dropping off, those that remain are of much 
 less extent ; has some purging, yet his countenance is good. 
 Since 2nd inst. has used the ointment only every second 
 night. Mixt. c. Decoct. Hsematoxyli Greta Ppt., Tr. Opii, et 
 Tr. Catechu urgente diarrhoea. 
 
 February 9th. Purging continues ; says that he was up 
 twenty times last night. Countenance good; scabs are 
 smaller. Haust. Anod. c. Tr. Opii gut. xxx. Vini Eub. giv. 
 indies. Mist. Cretae c. Tr. Opii urg. diarrhoea. 
 
 February 16th. Throat quite healed ; exposed ulcers 
 healing rapidly; scabs have almost all fallen off; bowels 
 regular ; ptyalism continues. 
 
 February 20th. He is evidently stronger and now out of 
 
ON SECONDAEY SYMPTOMS. 145 
 
 danger. Although his throat is healed he complains of 
 soreness lower down, and he points to a part on a level with 
 the top of the larynx as the seat of soreness. Says that solid 
 food is apt to stop there,, and it requires to be assisted by 
 taking a sup of fluid. When drinking, some of the fluid 
 passes up through his nose : ulcers are much more contracted 
 and with surfaces perfectly healthy; general appearance 
 vastly improved. 
 
 From this time he was ordered Pulv. Ipecac. Comp. at bed- 
 time, a repetition of his porter, and Inf. Citichonse c. Tr. 
 Cinch. Comp. et Tr. Opii, until April 5th. 
 
 On March 1st, swallowing improved, but some of the drink 
 comes through his nostrils ; all the ulcers are nearly healed. 
 
 March 28th. Swallows quite weU ; none of the fluid 
 regurgitates through the nostrils when he drinks. For ten 
 days past has complained of pains of his upper limbs, and of 
 his knees. Profuse night-sweats; sleeps badly; appetite 
 declining. 
 
 It is unnecessary to prosecute the details of this case 
 farther. I shall only add, that a subsequent use of mercury, 
 carried to salivation, did not cause the ulcer of the throat to 
 break out again. I shall have occasion hereafter to explain 
 by what principles I was led to use mercury in this case. 
 
 It not unfrequently happens that these relapsed ulcers of 
 the throat spread along from part to part of both the fauces 
 and the palate, and at times occupy a very considerable 
 portion of both. One rare and unpleasant consequence of 
 this extensive ulceration of these parts is, that in their closing 
 together and healing they form so complete a partition 
 between the mouth and nose that not even the air can pass 
 through, and thus the patient is for ever after prevented from 
 blowing his nose. Those who have not reflected on the 
 strange approaches that ulcerated parts make towards each 
 other in the act of healing, may doubt the possibility of this 
 occurrence; I have seen at least four or five instances of 
 it, and one of them happened to a patient while under my 
 own care. 
 
 WiUiam Clarke, set. 18, a delicate-looking boy, admitted 
 into 11th ward, March, 1886. Twelve months ago he was 
 
 L 
 
146 ON SECONDAEY SYMPTOMS. 
 
 treated for ulcerated tonsils, an ulcer on inner surface of 
 prepuce, and a small node on forehead. Mercury was used 
 pretty freely, but it seemed not to act favourably ; in three 
 months after this supposed cui'e the throat again became soTe. 
 His present symptoms are an ulcer on the back of the 
 pharynx, the upper end of -which is pretty much on a level 
 with the dorsum of the tongue ; it extends downwai'ds for an 
 iuch ; it is full half an inch ia breadth, being nearly as broad 
 as the back of the pharynx ; all its edges ai-e steep ; surface 
 covered with a thick, tenacious, purulent discharge ; this 
 ulcer is void of surrounding. sweUing or inflammation. He 
 complains rather of difficulty than of pain in swallowiag, for 
 he feels that the morsel is stopped at a certain point, and 
 requires a sup of the fluid to make it go down ; node on tibia 
 is remarkably small, and gives very httle pain. 
 
 April 12th. Appearance of the ulcer is very much improved, 
 and he says that his power of swallowing is so much better 
 that now the food scarcely stops at all ; general health very 
 good. 
 
 April 19th. Mouth is now quite sore enough. Says he feels 
 his throat quite well, and has no pain on the site of the node, 
 the swelling of which still remains. He now for the first time 
 complains of a stuffing of his nose, and says that he had felt 
 it for ten or twelve days past. 
 
 April 28th. Mouth nearly weU. He now complains that 
 he cannot blow his nose ; on examining with a cm-ved probe 
 I find that the communication between the mouth and nose is 
 quite closed up. This has taken place within the last fort- 
 night, since the time the ulcer low down in the phai-ynx began 
 to cicatrize. 
 
 This result is the more remarkable, because since his re- 
 admission into the hospital I could not observe any ulceration 
 at the upper part of the pharynx, and because the highest end 
 of the ulcer in the back of the pharynx did not reach within 
 an inch of the opening leading to the posterior nai-es. He 
 was discharged April 30th, no attempt to open the communi- 
 cation having been made. 
 
 That means may be discovered for preventing this perfect 
 closure of the parts, however impatient they may be of the 
 
ON SECONDARY SYMPTOMS. 147 
 
 presence of any foreign body, I can readily believe ; but when 
 once the miscbief is completed, I fear that we must despair of 
 being able to render any service, and for this reason, that the 
 natural texture and properties of the mucous membrane 
 towards the mouth are quite destroyed and altered, so that 
 instead of the soft velvet-like surface, we see a shining white 
 surface ; and thus whatever assistance we might gain from 
 having to deal with the mucous lining to the part is here 
 altogether absent. Monsieur CuUerier, with whom I lately 
 had a conversation on this subject,' informed me that he made 
 some attempts by operation to restore the communication, 
 but without success ; the parts closed again in spite of all his 
 efforts. 
 
 I shaU not dwell at length on what every surgeon knows, viz., 
 that venereal ulcers of the throat have in some instances 
 induced ulceration of the carotid arteries, terminating in 
 sudden death by haemorrhage. But I cannot refrain from 
 stating the following case, as illustrating in a rare manner the 
 very mischievous effects resulting from repeated and injudicious 
 courses of mercury employed in the treatment of venereal 
 ulcers of the throat. 
 
 Mr. A., an apothecary, set. 34, was affected with a venereal 
 sore throat, for which he applied to a surgeon of his acquaint- 
 ance, under whose care he underwent not fewer than three 
 salivations, and all of them very severe ; some ulceration of 
 the throat returning in a short time after each salivation. 
 He then consulted another surgeon, who 'either directed or 
 permitted him, at his o-wn urgent entreaty, to subject himself 
 to a fourth salivation. The soreness of his throat still 
 remaining in some degree, and his surgeon having positively 
 refused to renew the use of mercury, he became dissatisfied 
 with him, and went through a fifth salivation without the 
 advice of any surgeon. The throat still remaining sore, he 
 sent for me, evidently with the hope that I would order him 
 to resume the mercury in accordance with his own wishee. 
 On inquiring into his symptoms, I learned from him that for 
 some weeks past he was not only constantly confined to bed, 
 but almost to one posture, for he could not turn himseK in 
 the bed by any exertion unless he applied both his hands to 
 
148 ON SECONDAEY SYMPTOMS. 
 
 steady and support his head ; that he was totally unable to 
 raise himself in bed for the purpose of taking a drink, in 
 consequence of the impossibility of supporting his head ; and 
 lastly, that he was suffering under severe pains of the arms. 
 On examining the throat, which could only be done as he lay 
 on his side, I observed a very extensive foul ulcer at the back 
 of the pharynx. 
 
 This gentleman seemed very much displeased and not a 
 Uttle disappointed when I told him he should not use any 
 more mercm-y. It is imnecessary to add that I directed for 
 him a tonic plan of. diet, but without the benefit of country 
 air, for his removal was absolutely impossible. In about 
 three weeks from the time of my first visit to him, on entering 
 his room one morning he said, " Sir, I have here something 
 to show you; it is a piece of bone that came from my throat, 
 and caused such a fit of coughing as nearly choked me." On 
 examination, this proved to be a portion of the ring of the first 
 vertebra, with on one side the one half, and on the other one 
 third of the articulating processes. My alarm for his safety 
 may now be readily conceived. I apprehended of course that 
 in some unguarded movement of the head, either by his own 
 voluntary efforts, or perhaps by the awkwardness of an 
 officious nm-se, the remaining ties of the head, with the first 
 and second vertebra, might be snapped across, and with these 
 the thread of his life. 
 
 But contrary to my expectations, he felt himself daily 
 growing stronger : he became conscious of some acquired 
 power of moving the head ; this gradually improved, until at 
 length he was enabled to hold his head nearly erect, but with 
 so very little power of rotatory motion that he was obliged to 
 turn the trunk of the body when he wished to view any object 
 on either side. However, his flesh and strength returned, he 
 became corpulent, he married, and survived the loss of half 
 his atlas by five or six years. 
 
 Before we dismiss the subject of what may be termed the 
 pure or original forms of venereal sore throat, I shall only 
 observe, that when any one of these aif jctions is making an 
 alarming progress, and by sloughing or by phagedaena 
 threatens to destroy some impoi-tant portions of the throat. 
 
ON SECONDARY SYMPTOMS. 149 
 
 or suddenly to endanger life by laying open some great blood- 
 vessel, or more slowly, but not less certainly, by the ulceration 
 extending to the top of the larynx, I say that in such 
 emergencies the surgeon has but two resources left, but two 
 means of arresting the dangerous career of the ulcer, viz., 
 the application of muriate of antimony, or some other equally 
 powerful liquid caustic, or the use of mercurial fumigation. 
 His judgment must decide which is best suited to the 
 circumstances of each x;ase. I shall only remark, that if we 
 employ fumigations we cannot expect them in general to 
 produce their sensible effects in a shorter period than two or 
 three days ; then they are apt to excite very profuse and 
 uncontrollable salivation, which although it is almost certain 
 to arrest the further ravages of the ulceration, yet does not 
 accomplish^ a permanent cure of the disease ; but on the 
 contrary it leaves the system in a state badly able to bear the 
 subsequent use of mercury. 
 
 All those cases which have been profusely salivated by 
 fumigations, and in which a relapse has occurred, requiring 
 a fresh use of mercury, will be found very dif&cult of cure. 
 
 One caution relative to the application of caustics I must 
 not omit. In cases where the ulceration threatens to destroy 
 the bony partition between the mouth and nose, we should 
 confine the application of the caustic to the border of the 
 ulcer ; if we apply it to the centre we shall be in danger of 
 having it reach to the bone, and thus produce the very evil we 
 are so anxious to avoid. 
 
 There are a few affections of the throat and mouth which 
 sometimes follow shortly after a course of mercxu-y employed 
 for the cure of the venereal disease. It is a very remarkable 
 fact that these affections appear only under such circum- 
 stances. For if mercury have been employed for the removal 
 of any other disease, ex. cjr. inflammation of the synovial 
 membrane of the joints, disease of the liver, &c., we do not 
 witness any such troublesome consequences. Of these 
 affections the following is rather a rare one : — 
 
 The patient complains of a tenderness of throat rather than 
 of sore throat, says that if he eat some particular articles of 
 food, ex. gr. currants or gooseberries, his throat feels more 
 
150 ON SECONDAEY SYMPTOMS. 
 
 uneasy, not at the time of eating, but on the following day. 
 Either one or both tonsils present a very irregular surface, of 
 a peculiar j^ellow colour*, sometimes without any ulceration, 
 and sometimes with a few small very superficial ulcerations ; 
 at times a similar ulceration may be seen at the junction of 
 the anterior palatiue arch with the tongue. This pecuhar 
 eoloui" of the tonsils is sometimes accompanied with one or 
 more white spots on the edge of the tongue, across the 
 diameter of which a slight fissm'e may. run. This affection of 
 the thi"oat may, after a few weeks, disappear and remain away 
 for some days, then return nearly as before. With these 
 local affections the system does not appear to sympathise, for 
 the general health continues undisturbed. The patient, if 
 particularly questioned, admits that there is no soreness of 
 either the tongue or throat. This affection will continue for 
 many months gradually retiring, by leaving the patient free, 
 at first for a few days, and then for a week, and at length for 
 a month or two ; finally it disappears altogether. I have not 
 seen any other suspicious symptom attend this affection. 
 
 For the cure of this affection I have known most severe 
 courses of mercury employed, so as to excite very profuse 
 sahvation, and these even repeated more than once, but 
 without effecting any other than a momentary improvement 
 in the state of the symptoms, and this improvement has 
 ceased as soon as the ptyahsm began to subside. Most 
 assuredly this state of the throat does not require, nor wiU it 
 be benefited by, the use of mercm-y. The treatment which' I 
 have found most ef&cacious is to rub the parts very freely 
 with Sulphas Cupri, or with Argentum Nitratum daUy, or 
 every second day, generally alternating these applications. 
 The more active caustics do not succeed better, indeed not so 
 well as those I have mentioned. I have known different 
 preparations of iodine to have been employed ; but I regret to 
 say without affording any decided benefit. This affection is a 
 striking example in justification of the phrase of a disease 
 "wearing itseK out;" for in my judgment time alone has 
 effected the cure. 
 
 Mr. E — , in the month of January, underwent a full course 
 of mercury under close confinement, for the cure of a venereal 
 
ON SECONDAEY SYMPTOMS. 151 
 
 sore throat. Early in March he was in a profuse salivation, 
 which his constitution bore with comparatively slight disturb- 
 ance. He desisted altogether from the use of mercury not 
 until 28th of April. On 3rd June he complained of his throat 
 and tongue. I find on the right side along the edge of the 
 tongue, opposite to the molares teeth, two small fissures 
 surrounded with white circular spots. At the point of junction 
 of the anterior palatine arch with the root of the tongue is a 
 small superficial ulcer of a brown or buff colour — right tonsil 
 is enlarged. He cays that at the end of six weeks, after each 
 course of mercury, his throat has become sore ; he brushes 
 over the affected parts with a strong solution of Argentum 
 Nitratum every or every other day. 
 
 10th August, 1834. Now three months since he relinquished 
 the use of mercury; complains that his throat, during the last 
 fortnight, has become more tender, so that after eating fruit, 
 especially gooseberries and currants, he finds his throat more 
 sore on the next day. Surface of the tonsils is of a buff 
 colour, with an uneven surface, which gives it the appearance 
 of ulceration. I have observed that, for some days together, 
 the tonsil changes to the natural red colour. He rubs the 
 affected parts with solid Argentum Nitratum occasionally, 
 when the sensations become troublesome. 
 
 30th August. During the last fortnight he has not used 
 the Argentum Nitratum, either in a solid form or in solution, 
 as heretofore; he has merely gargled with sea- water. On 
 the right edge of the tongue is one small white spot with 
 a fissure running across it ; left anterior palatine arch has 
 a very superficial white ulceration or excoriation along its 
 edge; right tonsil, with a very irregular surface, has a 
 yellowish superficial ulcer on its upper end, and another 
 superficial sore is seen where the anterior arch comes in 
 contact with the tonsil above ; says that he has not any 
 soreness of the throat or tongue, except occasionally ; general 
 health very good. 
 
 12th October. Superficial yellow ulceration of left tonsil 
 still continues, although he has lately used the Argentum 
 Nitratum as often as the uncomfortable sensations of his 
 throat prompted him to do so ; his general health is excellent; 
 
152 ON SECONDABY SYMPTOMS. 
 
 he has gained weight dm-ing the last five months. This 
 morbid state of throat has now continued for five months 
 from the time he laid aside the use of mercury. 
 
 24th November. Ulceration of both tonsils superficial, and 
 of buff colour; he has been for days and weeks together 
 without feeling ' any pain or uneasiness, and yet with the 
 ulceration visible; at other times the ulceration becomes 
 painful, and continues so for some days; he occasionally 
 touches the ulcers ■with Argentum Nitratum, perhaps once in 
 eight or twelve days. It is now seven months since he gave 
 up the use of mercury. 
 
 15th January. His throat looks much better to-day than I 
 have ever seen it ; says that it remains well for seven or eight 
 days, then begins to grow sore, and when this soreness has 
 increased a good deal, he rubs it very hard with a pencil of 
 Argentum Nitratum ; the sloughs do not separate for two or 
 three days ; and so this comrse is run over and over again. 
 
 29th April. In January last, Mr. E — consulted two of the 
 most eminent surgeons in London, who assm-ed him that his 
 disease was not venereal, and could not be em-ed by mercury ; 
 he used iodine, but without the smallest benefit; stOl his 
 complaiut has not been removed ; for now about the centre of 
 the right tonsil there is a ckcular ulcer about the size of a 
 split pea, edges very shghtly raised, surface rather flocculent 
 and of a yellowish colour, no surrounding swelling or redness ; 
 this is not attended with pain, even in the act of deglutition : 
 he merely feels at times a dryness of his throat; general 
 health is very good; he has not touched the throat vnth 
 caustic during the last fortnight ; observe he had relinquished 
 the use of mercury on the 28th of last April, exactly twelve 
 months ago. N.B. — In three months more his throat got 
 perfectly well. 
 
 Another and more common affection of the throat followiug 
 a mercurial coiu'se, employed for the cure of some venereal 
 affection, is the following : — Over the anterior sm-face of the 
 velum palati, or on one of the tonsils, or perhaps on some 
 part of the inside of the cheeks, there appears an uTegular 
 wrinkled surface of a very white colour, looking not very 
 unlike the mark or track of a snail, or as if the part had been 
 
ON SECONDABY SYMPTOMS. 163 
 
 brushed over with a brush dipped in milk. Sometimes the 
 whitened surface retains its natural smoothness, and some- 
 times it is in parts wrinkled, resembling, in some degree, the 
 skin of the hands when long steeped in hot water. The 
 discoloured parts are sometimes free from ulceration, while in 
 others we may observe a very superficial ulceration, or rather 
 excoriation, and sometimes a fissure. 
 
 However, in some cases we find a distinctly ulcerated spot 
 in the discoloured part, while in others again we find an 
 ulceration of some part of the mouth remote from the white 
 spot ; and this appears with a raised or swollen white border, 
 the enclosed ulcer being of a red colour, and more resembling 
 an excoriation than a real ulcer. This affection of the 
 mucous membrane is found in a few instances so very widely 
 spread, that the entire surface of the mouth, throat, and gums 
 partake of this morbid state. 
 
 A very remarkable, and yet a very constant, attendant of 
 this state of mouth and throat is a very superficial ulceration 
 or excoriation around the anus, so that almost as often as we 
 question the patient as to the existence of such an affection, 
 we may be pretty sure to be answered in the affirmative ; and 
 scarcely does any patient pass through this disease without 
 suffering at one time or other from this excoriation around the 
 anus. This affection is rather troublesome than painful, and 
 it seems to disturb the general health very little, if at all; 
 for we find the patient in the enjoyment of good health and 
 good looks, and without the slightest disturbance of any one 
 of the functions. 
 
 If unattended to, this disease may continue for a great 
 length of time, certainly for many months, subject, however, 
 to occasional variations ; it may remain unchanged in one part, 
 while getting well in another, or even fixing itself upon some 
 new spot. What the ultimate result would be, if left entirely 
 to nature, I cannot say ; but I imagine that it would finally 
 be overcome by the powers of the system, or, as some express 
 it, "would ultimately wear itself out." 
 
 However great may be the extent and duration of this 
 affection of the parts within the mouth, if free from actual 
 ulceration, nay, even though it be accompanied with a 
 
154 ON SECOND ARY SYMPTOMS. 
 
 corresponding affection of the skin at the anus, still we should 
 not be tempted to treat it by mercury administered so as to 
 induce salivation, for such practice will end in disappointment. 
 I have seen the most full and long continued, nay, even 
 repeated salivations fail in effecting a cure, and this whether 
 the mercury had been employed by inunction or had been 
 given internally : neither does the muriate or any of the other 
 preparations of mercury possess any peculiar power over this 
 disease. No doubt, during the time that the salivary system 
 is under the full action of mercury, the mucous membrane 
 assumes a much more natural appearance, the whitish colour 
 of the ulceration is removed, an unnatural degree of redness 
 alone points out the seat of the disease ; but as soon as the 
 high action of the mercm-y begins to subside, and even before 
 the mercurial soreness of the mouth has ceased, we observe 
 with chagrin and vexation a return of the original affection in 
 its pristine vigour. 
 
 I have known this affection treated by protracted courses of 
 sarsaparilla alone, and combined with mineral acids, without 
 the patient deriving the smallest benefit from their use. The 
 application of solutions of Argentum Nitratum, or of Sulphas 
 Cupri, has appeared to me the most useful line of treatment 
 in this, as it is in that yellowish ulceration of the tonsils 
 already described as a sequela to a mercurial course, when 
 employed for the cure of the venereal disease. 
 
 I have described this affection as being sometimes free from 
 any ulceration, while in other cases ulceration may be seen 
 either in the discoloured patches or in some other remote 
 part totally free from this discolouration. Now, while we are 
 assured that this affection, if unaccompanied by ulceration, is 
 most certainly not a venereal symptom, and neither requiring 
 nor benefiting by the use of mercury, yet we must admit that, 
 when it is attended by ulceration in the discoloured parts, we 
 cannot give a very positive opinion on this important point. 
 After long and anxious endeavours to discover some feature in 
 the ulcer or accompanying whiteness, which might enable me 
 to decide this question, I freely admit that I have not been 
 able to succeed, and that I am obliged to be guided more by 
 the absence or co-existence of other symptoms which are 
 
ON SECONDABY SYMPTOMS. 155 
 
 unequivocally venereal. I need not say how very particular 
 and minute we should be in our inquiries for other symptom-s, 
 for, should we form a wrong opinion, we may subject our 
 patient to a course of mercury which is absolutely unnecessary, 
 and which will prove unavailing ; or, on the other hand, were 
 we to declare that the use of mercury is unnecessary, we 
 might thus give the patient unfounded confidence in his 
 exemption from the venereal disease, throw him off his guard, 
 and thus allow syphilitic symptoms to produce serious evils 
 before he could think it necessary to apply for surgical 
 assistance. Thus syphilitic iritis might, if unattended to, go 
 on to the destruction of vision by inducing opacity of the 
 crystalline lens, and closure of the pupil. 
 
 In the first of the following cases we have an instance of 
 this affection existing along with undoubted venereal symp- 
 toms, and in the next we find this affection appearing without 
 any such concomitant. 
 
 Mr. M— applied to me on 26th September, 1833. He 
 informed me that six weeks ago he perceived a chancre on the 
 inside of the prepuce, close to the froenum ; for this he used 
 twenty pills, which produced mercmial foetor of the breath, 
 but no soreness of the mouth. Caustic was applied to the 
 ulcer. For the last three weeks he had not used any medicine. 
 At present the site of the chancre is marked by a red spot, the 
 size of a split pea : this is rather an excoriation than an ulcer; 
 it is of a very red colour, moist, and very hard. On the middle of 
 the flat surface of the tongue is a small superficial ulcer, with 
 a fissure running across it. On the inner siurface of the lower 
 lip is a very superficial ulceration, of a circular form, the size 
 of a shilling : a great part of this diseased surface is of a 
 milky-white colour. There is a superficial ulceration on each 
 tonsil, of the same white description as that of the lip. 
 Sumat Pil. Hyd. gr. v. bis in die. 
 
 Oct. 6tli. Mouth slightly affected ; ulcer of the penis has 
 less hardness, and is of a more healthy red ; tongue is not 
 much altered ; throat appears to be well. 
 
 Oct. 18th. Mouth stni slightly affected ; ulcer of prepuce 
 much better, though still moist. The ulcer of the tongue 
 appears rather more extended; this I now rubbed with 
 
156 ON SECONDAEY SYMPTOMS. 
 
 Argentum Nitratum. Ulcer on the inside of the lip is also 
 more extended, and the white border which sm-rounds it 
 shows a greater degree of softness, being more raised. 
 Appetite good; he sleeps weU. P. 112. Eept. pil. una bis 
 in die. 
 
 Oct. 24th. He is now very fuUy affected by the mercury. 
 Mouth very sore ; fissure in tongue is healed ; surrounding 
 ulceration is rather more extended, and is now of a dirty- 
 yeUow colour ; ulcer of lip is also of a dirty-yeUow colour. 
 He complains of weakness, but has no palpitation. Omittatur 
 Pil. Hyd. 15^. Sulph. Quinse gr. x. Aq. vj. Acidi Sulph. DU: 
 3 i. Tinct. Card. Comp. J ss. M. § i. ter in die sumenda. 
 
 Oct. 29th. Ulcer of prepuce not quite healed, although 
 very much reduced in size, and some hardness remains ; 
 tongue imaltered ; ulcer of lip has its border raised and hard, 
 the centre skinned over and of a red colour. Fissure of 
 tongue rubbed with Argentum Nitratum; ulcer of lip with 
 saturated solution of Sulphas Cupri. Mouth is less sore. 
 
 Nov. 7th. He resumed mercury on the 3rd inst. Pil. Hyd. 
 gr. V. bis in die. Ungt. Hyd. Fort. 5 ss. om. nocte. Now he 
 has an iron taste on his mouth ; mercurial fcetor of breath is 
 pretty strong. 
 
 Nov. 13th. Since 8th inst. the ptyalism has been very 
 copious, with considerable swelling of left cheek, and ulceration 
 of left side of tongue. P. 126. Ulcer on surface of tongue is 
 healed, that on the lip is more clean, with cuticle over part of 
 it. Ulcer on prepuce clean, bleeding on the slightest friction, 
 but the hardness continues. 
 
 Nov. 16th. He spits four pints daUy. Ptyalism prevents 
 sleep ; thirst urgent. P. 90 only. Ulcer of lip as on 13th 
 inst. Ulcer of prepuce is healed, very slight hardness 
 remains. 
 
 Nov. 24th. Ptyalism less ; saliva viscid ; tongue and left 
 cheek stni ulcerated ; ulcer of lip as on 13th ; ulcer of prepuce 
 is healed, and perfectly free from hardness or thickening. 
 
 Dec. 4th. For last eight days has used Ungt. Hyd. 5 ss. 
 omn. nocte, et Pil. Hyd. gr. v. mane et nocte, by which his 
 mouth is again smartly affected. Gums are swollen and 
 ulcerated, but there is not much ptyalism ; thirst m'gent ; 
 
ON SECONDARY SYMPTOMS. 157 
 
 skin not very hot. P. 98. Ulcer of lower lip not healed ; a 
 smaller but similar ulcerate .1 spot now appears on the middle 
 of the lip, near the froenum. Ungt. Hyd. 5 ss. 0. n. PU. 
 Hyd. gr.»v. bis in die. 
 
 Dec. 7th. Original ulcer of lip quite healed and of nearly 
 natural colour; the small ulcer of Up remains unaltered. 
 Omitt. Pil. et Ungt. Hyd. Sumat Mixt. c. Sulph. Quinse. 
 
 Dec. 27th. Mouth free from mercurial influence. P. 96. 
 App. good ; place of the larger ulcer of lip can be distinguished 
 by its higher colour ; the new small ulcer remains. For 
 three days past he has felt some uneasiness in swallowing ; 
 on left tonsil is a broad very superficial ulcer of a dirty-yeUow 
 colour. 
 
 Jan. 1, 1884. Appetite good; general health good, except 
 that his pulse after walking is too quick. Ulcer of Up is 
 enlarged ; left tonsil as on 27th ult. ^. . Hyd. Cor. Sub. gr. ij. 
 Eesinse Guiaici 5 ss. ft. pil. octo. Sumat. unam. sing. noct. 
 Pulv. Sarsas. c. Carbon. SodsB mane et meridie. 
 
 Jan. 10th. Both ulcers of the lip are healed, but the 
 surface is raised and slightly discoloured : ulcer of tonsil a 
 little more deep, in other respects unchanged. 
 
 Jan. 19th. On right anterior palatine arch a superficial 
 ulceration exactly the same as that on the left tonsil — the 
 ulcer of this unchanged. 
 
 Jan. 31st. Ulcer of tonsil has now a white surface, with 
 soft white raised edges ; ulcer of right arch unchanged ; 
 general health good. He is now in good flesh and colour. 
 
 Feb. 9th. No sensible effect from the medicine. P. 82. 
 Complexion florid ; general health excellent ; ulcer of lip 
 rather more deep, or edges more raised and white. Appear- 
 ances of throat unaltered, but he feels less soreness in it. 
 I^ . Pil. Hyd. gr. vj. Ext. Cicutse gr. ij. ft. pil. duffi h. s. sumend. 
 
 Feb. 23rd. Copperish taste in mouth ; gums slightly sore ; 
 ulcer of lip more extended, although in parts disposed to heal ; 
 ulcers of throat unaltered ; all the ulcers touched with Acid. 
 Acet. Fort. P. 120 after walking. 
 
 March 9th. Mouth sore from the mercury ; ulcers of the 
 throat and lips much improved; appetite bad; headache; 
 bowels confined; sleeps well. 
 
158 ON SECONDARY SYMPTOMS. 
 
 March 16th. Mouth nearly well ; one small ulcerated spot 
 on each anterior arch ; ulcer of lip has been subdivided into 
 three small spots by the healing of interposed portions. 
 Sumat pil. duas mane nocteque. • 
 
 March 23rd. Weaker, and more easily thrown into perspi- 
 ration ; feels his throat more sore ; ulceration of it and of lip 
 as bad as ever ; gums sore. Eept. Pilulae. 
 
 March 30th. Mouth still sore ; throat and lip same as on 
 23rd. 
 
 April 20th. Ulcerations of lip and throat as bad as ever ; 
 they have lately been repeatedly touched with Solut. Arg. Nitr. 
 Sumat Acid. Nitr. Dil. gutt. xvi. ter in die. 
 
 May 25th. Symptoms unaltered. Sumat. Acid. Nitr. Dil. 
 gutt. XXX. ter in die. 
 
 June 1st. Throat a little better ; lip much better ; appetite 
 and strength good. Fumigentur ulcera quotidie c. Rubri. 
 Hyd. Cinerei 5 ss. 
 
 June 26th. Since 22nd has been fumigating daily with 
 Hyd. Ciner. 5 j. made up in a candle. Gums a good deal 
 swollen, with their apices between the teeth in a sloughy 
 state ; mercurial foetor of breath ; feels himself weak ; ulcer 
 of lip healed, but has left a discolouration which marks its 
 former site and extent ; ulceration of throat healed, but 
 natural colour is not restored ; spot on dorsum of tongue still 
 remains naked and destitute of papillae. 
 
 July 13th. Mouth smartly sore. P. 78. Thirst urgent ; 
 appetite indifferent ; sleeps well ; bowels costive. He is easily 
 thrown into perspiration by exercise ; lip and throat as on 
 26th June. Sumat. Sulph. Quinse gr. ij. ter in die. Omit. 
 Hyd. Ciner. 
 
 Aug. 17th. Tonsil with a superficial venereal ulceration. 
 Within the last few days a blister appeared on the under lip ; 
 this spot now presents the character of the former disease in 
 colour, but is not ulcerated. He has now also a superficial 
 ulceration at the verge of the anus obviously venereal. He 
 does not suffer pain from this when going to stool, but 
 whenever he is warm either in bed or by exercise. P. 78. 
 Lotio Nigra ano applicanda. 
 
 Aug. 24th. Symjptoms as on 17th. Has used the black 
 
ON SECONDAEY SYMPTOMS. 159 
 
 wash in a very careless manner. Spot on lip rubbed -with 
 Sulph. Cupri, and he is directed to wash it three or four times 
 a day with Solut. Sulph. Cupri. 
 
 Sept. 21st. Spot on lip scarcely discoloured ; ulceration of 
 tonsil less deep ; the integuments around the anus are healed 
 wherever the lotion has been carefully applied, but a super- 
 ficial ulceration still exists in the folds of the skin close to the 
 orifice of the anus. 
 
 Oct. 19th. Left tonsil is still slightly ulcerated, with a 
 yellow surface ; on the inside of right cheek there is now a 
 white spot. P. 90. General health good. Eepet. Solut. 
 Sulph. Cupri. 
 
 Nov. 16th. Superficial white ulceration of both the anterior 
 arches ; also about the right dens sapientiee adjoining part of 
 the left cheek. Eepet. Solutio Sulph. Cupri. 
 
 Nov. 23rd. Symptoms as on 16th inst. Sumat. omni 
 nocte Sulphureti Hydrargyri Eubri gr. v. 
 
 Dec. 14th. Throat much better; only one or two small 
 white spots on the right anterior arch and around the right 
 dens sapientiae. Sulphureti Hydrargyri Eubri gr. x. omne 
 nocte. 
 
 Jan. 4th, 1835. No sensible effect from the pHls. Throat 
 nearly as before in appearance and in feeling. Hyd. Calcinati 
 gr. i. Opii. gr. ss. omn. nocte. 
 
 Jan. 11th. Throat better in appearance; ulceration of 
 gums not better; no sensible effect from the pills. Eepet. 
 Pilulffi. 
 
 Jan. 20th. Mouth sufficiently affected ; throat not better in 
 appearance ; ulceration of gums as before. Omitt. Pilulse. 
 
 From this time all mercurial treatment was discontinued, 
 and he went to the country. He returned to me on the 22nd 
 of April, 1835, and informed me that an appearance of the 
 ulceration of his throat has siace repeatedly returned, but 
 that he always removed it pretty soon by the application of a 
 lotion of Sulphas Cupri. His general health is now excellent. 
 
 In the Eeport of 27th December, 1833, it is stated that the 
 ulcer on the left tonsil is of a dirty-yellow colour. This might 
 lead us to beHeve that the white condition of the mucous 
 membrane produced by mercury, employed for the cure of 
 
160 ON SECONDARY SYMPTOMS. 
 
 venereal symptoms, is nearly allied to the yellow ulceration 
 which arises under similar circumstances. After the use of 
 mercm-y continued with but Uttle interruption for twelve 
 months, we find on August 17th, 1834, "there is now a 
 superficial ulceration at the verge of the anus, obviously of a 
 syphilitic character." This I advert to, as it establishes the 
 very intimate connection between certain syphilitic affections 
 of the mouth and throat, and the skin around the anus. 
 After a perusal of the details of this case, I think we are 
 justified in concluding that this condition of the mucous 
 membrane of the mouth and throat (though a sequela of 
 syphilis when treated by mercury) is itself not to be cured by 
 mercury : and yet mercury will, at the same time, cm-e any 
 other truly venereal symptom which may exist along with it. 
 
 Alexander Hamilton, at. ann. 40, of a healthy appearance, 
 was admitted into 12 ward on March 10th, 1835. He com- 
 plained only of the state of his mouth and throat. The inner 
 surface of each lip was occupied by large patches of a white 
 colour, which on a superficial view appeared to be ulcerated, 
 but on closer inspection these patches were found te be raised, 
 to be of a milk-white colour, and traversed by fissures in 
 various directions. The right side of the tongue, the inside 
 of the corresponding cheek, and the anterior surface of 
 the soft palate and tonsils, were similarly affected. He 
 had a small and slightly indurated cicatrix on the glans 
 penis ; but no other venereal symptoms. His general health 
 very good. 
 
 Eight months previous to his admission he contracted a 
 gonorrhoea, and soon after the sore appeared on his penis. 
 For cure of this ulcer he immediately took some pills, which 
 produced salivation, but the sore did not get well until about 
 five months ago, when it was healed while he was a patient in 
 Mercer's Hospital. In one month after he had been discharged 
 from the hospital, the ulcer broke out again ; he then apphed 
 to an apothecary, who ordered him pOls, four of which 
 produced profuse salivation, and caused the sore to heal ; but 
 since that time his mouth has assumed the appearance above 
 described. He was ordered a tepid bath and purging mixtm-e, 
 and then to take every night two pills consisting of Pil. Hyd. 
 
ON SECONDAEY SYMPTOMS. 161 
 
 gr. V. c. pulv. Jacobi, gr. iii. and these pills he continued to 
 take until 14th April. A very slight mercurial action .was 
 ultimately produced by these pills, but without any permanent 
 improvement in the state of the mouth or throat. No doubt, 
 at times, one part would seem to improve for a few days, but, 
 at the same time, some other part appeared to be as much 
 disimproved. 
 
 He was next ordered burnt alum, washes of chloride of soda, 
 and a variety of topical applications ; but none of them, except 
 such as were possessed of some escharotic quality, appeared 
 to make any impression. The Sulphas Cupri, rubbed on 
 strongly, would often cause an evident improvement, but only 
 for two or three days, after which these parts fell back into 
 their former state. 
 
 At one time all the diseased parts of the mouth simul- 
 taneously put on an improved appearance, while all the throat 
 seemed to grow worse, for the notes on April 11th say there 
 is a very evident amendment in the symptoms ; the tongue 
 has now its edges thin and natural in appearance, having now 
 only two or three spots indented by the teeth. He himself 
 says that he feels the tongue quite well; the lips are less 
 swollen, and the white swollen mucous membrane is less 
 raised ; but he feels his throat more uneasy than usual; it has 
 a good deal of the white coating, or superficial ulceration on 
 the anterior arches. Mouth is scarcely affected mercurially. 
 
 May 20th. Although his general health has continued in 
 excellent order, yet his symptoms are nearly unchanged. 
 Altogether, we have not made any decided advances towards 
 curing this man. I now was determined to try if it would 
 yield to minute doses of mercury, and accordingly ordered E. 
 Hyd. Ciner. gr. i. fiat pilula ter in die sumend. 
 
 This plan having failed after a full and fair trial, I wished 
 to try the effects of change of air, and therefore I dismissed 
 him from the hospital on 29th May, and desired him to attend 
 as an out-patient, in order that different kinds of escharotics 
 might be carefully employed. This plan was regularly and 
 steadily employed; the result was a very gradual and slow 
 improvement, the steps of which do not require or admit of 
 verbal description. The Argent. Nitr. in solid, and saturated 
 
 M 
 
162 ON SECONDAKY SYMPTOMS. 
 
 solutions of Sulph. Cupri, were the applications generally 
 used. 
 
 July IQth, 1835. The throat was yesterday well rubbed with 
 Sulph. Cupri, and this day it appears a good deal better. 
 
 July 26th. Throat is now aU but well ; at present there is 
 only one small circular spot, not deeply white, not at all ulce- 
 rated, lying iu the centre of a red patch which covers the front 
 of the right side of the velum pendulum palati. 
 
 Aug. 4th. The ulcer of throat seems disposed to heal, but 
 he now complains of tenderness of tarsal bones of the left foot, 
 and also of pains of his shoulders and limbs. Sumat. Olei. 
 Tereb. Gutt. xxx. ter in die. 
 
 Aug. 8th. Throat is perfectly well ; pains of shoulders and 
 of limbs are also better, except that of the tarsus. 
 
 Aug. 17th. Paiu of foot has been much reheved by a bHster, 
 but still some slight tenderness remains. Pain of shoulders 
 entirely removed. Says he feels some uneasiness in his throat, 
 but I cannot on the most close examination discover any cause 
 for it. 
 
 Sept. 15th. An ulcer in form of a fissure has appeared on 
 the side of the tongue ; no other appearance of disease in the 
 mouth. Pain of instep had returned, but again removed by 
 another blister. 
 
 By further perseverance in the use of mUd caustics, this 
 disease was finally removed. 
 
 This affection of the mouth and throat some may imagine is 
 merely an effect of inflammatory condition of these parts left 
 on the subsidence of that action. Were this the case, we 
 should find it make its appearance immediately on the sub- 
 sidence of the high mercm-ial action. But we will often meet 
 with cases in which this symptom has not shown itself until 
 long after the ptyaUsm had ceased. Of this the following is 
 an instance : — 
 
 Captain B — applied to me 7th July, 1835. Says he had a 
 chancre iu August, 1834, which was treated by PH. Ehei. 
 internally, and by black wash, the only external apphcation. 
 Under this treatment it was healed in the latter end of 
 September. The chancre in a week or two opened again ; he 
 was then treated by Mr. Lawrence, of Brighton, who made 
 
ON SECONDARY SYMPTOMS. 1 63 
 
 him use mercurial friction twice a day. By this process his 
 mouth was not made sore, nor was he much reduced in strength 
 and flesh. He continued free from any symptoms of disease 
 until the latter end of May, when he felt a soreness of his 
 throat. He did not feel any uneasiness at the anus until three 
 weeks ago. The arches of the palate are pretty generally 
 affected with the white rugose state of the mucous membrane, 
 in which a few slight fissures appear. At the anus is a small 
 condyloma, with a very superficial ulceration or excoriation. 
 He is much surprised to learn that these two symptoms are in 
 any way connected, and he remarks that this disease ought to 
 have first made its appearance at the anus, because, as a 
 cavalry officer, he has so much riding exercise ; but perhaps 
 it seized first upon the throat because he was so much addicted 
 to smoking. 
 
164 
 
 CHAPTEE VIII. 
 
 OF VENEREAL DISEASES OF THE MOUTH, ETC. 
 
 Undbb this head we propose to consider all the venereal 
 ulcers of the mouth and tongue, as well as of other parts liable 
 to be secondarily affected. 
 
 The tongue is subject to two or three different forms of 
 venereal affections, some without and some with ulceration. I 
 have already mentioned the ulceration on the root of the 
 tongue at the point of connexion with the anterior palatine 
 arch, and also that which is found about the central point of 
 the base, on a range with the termination of this arch. In 
 addition to these we sometimes find the point, and sometimes 
 the edge of the tongue, the seat of an ulcer, which is strictly 
 a secondary venereal ulcer, and it is remarkable we seldom 
 have more than one other secondary symptom accompanying 
 it — ^perhaps only five or six spots of papular eruption, or a 
 Bohtary venereal ulcer on one of the limbs or on some part of 
 the body. This, like other forms of ulcers of the tongue, is 
 sometimes attended with profuse ptyalism, and sometimes 
 with scarcely any extraordinary flow of saliva. 
 
 The characters of this ulceration are not constant ; in some 
 cases we see the point of the tongue (when this is the seat of 
 the disease) broad and truncated, the surface covered with a 
 thin and rather a soft slough, the extremity appearing to the 
 eye much swollen, and presenting to the touch a very con- 
 siderable degree of hardness. In other instances of this 
 species of ulcer, in which a similar degree of swelling and of 
 hardness are present, yet the surface may exhibit merely an 
 ulcerated and a somewhat foul appearance. 
 
 When the ulcer is seated on the side of this organ, we find 
 it present appearances similar to those of the ulcer on the 
 point, but seldom attended with an equal degree of swelling, 
 although the hardness is not less. Occasionally, an enlarged 
 lymphatic gland under the jaw attends the venereal ulcer of 
 the tongue. 
 
OP VENBBEAL DISEASES OF THE MOUTH, ETC. 165 
 
 We find it a matter of much difficulty to distinguish the 
 venereal from the cancerous ulcer of the tongue : the surfaces 
 of both are subject to vary materially at different times, and 
 also either in the entire or in parts. Both are attended with 
 considerable hardness ; but I think that the hardness in the 
 cancerous form gives much more strongly the idea of a stony 
 hardness. There is one symptom which, when present, 
 strongly indicates the cancerous nature of the ulcer ; and that 
 is a slightly elevated narrow ring, of considerable hardness : 
 if this include an ulcer, with a surface so clean as at first view 
 to resemble an ulcer which is about to assume a granulating 
 state, then we may unequivocally declare it to be cancerous. 
 However, it must be admitted that the surgeon is unable to 
 decide from the appearances, especially if he overlook some 
 other concealed venereal symptom. In all such cases the 
 surgeon should give the patient the benefit, or the chance of a 
 slight ptyalism : if this be induced quickly, it cannot be 
 prejudicial to the cancerous ulcer, and it will so speedily 
 induce such a favourable change in that which is venereal 
 that every doubt must be removed by such a test. I have no 
 doubt that every surgeon must have occasionally met with 
 cases on the nature of which he could not pronounce until he 
 witnessed the improvement induced by the mercurial action. 
 When a fissure is suspected to be caused by the sharp point 
 of a tooth, we must have this cause removed ; and then, if the 
 ulcer heal, we are certain of its real nature. 
 
 In a few cases we may find a venereal ulcer on some portion 
 of the dorsum of the tongue, anterior to its base ; the place of 
 this ulcer having probably been determined by some accidental 
 irritation of that part. Ulcers in this situation are generally 
 of a circular form, large as a fourpeimy piece, and present pretty 
 strongly the characters of a secondary venereal ulcer of the skin. 
 
 In some cases we see a long narrow stripe of ulcer on the 
 under surface of the tongue ; this is of a white colour, and, were 
 it sunk below the level of the surrounding part, might be 
 supposed to be formed by an exudation of lymph : this lies so 
 far away from the edge of the tongue that we see at once it 
 cannot be mistaken for an ulceration caused by the pressure 
 of the teeth. 
 
166 OP VENEREAL DISEASES 
 
 The chronic, or, as it is generally denominated, scrophulous 
 ulceration of the throat, is found in some few cases to spread 
 to the tongue ; and, when once established there, is very apt 
 to spread forward, by a very slow but rather destructive process 
 of ulceration. In some of these cases the ulceration of the 
 tongue is not a continuation of that of the throat, but exists 
 independently of it. In general, however, that of the throat 
 has nearly ceased at the time that this of the tongue is 
 estabhshed. 
 
 These chronic ulcers of the tongue are to be distinguished 
 from those that are venereal ; which may be done by observing 
 that the former are much less foul, but, with still more 
 certainty by looking at the throat, and finding there those 
 silvery cicatrices which invariably follow this peculiar form of 
 chronic ulceration. 
 
 Before we dismiss the subject of venereal ulcers of the tongue, 
 I would observe that we occasionally meet with instances of 
 superficial ulcerations of this organ, coming on after a course 
 of mercury for the cure of either primary or secondary 
 symptoms, and which we should take care not to mistake for 
 venereal ulcers. I know not by what characters of the ulcers 
 themselves we could be enabled to decide this point; but I 
 think we shall avoid falling into any mistake if we refer to 
 the history of the case ; for those ulcers which are not venereal 
 will be found to make their appearance in twelve or eighteen 
 days from the time the mercury has been laid aside — indeed, 
 before we can be assm'ed that the action of this medicine on 
 the mouth has entirely ceased. 
 
 Let it not, however, be forgotten that, in some instances 
 where saUvation had been excited for the cure of either primary 
 or secondary symptoms, the ulceration of the tongue, caused 
 by the mercm-y, has not healed ; and, in the space of a few 
 weeks after the ptyahsm has subsided, such ulceration has 
 assumed all the characters of second venereal ulcers. I need 
 not add that such require another and more judicious com-se 
 of mercury. 
 
 I have already alluded to that appearance on the dorsum of 
 the tongue, in which patches of different sizes (but usually of 
 a circular form) appear, as if deprived of papillee; the surface 
 
OF THE MOUTH, ETC. 167 
 
 perfectly smooth ; these spots may be termed bald. Such are 
 sometimes found along with other symptoms, purely and 
 strongly syphilitic ; and sometimes, as I have already men- 
 tioned, they attend that white condition of the mouth and 
 throat which occasionally succeeds to a course of mercury 
 employed for the cure of syphilis; but never, I believe, when 
 employed for the cure of any other disease. So that, in 
 forming our judgment as to the necessity of using mercury m 
 such cases, we must be decided by the nature of the accom- 
 panying symptoms, rather than by any particiilar condition 
 of these spots. 
 
 I have, in a few cases, known an ulcer on the side of the 
 tongue arise merely from deranged digestion and a vitiated 
 state of the stomach ; and yet so strongly resemble a venereal 
 ulcer of this organ, that it might, by a hasty observer, be 
 pronounced syphilitic. Such appearances I have seen, in a 
 few individuals, repeatedly produced in a few hours by the use 
 of vegetables, or of acids. In all such instances the absence 
 of other syphilitic symptoms will prevent us from resorting to 
 mercury ; and, in a short time, the use of medicines calculated 
 to improve digestion and strengthen the stomach will cause 
 the ulcers to heal, and put an end to all doubt about the true 
 nature of these ulcers. 
 
 Venereal fissures are occasionally met with on the edges of 
 the tongue, and may run across the edge either in a straight 
 line or in an angular direction : the edges of these fissures are 
 remarkably hard, and we almost constantly find the fissure 
 surrounded by a superficial white bhster, somewhat like an 
 ulcer ; these ulcerated spots seldom exceed in extent the surface 
 of a split pea. As the edges of the tongue are subject to 
 fissures from other causes — ex. gr. from the irritation of the 
 sharp point of a broken tooth — we shall sometimes be at a 
 loss to decide upon them. If, however, we recollect that the 
 venereal fissure is generally surrounded by the small superficial 
 white ulcer, we shall acquire a confidence whenever we see the 
 accompanying white ulcer. 
 
 Not unfrequently we find smaU circular excoriated spots on 
 the hard palate ; these, sometimes, are accompanied by other 
 unequivocally venereal symptoms; and in other cases they 
 
168 OF VENEREAL DISEASES 
 
 appear in conjunction with the yellow or the white superficial 
 ulceration of the mouth, consequent on a mercurial course. 
 
 The natui-e of the accompanying symptoms must decide 
 whether or not we shall employ mercury in the treatment of 
 each individual case. 
 
 Venereal Ulceration oj the Gums. 
 
 The gums are sometimes, though not often, affected with 
 venereal ulceration ; this, if extensive, and allowed to remain 
 long uncontrolled, may induce disease, and exfoliation of some 
 of the alveoli, and the loss of one or more teeth. This 
 ulceration in some patients assumes aU the characters of a 
 secondary venereal ulcer ; while in others it is more of a pale 
 white surface, with considerable redness, and some swelling of 
 the adjoining gums. In this latter case we shall find the 
 accompanyiug ulcers of the throat, or of other parts, marked 
 by similar languid characters. It is a curious fact, that the 
 ulcer of the gums is generally confined to the external, and 
 that the inner gums remain unaffected until the disease shall 
 have injured the interposed bone. We may see the alveoli 
 laid bare, to some extent, by this disease ; and yet the teeth 
 remain firm and apparently unaffected. 
 
 When ptyalism has been induced by a course of mercury, 
 which has proved insufficient for the cure of any venereal 
 symptoms, we may find after the ptyalism has ceased, and 
 after the rest of the mouth has become completely well, that 
 the patient complains of soreness of the outer gums belonging 
 to the last molares. On examination, we discover ulceration 
 of these gums ; and, at the same time, ulceration of the cheeks 
 opposite to these teeth ; and these ulcers aje strongly marked 
 as secondary venereal ulcers in other parts. When we observe 
 these appearances, after aU the other ulcers of the mouth 
 (occasioned by the mercury) had healed, and that these ulcers 
 exhibit venereal characters, we do not hesitate to pronounce 
 that they are venereal. Of com-se they are then to be treated 
 on the same plan as other secondary venereal ulcers are treated. 
 
 We must take care not to mistake for a venereal ulceration 
 of the gums, that ulcerated state of them which we sometimes 
 find attendant on scrophulous thickeumg and ulceration of the 
 
OF THE MOUTH, ETC. 169 
 
 upper lip, and much more frequently a concomitant of lupus 
 of the nose or lip. A very little attention will enable us to 
 discriminate ; for here we observe that the ulcerated part 
 assumes the appearance of a mass of fungous yet healthy 
 granulations, terminated very suddenly by the natural mem- 
 brane of the gums ; this raised surface is not covered with pus, 
 but looks rather as if the granulated surface did not secrete 
 any fluid ; nor is there any line of ulceration between the 
 limits of this raised portion and the adjoining sound membrane. 
 In these cases, no doubt, we shall find the teeth more or less 
 loosened. 
 
 Again, wc sometimes find a considerable length of the gums 
 affected with a swollen, soft, spongy condition, to the depth 
 perhaps of one-eighth of an inch from their edges. This soft, 
 swollen part, has also a different colour from the rest of the 
 gums ; having a more highly red colour, with an orange tint 
 pretty strongly marked. This state of the gums is not to be 
 mistaken for venereal ulceration ; it not unfrequently seems to 
 have been produced by previous courses of mercury. 
 
 Ulcers of the Nose. 
 
 Ulcers of the alas nasi sometimes commence in the angle 
 between the nose and cheek, from a cluster of papular eruptions 
 degenerating into an ulcer. Whenever this ulcer shows a 
 tendency to phagedaena, or sloughing, it should be treated 
 with some very active caustic. For although this has been at 
 first withheld, lest it should produce a loss of substance, yet I 
 am certain that a much greater destruction of parts will be 
 caused as certainly, although rather more slowly, by the pro- 
 gress of the disease. 
 
 I am not in possession of any distinctive characters which 
 would enable us to pronounce an ulcer in the cavity of the 
 nostril to be a venereal ulcer. The symptoms of what is called 
 scrophulous ozsena correspond very much with those of the 
 venereal ozsena. No doubt we often find the scrophulous 
 ozsena has been preceded by scrophulous sore throat, which has 
 ended in the formation of those tense and silvery cicatrices 
 already alluded to, and this alone will sometimes serve to 
 distinguish them. 
 
170 OF VENEREAL DISEASES 
 
 But let US not mistake for a venereal affection appearances 
 which are often met with in some who have never been exposed 
 to venereal infection ; I allude to those instances of ulceration 
 of the nose, in which we discover in the septum nasi, about a 
 quarter of an inch from its anterior extremity, an opening 
 through the septum ; this is uniformly, I beheve, of a circular 
 form, is as large as the surface of a split pea, and has a shght 
 degree of ulceration on its edges. This state of the nose is 
 not imfrequently established before the patient is aware of its 
 existence, so very trifling is the uneasiness which it causes 
 either in its formation or when fully formed. And what is 
 equally remarkable is, that it wUl be found for years to remain 
 in precisely the same state ; at least I have not met with the 
 slightest alteration in any of those cases which I have watched, 
 and I have had opportunities of observing some few for eight 
 or ten years. 
 
 We must then hesitate to pronounce an ozsena to be venereal, 
 unless we find it existing along with some other decidedly 
 venereal symptoms; and that we can find its history inter- 
 woven with that of other secondary symptoms. It requires a 
 good deal of experience and close observation to enable us to 
 distinguish between that which is termed scrophulous and the 
 venereal, although it is not, I believe, possible to describe by 
 words the distinguishing marks. 
 
 Venereal Iritis. 
 
 On the subject of Venereal Iritis I have very little to offer. 
 I shaU only say that this is a symptom which cannot be 
 charged to the account of mercury; for it occurs in cases 
 which were treated by the non-mercurial plan. I think that 
 in the treatment of it we should not use mercury in such a 
 manner as may suddenly plunge the patient into a profuse 
 salivation ; for in general the disease is not so acute but that 
 it will admit of some delay, and will allow a sufficient time to 
 produce this effect of mercury according to the ordinary mode 
 of exhibiting it. The great disadvantage of a sudden and 
 profuse salivation is, that although it arrests and cures the 
 iritis, it renders all the other symptoms more slow and much 
 more difficult of cure. 
 
OF THE MOUTH, ETC. 171 
 
 When iritis takes place at a time ■when the system is 
 beginning to throw off a smart saHvation, perhaps while the 
 mouth is still smartly sore, although the flow of saliva has 
 begun to decline, or when it takes place in a case where the 
 mercury, though used in large doses, is not acting in a kindly 
 manner on the system, i say in either of these instances we 
 cannot attempt to cure the affection of the eye by mercury. 
 And again, when we have used mercury for the cure of the 
 iritis, and have induced ptyalism thereby, but without effecting 
 much improvement in the state of the eye, we must then have 
 recourse to other means of relief. In these cases we sometimes 
 succeed almost beyond our expectation, by giving bark largely. 
 Sulphate of quinine is the remedy which I have been most 
 frequently in the habit of employing, and generally with the 
 happiest effect. I have also seen oleum terebinthinae taken 
 internally, as also colchicum, apparently with much benefit. 
 
 We not unfrequently see in some of those who are afflicted 
 with secondary syphilis, a venereal ulcer on the edge of the 
 eyelid, and it is remarkable that this appears generally in 
 cases where many other symptoms of this disease exist along 
 with it. This ulcer of the eyelid, on a superficial view, appears 
 to occupy only a very small portion of the edge of the eyelid ; 
 but, on turniQg out the lid, we see it passing down on the con- 
 junctiva palpebrarum to half the depth of the eyelid, presenting 
 rather a raised surface • towards the globe of the eye. The 
 deformity and the injury to the globe of the eye, which such 
 ulceration may produce if allowed to extend itself, loudly 
 call for our active interference with local treatment ; and 
 accordingly we should employ caustics of such strength as the 
 condition of the ulcer may seem to require, in order that we 
 may as speedily as possible bring it into the condition of a 
 granulating ulcer. I have seen one case in which this kind 
 of ulcer took a very unfavourable turn ; it spread along the 
 conjunctiva palpebrarum, as far as the globe of the eye, seized 
 on it, and completely destroyed this organ. 
 
 The lacrymal sac and ducts not imfrequently suffer when 
 venereal ulceration has seized upon the nostril, and that, in 
 some cases, to such an extent that fistula lacrymalis is the 
 consequence. It is imnecessary to say that we cannot under- 
 
172 OF SECONDAEY VENEREAL ULCERS. 
 
 take any thing for the relief of the lacrymal passages until the 
 disease of the nose be cured ; and I may add that when this 
 has been accomplished, we generally find that there is no 
 occasion for our interference, for the disease of these passages 
 wiU subside in proportion as the ulceration of the nose 
 advances to healing, and the former will be cured even before 
 the latter is perfectly healed. 
 
 Secondary Venereal Ulcers. 
 
 Secondary venereal ulcers, which supervene on the eruption, 
 generally assume a eii-cular form. When the scab is first 
 removed, the ulcerated surface is uneven, foul, and yellow ; in 
 its progress towards healing we remark that it begins to 
 cleanse first in the centre ; then granulations arise in that 
 situation ; these extend towards the circumference where the 
 skin forms a deep edge, between which and the granulations 
 is a ring of the same yellow ulceration as appeared when first 
 the surface of the ulcer was uncovered. In proportion as the 
 ulcer proceeds the granulations encroach on this yeUow ring, 
 until at length they reach the edge of the ulcer. The central 
 granulations, to a large extent, will have actually cicatrized 
 before the entu-e surface of the ulcer is cleaned and healthy. 
 
 These ulcers are also remarkable for the strong tendency 
 which the central granulations have to assume a fimgoid 
 character ; so that, unless particular care be taken to prevent 
 it, they wUl leave, when healed, a very high and promiaent 
 cicatrix. The ulcers also often heal from one side only, so as 
 to resemble a kidney bean or a horse-shoe. 
 
 If a patient be afflicted with a number of these ulcers, we 
 may observe that many of them may be induced to heal by 
 applications of rather a mild kind, while two or three wiU 
 remain unhealed. This fact might lead us to suppose that 
 these ulcers were but little under the influence of the system. 
 Yet, again, under the most mUd applications all will sometimes 
 simultaneously and quickly heal, when the system has been 
 brought under the sanatory action of mercury, and this would 
 lead UB to suppose that all these idcers were very much under 
 the influence of the system. 
 
 Wlien a venereal ulcer has been healed before the disease 
 
OF SECONDAEY VENEREAL ULCBES. 173 
 
 has been eradicated from the system, it will be observed to 
 break out again either by a number of pustules forming in a 
 ring on the borders of the cicatrix ; or by a pustule covered 
 with a scab appearing on the edge of the cicatrix, this scab 
 being rubbed or falling off, the fresh ulceration is estabUshed. 
 
 However numerous or extensive venereal ulcers may be, and 
 however long they may have existed, whatever local or con- 
 stitutional treatment they may have undergone, still I think 
 we always find in one or more of them some appearance 
 indicative of their nature and origin; this appearance is not 
 such as would singly induce a surgeon to pronounce them 
 venereal, but certainly is sufficiently strong to make him 
 inquire into the history of the case, and try whether he could 
 trace them up to a venereal origin. In forming an opinion on 
 this difficult and very important point, he ought to be 
 influenced more by the present appearances than by the con- 
 sideration that mercury had been employed, and perhaps 
 repeatedly, vsdthout effecting their cure. The difficulty of 
 getting mercury to act favourably on some individuals, the 
 judgment required to employ this medicine at a fit time, and 
 to suit the doses and action to the existing state of the patient's 
 health, and to the peculiarities of his constitution — all these 
 considerations will weigh with him, and incline him to suspect 
 that mercury had not had a fair trial, if the venereal aspect of 
 any one of the ulcers favour the opinion that there is (as the 
 phrase goes) something venereal in them. 
 
 Although I have said that the cicatrix of a secondary 
 venereal ulcer often opens again either by a ring of pustules 
 forming around its border, or by a pustule and scab rising in 
 the centre, and each of these degenerating into ulcers, still I 
 do not mean to say that this is the only manner in which a 
 second or third crop of these ulcers appears. For not unfre- 
 quently a tubercle of rather a large size forms in the skin and 
 proceeds to ulceration, many such ulcers exhibiting in their 
 cavity a slough which seems to extend to some short distance 
 under the skin. These ulcers continue forming successive 
 crops, even for years, if the disease be but partially cured, 
 whether by imperfect courses of mercury, by sarsaparilla, or 
 by other reputed anti-venereal medicines. In illustration of 
 
174 OF SECONDARY VENEREAL ULCERS. 
 
 these remarks, I shall adduce the folio-wing out of many 
 similar cases : — 
 
 Mr. P. contracted the venereal disease three years ago. 
 The secondary symptoms were, in the first place, a rash ; next, 
 a sore throat ; then tubercles of rather a large size, some of 
 which went on to ulcerate, and became foul ulcers; and lastly, 
 swelling and induration of the right testicle. For these 
 symptoms he was treated in June and July, 1833, by calomel, 
 which he used without caution, exposing himself to the 
 weather, and living sometimes very freely, and always rather 
 full. By this medicine a very smart mercurial dysentery was 
 produced, with slight affection of the mouth. At this time all 
 the ulcers healed, and for one month remained well. At the 
 end of the month the ulcers began to break out afresh. At 
 present there are, near the upper end of the right fibula, two 
 small ulcers, of rather a healthy appearance, one on the dorsum 
 of the foot, with considerable extent of surrounding inflamma- 
 tion with a foul surface, a shred, apparently of ligamentous 
 texture in a state of sloughing, being extended across it. 
 Another ulcer in a foul state, but not larger than a sixpenny 
 piece, is seen on the calf of the left leg; swelling and hardness 
 of the testis remains. There are four or five small ulcers on 
 arms and trunk. He is not at all emaciated, nor has he a 
 sickly appearance. Such is his state now on the commence- 
 ment of a mercurial course to be used under confinement. — 
 Nov. 2nd, 1833. E. Ung. Hyd. Fort. §ss. divide in chartas 
 sex. Utatur una omni mane. Sumat mane nocteque PH. 
 Hyd. gr. v. 
 
 Nov. 6th. Two of the slighter ulcers are disposed to heal ; 
 the more severe ones are improved; mouth is not sore, but he 
 says that he feels it soon will be so; has used only two papers 
 of the ointment. Pergat. 
 
 Nov. 9th. Ulcer on dorsum pedis is more painful, edge of 
 the skin overhanging the ulcerated surface ; this now presents 
 a good deal of florid granulation, the surrounding inflammation 
 not so much extended, but the colour of it more intensely 
 high and brighter : ulcer on the caK of the leg unaltered in 
 its edges, surface more glazed and smooth, with but httle 
 of surrounding hardness ; mouth is becoming more sore. 
 
OF SECOKDAEY VENEREAL DLCEES. 175 
 
 Eepet. Pilulae ut 2nd inst. Utantur Ung. Hyd. Fort. 9iv. 
 in die. 
 
 Nov. 15. Has had mercurial tenesmus for last three days, 
 and mouth is now pretty smartly affected; ulcers are all 
 cleaner and have less of surrounding hardness, but still their 
 improvement appears to be rather slow. Omitt. Ungt. et Pilulse. 
 
 Nov. 18th. Ulcers improving, though slowly; I do not 
 think his mouth sufficiently sore. Ung. Hyd. Fort. 5ss. bis 
 in die. Pil. Hyd. gr. v. ter in die. 
 
 Nov. 22nd. He has rubbed (by mistake) a drachm of oint- 
 ment twice a-day until yesterday, when he used only one 
 drachm and one pill; mouth is now smartly sore, with a 
 strong tendency to ptyalism. P. barely 90; app. good; sleeps 
 well. Ulcer of dorsum pedis considerably better; that on calf 
 of leg not so much improved; all the other ulcers vastly 
 better. Utatur Ung. Hyd. Fort. gss. in die,et Pil. Hyd. gr.v. 
 .omni nocte. 
 
 Nov. 28th. Mouth very sore ; pretty deep ulcers on each 
 cheek opposite the dentes sapientise ; appetite failed him yes- 
 terday and this day ; gets five hours of uninterrupted sleep ; 
 pulse 106 and small ; the ulcers are all but healed ; that on 
 dors, pedis is now quite free from surrounding redness and 
 swelling: hardness of testis quite removed. Omitt. medica- 
 menta. 
 
 Dec. 1st. All the ulcers are cicatrized ; the old cicatrices 
 of former ulcers have assumed a dark copper colour, and are 
 sunk below the level of the skin, with a sharp, well-defined 
 edge : mouth is less sore ; appetite good ; no thirst ; sleeps 
 well. Ung. Hyd. Fort. 5ss. bis in die. PU. Hyd. gr. v. 
 omni nocte. 
 
 Dec. 7th. Mouth less sore ; some thirst. Eepet. med. ut 
 1st inst. 
 
 Dec. 11th. Mouth more affected; some thirst; appetite 
 good. Eep. Ungt. semel in die. Omit. PU. 
 
 Dec. 14th. Mouth very satisfactorily sore, and vnth more 
 ptyalism than ever. Omit. med. 
 
 Dec. 21st. Mouth nearly well ; symptoms all removed. I 
 now advised him to take pills of Hyd. Cor. Sub. ^th of a grain 
 three times a-day. 
 
176 OF SECONDAEY VENEEEAL ULCERS. 
 
 Jan. 13th, 1834. Has taken the piUs for eight days ; they 
 purged him, especially when he drank strong porter. I shall 
 only add that he has since enjoyed most excellent health, and 
 that he has not had any appeai'ance of even a suspicious 
 symptom. 
 
 Here is a case of venereal disease, continuing during a 
 period of three years, in spite of various attempts to cure it 
 whenever it made a fresh attack. The treatment was not on 
 every occasion dependent on the powers of mercurial medi- 
 cines ; for ia August, when he was affected with nearly the 
 same symptoms as he laboured under in November, 1833, he 
 began a course of sarsaparilla, and used it with great per- 
 severance and in large quantities, having taken it during 
 August, September, and part of October. 
 
 Why the sarsaparilla failed I shall not pretend to determine; 
 but I am fully convinced that the failure of the different 
 mercurial courses was caused by inattention and irregularities 
 on the part of the patient, and misjudgment and mistaken 
 indulgence on the part of the surgeon, who did not insist on 
 the course being conducted under confinement. Let us now 
 attend to the effects of the mercurial course last employed, 
 and which proved a cure for this tedious disease. We find 
 that the report on the seventh day of the treatment is rather 
 unfavourable, for it describes the ulcer on the dorsum pedis 
 as decidedly worse, and that on the caK of the leg as rather 
 worse. We find, too, that on the 15th November, the thir- 
 teenth day of the treatment, an improvement is admitted, but 
 is represented as slow, although the action of mercury on the 
 system for the last three days had been manifested by the 
 mercurial tenesmus. 
 
 Now, had these occurrences taken place with a practitioner 
 whose mind had been strongly imbued with fears of the 
 mischievous effects of mercury, he probably would have laid 
 aside the mercm-y altogether on the seventh day of the treat- 
 ment, regretting that he had ever been tempted to use 
 mercury, or lamenting that he had not begun to use it more 
 sparingly after the fourth day (Nov. 6th), when it appeared 
 to be agreeing so well with the different symptoms. Is it not 
 generally the case that about the seventh or eighth day, when 
 
ON SBCONDAEY VENEREAL ULCEES. 177 
 
 the mercury ordinarily begins to act sensibly on the system, 
 then we see a change apparently for the worse in the condition 
 of the ulcers ; this continues for two or three days longer, viz., 
 until the mercurial action comes to be fully established, and 
 then we find a decided improvement take place in the ulcers. 
 Let us not, therefore, determine upon laying aside the use of 
 mercury in cases of venereal ulcers, until we shall have seen 
 what effect this medicine shall have when it has come into 
 full action. 
 
 Now I suspect that this timidity in employing mercury, 
 this hurry to lay it aside upon the first appearance of any- 
 thing like an unfavourable change, has been the reason why 
 it has been so much disused in the practice of many surgeons. 
 Whereas the true rule by which we should guide our practice 
 is this : to desist from the further use of mercury in the 
 advcmced stage of a mercurial course, as soon as we perceive 
 a decided change for the worse in the ulcers (or rather 
 symptoms). Let us not confound together the bad changes 
 which take place iu the onset of mercurial treatment, before 
 this medicine has taken full hold of the system, with those 
 bad changes which we occasionally witness in the advanced 
 stage of the course, when the mercury has for some time had 
 full power over the system. 
 
 On the seventh day of the treatment I doubled the dose of 
 the ointment, knowing well that my patient's constitution was 
 one which yielded reluctantly to the power of mercury. 
 
 It must strike every reader that in this case the mercury, 
 after ptyalism was produced, was intermitted for much shorter 
 periods than in ordinary cases. This was rendered necessary 
 by the extraordinary quickness with which the action of the 
 mercury subsided in this patient. We know that in ordinary 
 cases, when ptyalism is excited, the action of the mercury 
 continues almost unabated from eight to twelve days. "Whereas 
 here the mercury was at no period omitted for a longer period 
 than four days ; and indeed during the whole course mercury 
 was employed in larger or smaller quantities, except for the 
 one period of three, and another of four days. I was forced to 
 this by the peculiarity of the patient's constitution, and should 
 not have done so from any desire to accumulate mercury. 
 
178 ON SECONDARY VENEREAL ULCERS. 
 
 Prom the reports of the 22nd and 28th November, we can 
 form a pretty correct notion of the little disturbance occa- 
 sioned by a very smart action of mercury. On the first of 
 these days, " pulse barely 90, appetite good, sleeps well." On 
 28th, "pulse 106, and small; appetite failed him yesterday, 
 and this day. Gets five hours of uninterrupted sleep." Surely 
 these slight disturbances of those few functions are not cal- 
 culated to make a lasting injurious impression on the future 
 general health ; particularly when we find, on December 1st, 
 that the " appetite is good ; he has no thirst ; he sleeps well." 
 
 It must be a very crazy system indeed that could not bear 
 these slight disturbances for so short a period with impunity. 
 
 Thus, in a period of forty-two days, was this gentleman 
 delivered from a disease which had materially interrupted his 
 pursuits and his enjoyments for a period of three years. If I 
 be asked why I did not at first employ this treatment, I shall 
 find my apology in the impossibility of persuading young men 
 now-a-days to submit to a vigorous use of mercury, under 
 confinement, when they see so many of their acquaintances 
 treated by very mild doses, and very sHght action of mercury, 
 used while the patient is debarred of very few of the ordinary 
 amusements and indulgences of life. Besides, so much has 
 been written within the last twenty years in praise of a non- 
 mercurial treatment, and so much in condemnation of mercury, 
 or at least of what has been termed its abuse, that it is 
 scarcely reasonable to expect that patients wiU submit to the 
 more rigorous treatment, until they have first had sad 
 experience of the inefficacy of milder measures. Mercm-y, 
 alone, accomplished everything in this case, with the exception 
 of a little laudanum to check the mercurial dysentery ; for the 
 ulcers were dressed with spermaceti ointment only. 
 
 I shall now only add that this gentleman has continued free 
 from any relapse, or return of any symptoms. In two years 
 after this cure he had occasion to undergo a course of mercury 
 for a primary sore : the cure was effected in the ordinary 
 time, with little more than the ordinary quantity of mercury ; 
 nor did any untoward circumstance impede the progress of 
 the cure. 
 
179 
 
 OHAPTEE IX. 
 
 YBNBBEAL EEUPTIONS, NODES, AND DISEASES OF THE TESTICLE. 
 
 Modern writers on the venereal disease have bestowed much 
 pains in observing and arranging, in a nosological order, the 
 varieties of cutaneous eruptions which form a part of secondary 
 syphilis. Their labours have been attended with much advan- 
 tage in the treatment of some of these affections, as we shall 
 presently remark; and I should think the subject might BtUl 
 deserve a continuance of that zeal and minute research 
 which some have bestowed upon it, were I convinced that each 
 form of these eruptions constituted a distinct species in the 
 disease. I fear, however, that any superstructure raised upon 
 this hypothesis will not stand the test of time, as I do not 
 believe that these eruptions can be considered as characteristic 
 of distinct and different forms of syphilis. 
 
 My reasons for dissenting from others upon this point are 
 the following : — First, I have not unfrequently observed 
 varieties of eruption exist together in the same individual; for 
 example, I have seen smaU venereal lichen on the face, while 
 a large form of papular eruption occupied the trunk and the 
 extremities ; sometimes, also, I have found spots of a pustular 
 character scattered through a general crop of the papular 
 eruption. Secondly, I have noticed, as a very frequent 
 occurrence, that when the first eruption has been removed, 
 either by the use of mercury or by other means, that the 
 second crop has proved of a different kind; thus, when the 
 first eruption was of that small pimply kind which resembles 
 measles, it has been succeeded by a papular eruption, and 
 this again by a pustular crop. And, thirdly, by injudicious 
 treatment ; for example, by the excessive use of mercury, in 
 bad habits, any one other form of eruption may be made to 
 degenerate into one which is most obstinate and severe, 
 namely, that of rupia. 
 
 I must declare that, after long and careful observation, I 
 
180 VENEREAL ERUPTIONS. 
 
 have not been able to trace particular forms of eruption to 
 particular forms of j)rimary ulcers. 
 
 It is hardly necessary for me to repeat, that venereal 
 eruptions, like other secondary symptoms, are often ushered 
 in by a smart degree of fever, and that we almost uniformly 
 observe that the fever which precedes the first eruption runs 
 higher than that which ushers in any subsequent attack. 
 Sometimes the eruption is preceded by lassitude and shifting 
 pains of the limbs, which become more severe in the evenings 
 and during the early parts of the night ; while in a few cases 
 the premonitory symptoms, if any, are so slight as not to 
 attract the notice of the patient. By close and repeated 
 examinations we shall find that some spots of the eruption 
 appear to decline, and that fresh spots come out during the 
 first three or four weeks ; after this, probably about the sixth 
 week, the general eruption declines so very remarkably as to 
 lead the patient to indulge a sanguine hope that he is about 
 to be relieved from it altogether. But whatever advances it 
 may make towards a cure, these never go so far as to leave 
 the skin free from stains of a pretty deep hue. After a period 
 of four or six weeks of apparent amendment, the patient's 
 hopes wUl again be damped by the appearance of a fresh crop 
 of eruption, and probably one of a different character, which 
 is generally preceded by an eruptive fever, more or less severe. 
 Not unfrequently, a peculiar, pale, sickly aspect, loss of 
 appetite and of strength, night-sweats, and a pain in some 
 one joint or limb, affect the patient for one or two weeks 
 previously to the second or third crop of eruptions. 
 
 In some cases the eruption is very general, occupying 
 almost every point of the skin; in other cases it is very 
 partial, showing itself, for instance, only about the ankle and 
 tendo Achilhs. I think we may expect to find, that the 
 eruption which is spread over a wide surface, however thickly 
 it may be set, will prove more tractable than that eruption 
 which is confined to a small portion of the limbs, and which 
 may not exceed the number of twenty or thirty spots. 
 
 In long-protracted and obstinate cases of syphilis, confined 
 to the first order of parts, we frequently see this partial 
 eruption as one of the last lingering symptoms; I cannot 
 
VENEEBAL EEUPTIONS. 181 
 
 pretend to say for what length of time any of those eruptions 
 might continue to preserve its identity through successive 
 crops, nor for what length of time any one of them might 
 continue to infest the skin ; but I have seen one instance 
 where a single patch of papular eruption, accompanied by 
 other suspicious symptoms, yielded kindly to a course of 
 mercury, at the end of four years from the appearance of the 
 original chancre. 
 
 If the practitioner pay close attention to his case, he cannot 
 (and he ought not) often be guilty of error in discriminating 
 venereal from other eruptions ; yet such mistakes have occa- 
 sionally occurred. Thus I have known a medical practitioner 
 treat for measles a young man to whom he was called, while • 
 labouring under the fever which ushered in that very small 
 red venereal rash which so much resembles the eruption of 
 measles, and this resemblance was strengthened by the 
 suffused condition of the eyes, which ordinarily accompanies 
 this form of venereal eruption. A still more serious mistake 
 I have known to have been made by an eminent physician, 
 who mistook for papular venereal eruption those papulae 
 which are often seen on the shoulders and backs of young 
 persons with coarse skins. In this case the subject was a 
 young man with incipient hectic — this the doctor considered 
 as springing from venereal infection ; and having subjected the 
 patient to a pretty free use of mercury, he saw him quickly 
 sink, overwhelmed by the rapid and accelerated advance of 
 pulmonary hectic. 
 
 If, without trusting to a vain conceit of our own skill, by 
 assuming that we can know by sight aU the symptoms of the 
 venereal disease, we merely take the trouble of enquiring care- 
 fully into the history of each case, we shall seldom commit 
 any very serious error. 
 
 One and the same line of treatment wiU not prove equally 
 successful in aU the various forms of syphiUtic eruptions. 
 Experience proves to us that the scaly eruption, the copper- 
 coloured blotch, and the papular eruption, are those which 
 yield most readily, and are most certainly and perfectly cured, 
 by the action of mercury, given in the ordinary doses. But 
 the pustular eruption, and especially when of a larger size 
 
182 VENEREAL ERUPTIONS. 
 
 i 
 
 than ordinary, requires a very particular treatment. No one 
 fact can be more clearly established than this ; — ^that if mercury 
 be used too largely in cases of pustular eruption, the latter 
 wUl quickly degenerate into venereal ecthyma or rupia, or 
 spreading venereal ulcers. This form of eruption is one of 
 those venereal affections which, whUe it is materially aggra- 
 vated by large doses of mercury, can be certainly and safely 
 cured by small doses, as I shall endeavour to show in the 
 chapter on minute doses of mercury. If we watch with care 
 the progress of the pustular eruption, we must be struck with 
 the strong disposition which it betrays of running into, or 
 of being converted into, ulcers. Sometimes the pustules, 
 spreading widely and stiU keeping superficial, form ulcers 
 covered with thin soft yellowish crusts ; while in other cases 
 each pustule, without enlarging much, forms into a deep ulcer 
 covered with a brown scab, which is depressed below the level 
 of the skin. Now, in either of these cases, mercury adminis- 
 tered in very minute doses, and with extreme caution, will 
 effect a cm-e, and that too in a very short time. 
 
 It would seem as if the pustular ulcer was closely allied to 
 the rupia ; for I have in some few instances seen, on the same 
 person, a soft, white, flat scab on the spots on the face, and on 
 the bald part of the scalp ; while on the shoulders only scabs 
 of rupia were to be seen. 
 
 The scabs and ulcers of rupia appear to be very little 
 imder the influence of mercmy. I have seen this medicine 
 administered, in eases of this affection, to patients of pretty 
 vigorous habits; and although it acted in a most kindly 
 manner, and produced a full and healthy ptyalism, yet it had 
 not any effect in causing the scabs of rupia to dry up and fall 
 off ; nor did it induce, in those ulcers which had been exposed 
 by the previous removal of the crusts, any disposition to heal ; 
 the only change induced by it on these was to convert them 
 into ulcers, which, though florid, presented one uniform 
 smooth surface, sunk below the level of the skin, and totally 
 devoid of granulations, which proved very slow and difficult 
 to heal. 
 
 But the administration of mercury to patients afflicted with 
 rupia is worse than useless in all instances where the patient 
 
VENEREAL EEUPTIONS. 183 
 
 is naturally delicate, or has been much reduced and lowered 
 by the previous disease; for in all such it proves almost 
 invariably fatal, by increasing the weakness, and generally by 
 inducing an uncontrollable diarrhoea. It was only in a few 
 very robust men that it could be said not to have proved 
 highly dangerous or fatal. 
 
 In treating cases of papular eruption we shall often observe 
 fresh spots of eruption coming out during the early exhibition 
 of mercury. But as soon as the mercury has fully taken 
 possession of the system, fresh spots cease to appear, and the 
 general crop becomes more faint in colour : so far we may 
 rest assured that aU is doing well ; but if, after this, we observe 
 some fresh spots come out, and some few spots of the original 
 eruption appear covered with a soft scab, around the edge of 
 which a ring of pus appears, then we have most positive proof 
 that the mercurial action has been carried too high ; and 
 should we persist in the same line of treatment, using mercui-y 
 in the same doses, we shall meet with sad disappointment. 
 For the results of such practice will be that these scabs wiU 
 each of them degenerate into ecthyma or rupia, and that a 
 considerable number of fresh spots "of eruption will come out, 
 each of which wiU be very speedily covered with a scab, and 
 degenerate into rupia. We shall have then substituted for a 
 papular eruption, which is a comparatively mild form of 
 eruption, a very severe one, viz. ecthyma, or one which is 
 most unmanageable, viz. rupia. Nor does the mischief end 
 here ; for as soon as the new form of disease is established, we 
 find that the health breaks down; a sharp degree of fever (of 
 the type of hectic) sets in, and this, in no great length of time, 
 is followed by diffused pains of the limbs, and occasionally by 
 swellings of the smaU bones and small joints of the tarsus and 
 metatarsus, or carpus and metacarpus. But the papular is 
 not the only form of venereal eruption which may be made to 
 degenerate in this manner; I have seen cases of scaly 
 eruption converted into rupia by the injudicious use of 
 mercury. Let it then be a rule of practice to desist from 
 mercury, or to reduce the doses immediately upon perceiving 
 the commencement of such a change; and let us most 
 anxiously examine the eruption frequently, that we may be 
 
184 VENEKEAL EKUl'TIONS. 
 
 enabled to discoYer the first approach of such a change. 
 There is also this additional motive to induce us to watch the 
 changes ia the eruption, viz. that the general health does not 
 begin to suffer until the ecthyma has been estabUshed ; and 
 consequently we cannot derive any indication from the consti- 
 tutional symptoms, which would enable us to resist those 
 changes in their commencement ; and when the fever has set 
 in we have to contend with deranged symptoms, and with 
 broken-down health and an enfeebled system. Should we be 
 so careless as to overlook this change in the eruption, we shall 
 by our injudicious practice convert a very mild form of 
 eruption, unattended by any fever, or at most by one of a very 
 mild and manageable form, into the most obstinate form of 
 eruption, accompanied by a high degree of debilitating fever, 
 and presenting in their combination a disease very tedious, 
 and most difficult to manage. We shall recur to this subject 
 when speaking of the treatment of rupia. 
 
 There is one sequence of venereal eruptions well deserving 
 of our most anxious study; it is this: a patient whom we 
 imagine has been perfectly cured, by a mercurial course, of 
 some one form of eruption {ex. gr. the scaly or papular), may, 
 in the course of eight or ten months afterwards, apply to us 
 for advice under the following circumstances : his general 
 appearance may be that of perfectly good health, but he may 
 have a very few spots of eruption; these may be scattered 
 over different parts of the limbs ; the entire number may not 
 exceed a dozen ; two or three may be found on the fingers of 
 one hand, or on its pahn or dorsal surface ; perhaps two or 
 three more on the opposite wrist, and two or three in the 
 neighbourhood of the knee or ankle. These are found of the 
 same character in every patient, whatever may have been 
 that of the original eruption : each spot is of a coppery hue, 
 is elevated above the sm-rounding skin, and is of a homy 
 consistence, or rather of the firmness of an ordinary corn on 
 the toes. Sometimes in the palm of the hand is seen a copper- 
 coloured ring, pale in the centre, with a hard red raised 
 margin, about a quarter of an inch broad. A most important 
 point for our consideration in this case is to decide whether 
 such symptoms are to be considered as true venereal symptoms ; 
 
VENEREAL ERUPTIONS. 185 
 
 whether the patient should be considered as still labouring 
 under syphilis ; and whether the offspring of such a person, 
 whether male or female, would be likely to be infected. Such 
 cases of this peculiar form of eruption as I have had an 
 opportunity of watching for any length of time were either on 
 females too old to have children, or on young men who had as 
 yet remained in a state of celibacy ; so that my experience 
 does not enable me to offer any opinion on this subject. 
 
 Let not this form of eruption be confounded with that mar- 
 bling of the surface, or with those broad distinct spots which, 
 as a second and third crop, appear on the trunk, while from 
 eight to twenty such spots appear in the skin of the palms of 
 the hand ; for this latter eruption is generally accompanied 
 by pretty extensive ulcerations of the edges of the tongue, and 
 yields readily to the influence of mercury. 
 
 I am at a loss to know what kind of treatment is best 
 suited to such cases. I have tried mercury internally, in 
 larger and smaller doses, and pushed it even to ptyalism. 
 These spots have quickly disappeared when the patient became 
 salivated ; but even a protracted ptyalism has not prevented 
 .them from recurring. They have also disappeared in cases 
 where the mercury was not producing any sensible effect on 
 the system. I am disposed to think that I have seen more 
 benefit, in such cases, from Hydrarg. Calciaatus than from 
 any other prej)aration of mercury ; but I am ready to confess 
 that I doubt whether in any case my plan of treatment was 
 really useful. Indeed, I shall even say that I doubt whether 
 such cases are not cured as effectually, and as well, by the 
 ' unaided powers of the system, as when treated by any kind of 
 medicine. Sarsaparilla was as little successful as mercury in 
 effecting their removal. I have had opportunities of watching 
 some few of these cases for years together, and I found that 
 this symptom recurred occasionally for three years after the 
 supposed cure of the original eruption. 
 
 Venereal Nodes. 
 
 Nodes arise only in the later stages of syphilis : the disease 
 may then be said to attack those structures which Mr. Hunter 
 calls " secoiid in order." Such parts of the bones as are most 
 
186 VENEKEAIi NODES. 
 
 thinly covered, and are possessed of the most hard and close 
 texture, are the seats in which this symptom, when purely 
 venereal, makes its first appearance. No doubt we frequently 
 meet with nodes on the soft cancellated ends of bones, and on 
 the small bones of the tarsus and metatarsus, carpus and 
 metacarpus; but we shall generally find that nodes occur iu 
 these latter situations in patients who have employed more 
 than one unavailing course of mercury, the venereal disease 
 being stiU unsubdued, although much altered by the treatment 
 and by the attendiag deterioration of the general health. 
 
 A venereal node sometimes forms without much pain, not 
 more perhaps than what directs the patient's attention to its 
 seat ; but in other cases it is ushered in by severe pain. In 
 some instances I have observed the tumour to be for a few 
 days soft and very painful, then it became firm, and at the 
 same time almost totally free from pain. Those nodes which 
 are solid at their origia, indeed I might say aU nodes, may in 
 com-se of time proceed to suppuration, but this is generally a 
 very slow process, and takes place only in nodes of long 
 standing. 
 
 A node once formed wiU often remain for months together . 
 apparently unchanged; no increase of size, no discoloration 
 of integuments, no feel of fluctuation discoverable. In other 
 cases, however, a node will slowly undergo the process of 
 chronic suppuration ; this I have observed to have occurred 
 more frequently in nodes on the bones of the cranium than in 
 other situations. The formation of the pus does not bring 
 with it any mitigation of the pain, if the node had been pre- 
 viously painful. But in many such the node had ceased to be 
 painful either long before or immediately on the commence- 
 ment of this suppurative process. 
 
 When the bone has been exposed by art or by the natural 
 process of ulceration, we see it in some cases exfoliate by a 
 pretty thick plate ; in which case the patient has to submit to 
 a very protracted ulceration of the integuments. In other 
 instances the denuded bone is soon perforated with numerous 
 small holes, through which healthy red granulations arise, 
 and at length, by their increasing numbers, cover the entire 
 surface from our view, and iu a short time proceed to 
 
VENEREAL NODES. 187 
 
 cicatrization ; thus effecting a cure without our being able to 
 discover any exfoliated bit of bone. Yet that the surface of 
 the bone has been removed we are afterwards assured by seeing 
 the depressed state of the integuments, and feehng the rough- 
 ness of the surface, which ever after remains. 
 
 The bones of adults are subject to some diseases which 
 simulate venereal nodes. One of these is periostitis. I shall 
 not here attempt to describe the local conditions by which we 
 may distinguish the one from the other, because I think this 
 can only b^ done with certainty and safety by referring to the 
 previous history of the case, and by a close investigation and 
 inquiry for other accompanying venereal symptoms. 
 
 When examining a case of this disease, we should most 
 carefully distinguish it from what I would call a " general 
 nodose affection of the bones;" because mercury, which 
 effectually cures the venereal node, exasperates to an intoler- 
 able degree this general condition or diathesis. The local 
 condition of the parts can assist us, but in a slight degree ; 
 however, I think we may say that a greater number of the long 
 bones are at once engaged in this general nodose disease than 
 we ever meet with in pure syphUis. Again, the form of the 
 swelling differs ; for in the venereal node it assumes a rounded 
 figure, whereas in the other disease the tumour assumes a 
 more elongated form. It occupies, for instance, such a length 
 of the anterior surface of the tibia as to give to the bone some 
 resemblance to one which is curved by rickets. Both these 
 bony tumours are attended with severe pain, and in both also 
 this is aggravated at night, especially when the patient becomes 
 warm in bed. This nodose disease, in general, attacks those 
 who have passed the age of puberty, although I have seen a 
 few cases in which it attacked children of both sexes at the 
 age of ten or eleven years, the subjects being in every other 
 respect to all appearance perfectly healthy. 
 
 We never can venture to form an opinion as to the real 
 nature of a node until we shall have made the most minute 
 inquiry into the history of the case, and searched most care- 
 fully for any other symptom of syphUis ; for the accompanying 
 venereal symptoms are often so trifling or so obscure as to be 
 unknown to, or unnoticed by, the patient himself. 
 
188 VENEREAL NODES. 
 
 The condition and seat of a node afford us some criterion by 
 which we can judge whether it be easily curable or not, and to a 
 certain degree indicate the appropriate line of treatment. 
 The node m the centre or in the hard part of a bone wiU be 
 found much more easily treated and cured than one on the 
 cancellated structure. The former node will bear, and it also 
 requires, pretty active and full doses of mercury for its cure, 
 while that on the cancellated structure of the bone will require 
 the mercury to be used in moderate doses, administered with 
 much judgment. Very many years ago I heard a most intel- 
 hgent physician declare that nodes on the bones of the hands 
 or feet were of aU nodes the most difficult to cure : a long- 
 continued observation has proved to me the justness of this 
 remark. 
 
 In the treatment of pure venereal nodes I believe we may 
 entrust the final cure to the operation of mercury ; but untU 
 the mercury is brought to act upon the system we must use 
 our best endeavours to mitigate the sufferings of the patient ; 
 for this purpose I know not of any remedy more effectual than 
 blistering the part, allowing it to heal, and bhstering it again 
 as quickly as we can ; indeed the bhster sometimes acts like 
 a charm in such cases. Every surgeon must have met vyith 
 cases of pure nodes which could not be removed; by the 
 mercurial course and bhstering they were relieved of all pain, 
 but the swelling remained permanent. Some have proposed 
 the early opening of the tumour, and evacuating all the con- 
 tained fluid. To this proposal I would object, that in some 
 cases this practice is followed by painful suppuration, and by 
 very copious discharge, and not unfrequently by caries and 
 tedious exfoliation of the bone. It seems to me preferable, in 
 aU cases, to try the local effects of bhstering and the consti- 
 tutional influence of mercury ; and by means of these 
 endeavour to avert suppuration and ulceration. This rule 
 should be most strictly adhered to in the case of nodes on the 
 forehead, or in any exposed part of the body ; for when a node 
 has been of long standing we often find that a sort of chronic 
 suppuration is established, the integuments become thin, and 
 sometimes red ; at other times they are reduced to the utmost 
 degree of thinness, and yet may retain the natural colour, so 
 
VENEKEAL NODES. 189 
 
 that the surgeon is actually tempted to give vent to the fluid 
 by the puncture of a lancet. Yet if he will but resist the 
 temptation which the very thin state of the skin offers to him 
 to open it, and will still apply repeated blisters, he will have 
 no reason to lament his forbearance. For as soon as the 
 mercury comes to act favourably on the system, he wUl per- 
 ceive that the fluid begins to be absorbed, and that this process 
 will finally be terminated by the adhesion of the skin to the 
 surface of the bone. From the depressed position of the skin, 
 and the sunken unequal surface which the bone presents to 
 the touch, after the node is cured, we are convinced that an 
 absorption of the bone has gone on to some depth. Now if 
 we had adopted a different practice, — if we had opened the 
 tumour by even a very small puncture, — the result would, most 
 probably, have been an unhealthy tedious suppuration, perhaps 
 also an exfoliation of bone, and certainly a very unseemly 
 depressed cicatrix. 
 
 With respect to the constitutional treatment of nodes on the 
 small bones, or on the spongy parts of long bones, I shall only 
 remark that in general, when they appear, the system is in a 
 state which will be injured by large doses of mercury, and 
 that it requires sound judgment and nice discrimination to 
 employ this medicine in such a manner as to remove the 
 disease ; the most dangerous error which we can commit in 
 such cases is to admiaister it too largely : we are not to omit 
 ths use of other auxiliary means ; in the selection of these we 
 must, of course, be determined by the existing circumstances 
 of each case. 
 
 It may not be amiss to mention the extraordinary influence 
 which a node on the femur sometimes has upon the condition 
 of the entire limb. The node on this bone is generally seated 
 in its lower third or lower half, and on its anterior surface. 
 Of course it is scarcely perceptible by the eye, but is readily 
 detected by carrying the hand along the front of the bone, and 
 by squeezing it as we descend. Should the disease have 
 existed for any length of time we shall, upon close examination, 
 discover that this Hmb, through its entire length, is less full 
 than the other which is free from disease : and if we compare 
 the nates we shall be led to suspect that there is morbus 
 
190 VENEKEAIi NODES. 
 
 coxae, so close is the resemblance of the buttock of the affected 
 side to the condition in which we find it in that disease ; 
 indeed, there is only wanting the painful feeling in the groin 
 to complete the picture ; as not only is the Hmb more wasted, 
 and the nates more flat, and its fold more low, but there is 
 even an apparent elongation of the limb at the knee and 
 ankle, and in some cases I have seen these characters fully as 
 striking as in cases of genuine simple morbus coxte. 
 
 I have no doubt that nodes are sometimes excited by the 
 injudicious use of mercm-y, or by the irregularities of the 
 patient. I have known cases in which mercury having been 
 largely and repeatedly employed for the cure of other symp- 
 toms, and the patient, having been again subjected to a fresh 
 course of merciuy, has complained, even while his system was 
 decidedly under the influence of this medicine, of a swelling 
 and tenderness of one or more of the long bones. The 
 tubercles of the tibia are frequently the seats of this affection ; 
 when thus attacked they are not seen to become much enlarged, 
 but are rather soft, and exquisitely tender to the touch ; and 
 not unfrequently the integuments covering them assimae a 
 reddish tiat. Nodes which form from the above cause on 
 other parts of the long bones are, from their commencement, 
 very painful, and of different size in different individuals; 
 but in aU cases they are rather soft. The pain attendant on 
 all these is more widely spread along the limb than in cases 
 of pm-ely syphiHtic nodes. Of course patients under such 
 circumstances are not fit subjects for the use of mercury. 
 Bhstering these tumours will generally procure temporary 
 relief from pain, while, at the same time, we shall use our 
 best endeavours to repair the mischief caused in the constitu- 
 tion by the injudicious use of mercury. And here I must add, 
 that it has never fallen to my lot to witness an instance of the 
 use of mercury producing nodes, except when it was adminis- 
 tered for the cure of the venereal disease. 
 
 Affections of the larger joints are not unfi-equent among 
 patients labouring under secondary syphilis, and more so 
 while the disease is seated in those parts which Mr. Hunter 
 has classed as " the first order of parts ;" they may also often 
 be met with when the disease is seated in the parts " second 
 
VENEEEAli NODES. 191 
 
 in Order." These affections do not deserve the title of purely 
 syphilitic symptoms ; at least I cannot recollect having seen 
 them, except in cases where the patient had imdergone a 
 course of mercury for some form of secondary syphilis, and 
 where, notwithstanding, the disease was not thoroughly 
 subdued. 
 
 Effusions into, and distensions of, the synovial membranes 
 and bursas of the large joints are very frequently met with in 
 patients labouring under secondary syphUis. I cannot venture 
 to say that these never are purely venereal symptoms ; but as 
 far as my memory serves me those I have witnessed might, 
 with very few exceptions, be traced to mercurial courses mis- 
 managed, either on the part of the surgeon or of the patient. 
 In a few cases they may have been caused by over-exertion of 
 the limb. The knee and elbow are the joints most frequently 
 thus affected, the wrist less frequently ; but when it does 
 occur, it presents a more obstinate and intractable case. 
 Although these swellings may not be considered as purely 
 venereal symptoms, yet that they are more or less connected 
 with syphilis would appear from this fact, that when they 
 have resisted (as they occasionally do) blistering and a variety 
 of topical treatment, they readily yield along with the true 
 venereal symptoms to a subsequent judicious use of mercury. 
 
 In connection with these affections of the joints, I would 
 just observe that syphilitic patients often complain of pains in 
 the limbs; when these are described as passing along the 
 greater extent of the limb, and particularly if on inquiry we 
 learn that they, at different times, attack different parts of it, 
 we may be assured that, unless they prove to be the precursors 
 of some fresh eruption, they are not venereal, — that mercury 
 will not relieve them, and that they have been caused by mer- 
 cury. The only condition which forms an exception to this 
 opinion is the case of a node on the fibula ; for this is frequently 
 attended with a more wide-spreading pain than a node in any 
 other position. 
 
 I believe it is unnecessary to notice the incorrectness of that 
 opinion which considers nocturnal exacerbations as pathogno- 
 monic of venereal pains. The pains of gout and rheumatism 
 also obey a similar law. 
 
192 VENERKAIi TESTICLE. 
 
 A very common form of those affections is observed in the 
 elbow joint ; the patient has not full power of it, he cannot 
 fully flex it, nor extend it much beyond a right angle ; very 
 rarely is there any pain or any tenderness from pressure, when 
 made upon the prominent parts of the joint. Not unfrequently 
 this affection of the joint is attended by tumefaction caused 
 by effusion into some of the adjacent bursas ; but in all these 
 cases we feel the tendon of the biceps extremely rigid, yet not 
 swoUen or tender to the touch. As a further proof that this 
 symptom is not purely venereal, we find that it sometimes 
 yields to blisters, often to blisters and to a course of sarsa- 
 parilla. It is not benefited by putting the patient immediately 
 under a second course of mercury, although it is found to yield 
 pari passu, with the truly venereal symptoms, to the powers of 
 this medicine when employed with judgment and under 
 favourable circumstances. 
 
 A similar, but much more rare affection, is that which 
 engages the knee. The joint in this case, though to a certain 
 degree moveable by the hand of another, can be moved only 
 in a very trifltug degree by the patient. No swelling or 
 tenderness necessarily attends, but the hamstring tendons are 
 felt as tense as it is possible to imagine them to be, although 
 the muscles are not in action. 
 
 Venereal Affections of the Testicle. 
 
 On the subject of Venereal Swelled Testicle I have but very 
 little to offer. It is among the latest symptoms of the disease ; 
 it generally takes place slowly, without much pain, and it con- 
 tinues of the same indolent character throughout its entire 
 course. I cannot recollect any case of what I consider purely 
 venereal swelled testis which went on to suppuration, although 
 I have seen this occurrence take place in some where the 
 debilitated and deranged state of health appeared to be the 
 exciting causes of this result. If I were to attempt a descrip- 
 tion of this affection, I should say that the entire of the organ, 
 that is, both the epididymis and the body of the testis, are 
 involved in one common swelling, that the tumour presents to 
 the eye a surface smooth and but little discoloured, and to the 
 feel a firm and uniform consistence, but nothing of a stony 
 
VENEREAL TESTICLE. 193 
 
 hardness, nor is it very weighty in proportion to its bulk ; a 
 fulness, but not a hardness, of the chord can also be felt. 
 These I conceive are its leading features. I shall not attempt 
 to discriminate it from the cancerous testicle, nor from 
 that condition of the gland which is by some denominated 
 scrophulous, a term which is often applied with very little 
 reason or accuracy to many anomalous swellings of the 
 testicle. A reference to the history of the case, and the 
 co-existence of some other symptom of a syphihtic nature, can 
 alone enable us to form a correct diagnosis. The syphihtic 
 testicle, in a patient of unbroken health, is one of those 
 symptoms which yields most regularly and uninterruptedly to 
 the action of mercury when judiciously administered; the 
 gland also, to all appearance, regains its healthy structure, 
 and is enabled to resume its function. 
 
 But in some instances the venereal affection of the testicle 
 appears under very different characters. When the gland 
 becomes engaged in a patient who is naturally of a bad habit 
 of body, or whose health has been broken down by repeated 
 and mismanaged courses of mercury ; one, in short, in whom 
 the local affection may be ascribed fully as much to a reduced 
 state of health as to a venereal taint. In such, I say, the 
 condition of the testicle is very different from that which we 
 may consider a purely venereal swelled testicle ; for the 
 swelling in many such cases does not involve in one common 
 mass both the epididymis and the body of the gland ; nor does 
 it in general acquire the same magnitude as the purely 
 venereal swelling of the testis. In such cases we not unfre- 
 quently find, on a careful examination, one or two points into 
 which the end of the finger appears to sink, as if a fluid or a 
 smaU cavity existed beneath the sktu. But these two affec- 
 tions of the testis differ very widely in another most essential 
 point — namely, as to their treatment ; for, in the latter form 
 of the disease, the treatment becomes a matter of great 
 difficulty, and one which requires very nice discrimination and 
 sound judgment ; because we have to contend not only with a 
 shattered system, but with such a combination of local and 
 constitutional derangements as frequently cause our patient 
 
194 VENEREAL TESTICLE. 
 
 to sink under accumulated sufferings, the disease of the 
 testicle being the mildest of his complaints. 
 
 Such patients may be considered as in the very last stage 
 of the venereal disease, and on the very threshold of being 
 afflicted with those constitutional changes which (from 
 experience) are known to be the prelude of death, and which 
 bring to a close the existence of those who have thus been the 
 unhappy victims of protracted syphilis. 
 
 Some few, however, of these cases admit of being cured — ^that is, 
 Mf e may be saved ; but the testicle cannot ever after be considered 
 as restored to its perfectly healthy state, for we shall always 
 be able to discover by the touch a considerable deviation from 
 its healthy feel; we shall find, also, that it is in general 
 rather wasted, and that there is some degree of hardness 
 remaining in the greater portion of it, while a deep depression 
 and a softness may be felt in one or two spots. 
 
 Having now glanced at this long catalogue of miseries, to 
 which the venereal disease gives bii-th, and having also 
 touched upon the appropriate treatment, it is scai'cely 
 necessary for me to remind the reader that either the 
 injudicious use of mercury or the misconduct of the patient 
 has a large share in inducing some of these pernicious con- 
 sequences, and in rendering many of them most unmanageable. 
 How erroneous then must have been that opinion, which for a 
 time took possession of the minds of surgeons, when they 
 imagined that a disease was proved to be not venereal, merely 
 because it was not cured by mercury, or perhaps because it 
 was made worse by this medicine ! By acting on this opinion 
 the surgeon was obUged, in the after-treatment of the case, to 
 have recourse to any, or almost every other medicine, and to 
 every remedial measure, rather than again resort to that 
 which had already done so much mischief. In those pro- 
 tracted cases some surgeons came to the conclusion that the 
 symptoms which they witnessed could not be venereal, because 
 such a lengthened period as two or three years had intervened 
 since the receipt of the original infection, or appearance of the 
 primary disease. If we take the trouble to trace the history 
 of any number of these cases of protracted syphilis, we shall 
 find that they present considerable variety ; thus in some it 
 
PEOTKACTED STPHILIS. 195 
 
 may have continued for five or six years in a very mild degree 
 indeed, while other unhappy sufferers have been subjected to 
 almost every symptom of the xlisease, many of which too have 
 afflicted them simultaneously, and with peculiar and aggravated 
 severity. 
 
 From a vast number of cases of this description which I 
 have witnessed, and of which I have notes, I shall here adduce 
 two only to prove that this disease may exist, in an obvious 
 form, for at least five or six years. The first of these cases 
 shows that the symptoms, few and mUd, never completely 
 disappeared; that they did not give rise to any further 
 symptoms ; and that, being only kept in check by repeated and 
 insufficient courses of mercury, they continued to exist, and 
 yet did not very materially disturb or injure the general 
 health. 
 
 Mr. H., in June, 1830, was treated for a recent chancre by 
 piUs of calomel, which he took to rather a large amount, and 
 for a period of six weeks. By this treatment his mouth was 
 not at any time satisfactorily made sore ; indeed it was only 
 affected at intervals, and then very slightly, although the 
 mercury was pushed so as frequently to disturb the bowels, to 
 impair his appetite, and to injure his sleep. In the course of 
 eleven months after the healing of the chancre, he was 
 affected with iritis and a few clusters of papular venereal 
 eruption; these symptoms were made to recede, though 
 slowly, by a course of Plummer's pUl, which acted in a 
 manner equally unsatisfactory as the plain calomel had done. 
 
 In August, 1831, a cluster of these papulas appeared on the 
 left temple, and he also was affected with a superficial ulcera- 
 tion of the membrane covering the septum nasi, a Httle way 
 above the anterior edge of the septum. He was then directed 
 to take Hydr. Oxymur. in solution, to the amount of an 
 eighth of a grain every day; and also to combine with it 
 Decoct. SarssB c. Extr. Fluid Sarsse. To the ulcer in the nose 
 he applied Ungt. Hydr. Nitr. diluted with seven parts of lard : 
 this process he continued for three weeks, when he was called 
 away to the country, the symptoms having been nearly 
 removed. 
 
 In November, 1832, he again applied for advice, on account 
 
196 PEOTRACTED SYPHILIS. 
 
 of the same symptoms, which were very much in the same 
 state as in August, 1831. He was again directed the Ungt. 
 Hydi-. Nitr. and the Lotio Nigra as applications to the ulcers 
 in the nose, and to take Pil. Hyd. gr. iij. Extr. Conii gr. ij. 
 sing. noct. ; this plan he continued without any variation, 
 except that of increasing the dose of the pills, from the middle 
 of November until the 20th of Dacember, when he again went 
 away into the country, his symptoms being a good deal 
 subdued, but obviously not cured. 
 
 In April, 1833, he applied to me for the same symptoms, 
 and in precisely the same state in which he exhibited them in 
 November, 1832. He was now directed piUs of calomel, 
 antim. tart, and opium, so as to take two grains of calomel 
 every night — the same applications as formerly to the nose. 
 This plan he commenced on the 26th of April, and finished on 
 the 17th of June. Even now the mercury did not act in a 
 favourable manner, and he left town with his symptoms all 
 but well. 
 
 January 15th, 1834, he called on me, and declared that he 
 was firmly resolved to use every means, and for any length of 
 time that I might think necessary, for the removal of aU traces 
 of this complaint. At that period the symptoms were as 
 follow : the cluster of papular eruption on the temple existed 
 as before ; the septum nasi was superficially ulcerated in each 
 nostril ; the ulcers were seated not far from the anterior edge 
 of the septum, but not on corresponding parts of it ; these 
 ulcers were neither painful nor very sore, nor was there much 
 surrounding inflammation, but they exhibited very distinctly 
 the characters of venereal ulcers. 
 
 I now directed for him I^ Calomelanos 9i. Pulv. Ipecac. 
 Comp. 5SS. fient pilulsB decem. Sumat unam mane nocteq. 
 The ulcers to be lightly touched, two or three times a day, 
 with Ungt. Hydr. Nitr. Dilut. 
 
 January 31st, 1834. Upper gums ulcerated, and sufficiently 
 affected; ptyahsm is apparently coming on; he is languid, 
 especially in the evenings. Appetite good, thirst not urgent, 
 some griping. ^. Inf. Cinchonoe §vi. Tinct. Cinchonte 5vi. 
 Tinct. Opii Gutt. xxx. Syrupi gss. m. sumat gi ter in die. 
 Eepet. pilulaB. 
 
PROTBACTED SYPHILIS. 197 
 
 February 5th. He feels much strengthened since he began 
 the bark mixture ; upper gums are much fuller, and more 
 ulcerated ; sleeps well. Eepet. pU. and mist. 
 
 February 11th. Mouth is sufficiently affected ; ptyalism is 
 established, but not copiously; ulcers of the nose appear to 
 be perfectly healed. Eepet. mist. Sumat pil. unam sing- 
 noct. 
 
 February 21st. Mouth is still fully affected; he is more 
 oppressed with languor. He goes to the country to-morrow, 
 being called away by professional business, and promises to 
 keep within doors and take the pills for a fortnight longer. 
 
 I have seen this gentleman lately ; he continues free from 
 any return of his disease, and enjoys excellent health. 
 
 In the history of the following case we shall find the disease 
 passing through its different stages, and yet retaining firm 
 possession of the parts already attacked, while it proceeded to 
 fix itself in some new situation, resisting at various periods 
 the use of aU anti-venereal medicines, as well as of various 
 remedial measures — mercury in various forms, sarsapariUa, 
 acids, alkalies, opium, arsenic, sea-bathing, country air, &c. ; 
 and yet, at the end of six years, finally cured by mercurial 
 unction, pushed to a smart ptyalism, while the patient was 
 confined to the house. 
 
 Mr. A. applied to me in July, 1828, for the cure of a recent 
 chancre. He used mercury under my care for fom- weeks ; 
 although the medicine did not act in a kindly manner, stiU 
 the ulcer was nearly healed at the end of the month. Circum- 
 stances over which he had not control obliged him now to 
 apply to another surgeon, who in a few days advised him to 
 lay aside the mercury. He returned to me again in the 
 course of six weeks, complaining of sore throat and venereal 
 eruption — Psoriasis. I advised Pil. Hydr., which he used for 
 a few weeks, and then went into the country, having derived 
 very little benefit from the course I had directed for. him; for 
 in this, as in the first instance, the system received the 
 mercury in a very unkindly manner. After an absence of 
 seven or eight weeks, during which he laid aside all mercurial 
 medicines, he again applied to me with his throat more 
 uneasy and the eruption still out. Mercury was again resorted 
 
198 PROTRACTED SYPHILIS. 
 
 to, but appeared to disagree with him more decidedly than 
 hitherto. A node formed m the course of a few months, and 
 his left testicle became hard and enlarged. After the complaint 
 in the testicle was established, his general health seemed to 
 improve a good deal ; and for some months prior to April, 
 1829, he complained chiefly of the size of the testis, which 
 was increased by effusion into the tunica vaginalis. 
 
 On the 11th of April, 1829, I learned from him that, 
 without any assignable cause, within the last fortnight his 
 health had very much declined ; and his symptoms at present 
 are a node on the lower part of the right tibia, from the upper 
 part of which bone another node had been removed about 
 three weeks ago, by the application of two bhsters ; painful 
 swelling of the left tarsus ; the end of the nose is a good deal 
 swollen, and beset with a cluster of pustules, which are 
 covered with white flat scabs ; two of the pustules, however, 
 have scales which affect the shape of rupia ; a broad flat scab 
 on the left zygoma, testicle enlarged and hardened, and 
 affected with hydrocele ; both arches of the paTlate have white 
 ulcers on their edges ; a yellow foul ulcer on the back of the 
 pharynx, high up ; pulse 108 ; skin hot. 
 
 I advised a piU, composed of Pulv. Jacobi gr. ij. Calomel 
 gr. i. omni nocte. 
 
 April 29th. For some days past he has complained of pain 
 on the inner side of both knees ; this is felt most severely 
 when he coughs or sighs ; the knees are free from sweUiug ; 
 the mouth, within the last three days, has become very slightly 
 affected ; the ulceration of the throat heals in one spot and 
 breaks out in another ; pulse stni 108 ; the right nostril feels 
 stuffed, and the membrane covering the lower spongy bone is 
 thickened and ulcerated; some new spots of eruption have 
 appeared. Omittatur Calomel. Pope's Extract of SarsaparUla. 
 
 May 31st, 1829. He is able to walk and jaunt about, has 
 acquired a good appetite, and sleeps well ; he has picked off 
 the scabs from the, end of the nose, which now presents a very 
 irregular rugged sui-face; the throat is healed; the nose, 
 internally, is much better, but not yet healed ; the testicle is 
 very little improved ; pulse still at 96. 
 
 July 1st, 1829. Flesh and complexion improved; general 
 
PEOTBACTED SYPHILIS. 199 
 
 health very good ; pulse still 96. He now complains only of 
 weakness in his knees. 
 
 November 6th, 1829. About the middle of July his throat 
 again ulcerated; his strength and appetite failed him. A 
 strong solution of Arg. Nitr. (9i. in §i.) was daily appHed to 
 the ulcers of the throat, and he took small doses of blue pill 
 and cieuta until the beginning of September. No very sensible 
 effect of the mercury on his mouth ; yet the throat was nearly 
 healed and his general health re-established. But this happy 
 state did not continue long ; for in the latter end of October 
 the right anterior arch of the palate became very much 
 swollen and red, with a whitish sloughy ulcer on its centre, 
 attended by much pain. I now feared that the entire arch 
 would have been destroyed by sloughing; but this evil was 
 averted by the appUcation of various caustics— Solut. Arg. 
 Nit. Mur. Antim., and Solut. Sulph. Cupri; of these, the 
 Mur. Antim. seemed to be the most useful. The edge of the 
 arch, however, and a part of the right tonsil were destroyed. 
 
 When his throat was nearly healed, he began to complain 
 of pain passing from the right hip down the thigh ; at the 
 same time a considerable effusion into the knee took place. 
 These symptoms were much reUeved for five or six days by 
 the exhibition of Sp. Terebinthinse internally; but after this 
 short period this medicine seemed to have lost its influence 
 altogether. I now gave him Pil. Hyd. gr. iv. Pulv. Jacobi gr. 
 ii. semel in die, and after a week increased them to two pills 
 daily; by this treatment no sensible mercurial action was 
 produced, and yet his symptoms all yielded. 
 
 Feb. 8th, 1830. This amendment continued only for twelve 
 or fourteen days ; he then complained of renewed soreness of 
 throat and stuffing of his nose. Ulceration now seized on the 
 left anterior arch, and at the same time a deep circular ulcer 
 formed on the back of the pharynx, immediately above the 
 edge of the velum ; a small node has arisen on the fibula, a 
 little above the outer ankle ; about ten days ago a scab of 
 rupia falling off the right leg exhibited the surface healed, 
 while a larger rupia on the left thigh is daily extending in its 
 circumference. 
 It were an useless waste of time to describe in detail the 
 
200 PROTRACTED SYPHILIS. 
 
 further progress of this case, and the line of treatment 
 adopted ; it will be quite enough to say that I had to contend 
 with symptoms such as have been already described: thus 
 these symptoms occasionally, and with them his general 
 health, improved for a time ; but that the ulcerated throat, 
 ulcers on the sm-face of the body, and swelling of both testes 
 continued to exist, although the ulcers would heal up in one 
 part, and then seize upon some new spot : and shall merely 
 state that in August, 1832, a node appeared on his forehead, 
 and another on his right thigh. During parts of this long 
 period his general health would improve very much, and this 
 improvement was sometimes apparently produced, but always 
 for a time promoted, by his going into the country or repairiag 
 for a time to the sea-coast. Yet such happy intervals were 
 never of a longer duration than four or five weeks. During 
 this amended state of his general health the local symptoms 
 became less severe and less troublesome ; but they did not at 
 any time disappear entkely, even for a very short period. 
 
 The treatment was at one time with various internal pre- 
 parations of mercury, and on two occasions with ten-graia 
 doses of merem-ial ointment. Sarsaparilla, bark, acids, cicuta, 
 alkahes, arsenic, and opium,— each of these would appear for 
 a short time to afford benefit ; but I was compelled to lay them 
 aside when I saw the general health and the local symptoms 
 fall back after each of them had been employed for some time. 
 
 In this vacillating condition of amendment and relapses was 
 passed the long period from Feb., 1830, until Nov., 1833. I 
 now determined to employ mercury in such a manner as to 
 induce a smart degree of ptyalism in a short period, having 
 prevailed on him to employ this process under strict confine- 
 ment to the house. The state of his case at that time is here 
 annexed. 
 
 Nov. 8th, 1833. Mr. A. has at least from twenty to thirty 
 ulcers, chiefly on his limbs; some of these had, about six 
 months previously, commenced in the form of soft round 
 tumours the size of a marble ; these came slowly to suppura- 
 tion, and on opening exposed cavities which were occupied in 
 part by a soft white slough. This was not confined to the 
 limits of each ulcer, but was seen to stretch beyond the borders 
 
PROTEACTBD SYPHILIS. 201 
 
 of its cavity. Others of these ulcers had begun as pustules, 
 forming on the edge of some old cicatrix, then ulcerating and 
 spreading into sores varying in size from that of a shilling to 
 that of half a crown. From the nose he daily, with great 
 effort, blew down large brown crusts or scabs. Behind the 
 velum palati, and very high up towards the base of the skull, 
 was an ulcer which created very considerable uneasiness, 
 although it did not render deglutition very painful ; his face, 
 especially his forehead and cheeks, were thickly studded over 
 with tubercles of a dark copper colour; the upper lip and 
 nose were a good deal swollen and thickened ; he had a pretty 
 large node on the head and another on the femur, but these 
 were in an indolent state; both testicles were very much 
 enlarged, quite beyond the ordinary enlargement of diseased 
 testicles ; in the tunica vaginaHs of the left there was a 
 quantity of fluid ; his general health was tolerably good ; he 
 was not emaciated, nor had he any degree of hectic ; but for 
 the last two months he has complained of a sensation of 
 fulness in the epigastric region, more troublesome after taking 
 food ; on examination the liver was found to descend much too 
 low ; no trace of jaundice. 
 
 Nov. 8th. Sumat Pil. Hyd. gr. iii. Ext. Cicutse gr. i. ter in 
 die. Ungt. Hyd. Fort. 5ss. omni nocte. 
 
 Nov. 10. No sensible effect from the mercury; he com- 
 plains that the skin in front of his thigh is extremely tender, 
 although it is perfectly free from any discolouration or 
 swelling ; in the centre of this very sensitive skin is a cluster 
 of tubercles, now covered with scabby crusts. 
 
 Nov. 12th. Pulse 96 ; gums swelling ; mercurial foetor 
 pretty strong ; some scabs on the thighs are drying, and seem 
 disposed to fall off. 
 
 Nov. 14th. The bowels have been dysenterically affected 
 yesterday and this day ; has not used any mercury to-day ; 
 cheeks are swollen, gums ulcerated, tongue sore to his 
 feehngs, but is not ulcerated ; says that he has no sense of 
 weakness : the tubercles on his face are very much improved, 
 less swollen or full, and of a less bright colour ; the soreness 
 of the skin around the scabs on his thigh, which had been 
 very distressing, is now quite gone. Omitt. Ungt. et. PU. 
 
202 PROTRACTED SYPHILIS. 
 
 Nov. 17th. Mouth as on the 14th ; he sleeps well ; has a 
 good appetite, but cannot admit solid food ; pulse 96 ; he has 
 lost aU feeling of fulness or uneasiness of stomach; the 
 improvement in colour of all those parts of the face which had 
 been occupied by the tubercles is more striking ; swelling and 
 thickening of lip and nose are materially reduced ; tubercles 
 are smaller in circumference, and much more flat ; idcers of 
 the limbs are aU clean and healthy ; scabs on the thighs are 
 fast approaching to fall off; they are contracted in circum- 
 ference and height, their edges dry and detached from the 
 skin ; in a word, there is every prospect of a speedy cure of 
 this very tedious disease by the present course of mercury. 
 Eepet. Ungt. et Pilulse Hyd. 
 
 Nov. 24th. Mouth stiU sore; appetite good; pulse 78; skin 
 temperate ; sleeps for five or six hours every night; ulcers are 
 aU covered with luxm-iant granulations, and are healing ; scabs 
 all drying, and look as if about to fall off ; he can read with 
 pleasure, not only light books, but even those on professional 
 subjects ; on two separate days only, since the last report, has 
 he omitted the pills and ointment : the ointment has been 
 always applied to the abdomen, as the numerous ulcers of the 
 limbs prevented its apphcation to them. Pergat. 
 
 Dec. 3rd. Has not used any mercury for the last three 
 days ; bowels have been purged each day so much as to require 
 opium; the mouth is fully sore; the discoloured spots on the 
 face present a more faded colour, and the appearance of the 
 face is altogether vastly improved; among all the numerous 
 scabs, from one only on the forearm could I press out one 
 small drop of matter. 
 
 Dec. 7th. Had a sense of weakness last night when going 
 to bed, but no palpitation thenor at any other time; pulse 74 ; 
 appetite good; no thirst; sleeps well; mouth overflows at 
 night; a crust has come down from the left nostril; both 
 testicles are hard, fuUy one-third larger than natural; with 
 fluid to the amount of an ounce in each tunica vaginalis. 
 Mist. c. Sulph. Quinae ter in die. Ungt. Hyd. Fort. 9i. 
 quotidie testibus affricand. 
 
 Dec. 10th. Pulse 76; sleeps well; appetite good, but cannot 
 make use of sohds; no thirst: skin cool; countenance good; 
 
PEOTKAOTED SYPHILIS. 203 
 
 mouth quite sore enough; ptyalism reduced; yesterday, 
 immediately after a large discharge from his bowels, felt a 
 weakness for ten minutes, but not the shghtest feel of palpi- 
 tation ; scabs have dropt off from every ulcer, except two or 
 three small ones. Omittantur Ungt. Hyd. et PU. Hyd. Eep. 
 Mist. c. Sulph. QuinsB. 
 
 Dec. 14th. Yesterday and this day has been teazed with 
 dysenteric purging, for which he took each day !?> . Tr. Opii. 
 Gutt. XXV. ; mouth still very sore; pulse 96; skin hot. IJ^.Olei 
 Eicini gvi. aq. Cinam. §vi. Tinct. Ehei gi. Tinct. Opii. Gutt. 
 XXX. M. fiat haust. statim sumendus. 
 
 Dec. 26th. General health very good; he feels himself 
 growing stronger ; mouth is now well, except around the lower 
 dens sapientiffi of left side, where the soft parts are ulcerated, 
 although free from slough. ^. Calomelanos 9i. Piper, 
 indici gr. vi. fient pilulse septem. Sumat unam meridie 
 nocteq. 
 
 Here let me observe, that I was soUcitous to bring his 
 system again under the influence of mercury; because his 
 disease having been of such a very long standing, it seemed 
 natural that it should require a very complete and long-con- 
 tinued influence of mercury to eradicate it effectually. And 
 his constitution had been so much improved by the late 
 ptyalism, that I felt confident it would very safely bear the 
 ptyaHsm which I was about to inflict on it. 
 
 Dec. Slst. The pUls on the night of the 27th purged him 
 a good deal, so that he did not take another until the night of 
 the 28th, when he took one only ; he has not since that time 
 taken any more, because he found that this fourth pill not 
 only had excited purging, but had also caused very consider- 
 able soreness of his mouth; the gums, especially the inner 
 gums in both upper and lower jaws, present one ulcerated 
 edge, and the cheeks at the angles of the jaws are swollen and 
 ulcerated afresh ; the edge of the tongue feels to him sore, but 
 it is not ulcerated ; with all this his pulse is 76 ; appetite 
 good ; general health very good. 
 
 Jan. 9th, 1834. Mouth is still a little sore; pulse quiet; 
 appetite for breakfast is bad, — for dinner is good. 
 
 Jan. 30th. Testes, though smaller, are still hardened and 
 
204 PEOTEACTED SYPHILIS. 
 
 enlarged; all the fluid seems to have been absorbed; no other 
 trace of his former disease remains; general health very 
 good. 
 
 Nov. 2nd. Mr. A. called on me this day ; he appears in 
 excellent health : can walk twelve or fourteen miles a-day ; 
 says that occasionally some crusts are expelled from the 
 nose ; whenever this occurs, he uses the Lotio Nigra with 
 immediate benefit ; pulse 80 ; testicles much reduced ; the 
 left one is Kttle beyond the natural size ; right testis is still 
 much too large. 
 
 November 2nd, 1836. Mr. A. continues to enjoy excellent 
 health; very sUght induration or enlargement of the testes 
 stiU continues. 
 
205 
 
 CHAPTEE X. 
 
 ON THE USE OF MEECXJRY IN VENEREAL HECTIC FEVEE. 
 
 I HAVE long been impressed with an opinion that the 
 judicious management of mercury, the adaptation of the 
 medicine to the general condition of the patient, and to the 
 circumstances and states of his venereal symptoms, afforded 
 the most likely means of enabling us to overcome the disease 
 of syphilis, under all the various forms and in all the various 
 combinations in vyhich it presents itself to our view. In this 
 opinion I feel confirmed by having ascertained that this very 
 valuable medicine may be administered not only with safety^ 
 but with certain expectation of effecting a cure under 
 circumstances of venereal symptoms and conditions of the 
 constitution which have hitherto been considered as absolutely 
 prohibiting its use. I shall now proceed to consider this 
 subject in detail. 
 
 Should a patient present himself labouring under secondary 
 symptoms, at the same time complaining of total loss of 
 appetite, of urgent thirst, emaciation to such an extreme 
 degree that he is almost exhausted by night sweats, which 
 oblige him to change his night dress two or three times every 
 night ; under these circumstances, I believe few surgeons 
 would ask the question, can we venture to exhibit mercury to 
 such a wretched sufferer ? I believe the usual answer and 
 the usual practice in such cases would be to postpone the use 
 of mercury, and to endeavour to bring the general health into 
 better order, by means of country air, asses' mUk, light 
 nourishing diet, sarsaparUla, acids, &c. ; in fact, to use every 
 other means rather than resort to mercury under these 
 apparently disadvantageous conditions; and no doubt many 
 such patients have then: health considerably improved by 
 pursuing this restorative plan for a period of two or three 
 months. However, at the expiration of this period, their 
 venereal symptoms are found to be very little, if at all 
 
206 MBRCUEY IN VENEREAL 
 
 amended, and sometimes they are even in a worse state than 
 when they commenced this plan. I may also add, that in 
 some cases of this extreme emaciation and hectic the restora- 
 tive plan altogether fails, and these individuals die as if worn 
 out by the long continuance of the hectic ; or they are carried 
 off by some of those affections which I have elsewhere 
 described as the sequelae, or as the last stages of the venereal 
 disease. (Vide History of the Disease.) 
 
 I am happy to have it in my power to declare that all this 
 preparation and all this delay are absolutely unnecessary in 
 such cases; and I most confidently assert that a patient 
 affected with secondary symptoms, even though extremely 
 attenuated, and as it were melting away under the effects of 
 hectic, can with perfect safety and advantage at once commence 
 a course of mercury, by which not only shall his venereal 
 symptoms be removed, but at the same time his general 
 health be re-established. 
 
 I shall not, however, attempt to establish this point by 
 reasoning, or to persuade my reader merely by argument or 
 assertion. I hope to convince by adducing facts; and the 
 first case to which I wish to direct attention is that of Mr. G. 
 
 Nov. 21st, 1830. Mr. E. G. says that seven weeks ago an 
 ulcer appeared on the external skin of the penis ; by applica- 
 tion of the yellow wash (Lotio Hyd. Cor. Sub. c. Aq. Calcis) 
 and of mercurial ointment this quickly healed. A second 
 ulcer appeared on the prepuce in eight days after the first was 
 healed ; to this he applied Lotio Nigra only : this now appears 
 as a florid granulating ulcer of oblong shape, but with very 
 hard base; his skin is everywhere covered with a venereal 
 papular eruption; yesterday, for the first time, he felt his 
 throat sore ; a long superficial foul ulcer runs along almost 
 the entire length of each tonsil ; the gum around the lower 
 right dens sapientiss is ulcerated ; he complains of pain of the 
 shoulders, pain and tenderness of the sternum, which symptoms 
 distress iim more severely at night : on the left side of the 
 neck a large mass of glandular swellings extends from the ear 
 half way down to the clavicle ; under the chin are two or three 
 distinct large lymphatic glands, and about the same number 
 are seen on the right side of the neck ; none of these have the 
 
HECTIC FETEE. 207 
 
 integuments red or discoloured; appetite very bad; bowels 
 free, but not purged ; has profuse night sweats, requiring him 
 to change his night-dress three or four times every night : he 
 is much emaciated, and is very pale ; pulse 120 : he says that 
 every day he thinks some fresh glands become enlarged, and 
 that his strength is daily and rapidly declining, and is now at 
 a very low ebb. Descendat in bain, tepid. I^ . Pil. Hyd. gr. iii. 
 Extr. Conii gr. ii. fiat pilula, mane nocteq. sumend. Bibat 
 Decoct. Sarsse c. Extr. Fluid. Sarsse ad semUibram in die. 
 
 Nov. 27th. Pains less : glandular swellings beginning to 
 decline ; ulceration about dens sapientiae exhibits less of 
 venereal character ; night sweats appear to have ceased for 
 the two last nights ; appetite is now good : he reports himself 
 as being much better in point of strength and general feehng. 
 Eepet. Pil. et Decoct. Sarsae. 
 
 Dec. 1st. Sumat Pil. i. sing. noct. Eepet. Decoct. Sarsse. 
 
 Dec. 4th. Mouth affected; ulcers of tonsils better, and much 
 less soreness of throat ; glandular swellings still more reduced ; 
 strength improved; sleeps well; appetite good. Omit. Pilulse. 
 
 Dec. 17th. Mouth well; superficial ulcer of right tonsil 
 improved ; ulcer of left tonsil healed ; gum still ulcerated, but 
 not at all painful. Sumat Pil. i. mane et nocte. Eepet. 
 Decoct. Sarsse. 
 
 Dec. 29th. Gums are swollen; ulcer of the molar gum 
 much better ; pulse 100, after he had walked a quarter of a 
 mile. 
 
 Jan. 10th, 1831. Mouth slightly affected ; pulse 84. Sumat 
 Pil. i. merid. nocteq. 
 
 15th. Mouth slightly affected ; has been long free from the 
 pains of shoulders and sternum; eruption has long since 
 disappeared ; ulcers of tonsils healed, but the anterior arches 
 appear rather too red and slightly swollen; glands of neck 
 reducing more rapidly since he began to take two pUls per 
 diem. Eepet. Pil. i. bis in die et Decoct. Sarsae. 
 
 Jan. 24th. Has taken three pUls daily for the last five 
 days ; mouth slightly affected : he is obliged to go to England. 
 Although aU his venereal symptoms have disappeared, and the 
 glandular swellings have been entirely removed, and his flesh 
 and strength are now almost completely restored, still I think 
 
208 MERCURY IN VENEBBAL 
 
 he has not used mercury enough to secure him against the 
 danger of a relapse. 
 
 In the month of February, Mr. G. consulted Sir B. Brodie 
 on account of a sore throat. Sir B. told him that his disease 
 was not venereal, but the consequence of venereal, and ordered 
 a pOl of Hyd. Oxyn. gr. ss., to be taken at mid-day with Ext. 
 Sarsse. He used the medicine rather carelessly. He returned 
 to Dublin in October following, with a decided venereal ulcera- 
 tion of right anterior arch of palate : but his general health 
 was then pretty good, and there was not any return of the 
 swellings of the lymphatic glands of the neck. By the use of 
 Hyd. Calcinatus, combined with opium, and at the same time 
 by the use of Decoct. Sarsse, he got quite weU in the course of 
 six weeks. 
 
 Remarks. 
 
 I despair of being able accurately to depict the almost 
 deplorable condition of this young man when he came imder 
 my care. His venereal symptoms were not, any of them, of a 
 severe character ; yet his general health appeared to be com- 
 pletely broken down. When we find him at once affected 
 with loss of appetite, loss of sleep, quick pulse, profuse night 
 sweats, wasting of flesh, loss of strength, enlargement of the 
 cervical lymphatic glands, and every day adding to their 
 number and size, a sure indication that the health was daUy 
 and hoiurly sinking, I think we here have a combination of 
 symptoms calculated to excite our most serious fears for the 
 patient's safety. In fact, so rapid and headlong was the 
 course of his symptoms, that I altogether despaired of being 
 able to check their progress by any restorative treatment, and 
 therefore I determined to rely on small doses of mercury. 
 
 I admit that it may be questioned whether as to the 
 sarsaparilla, the cicuta, and the mercury, which was the most 
 useful remedy ; or what share each of these had in arresting 
 the progress of these alarming symptoms. But this much at 
 least must be conceded, that in this case the mercury did not 
 bar his recovery, nor did it produce any of those mischiefs 
 which, from recent publications, we might have been led to 
 anticipate. This case I have brought forward to show that 
 
HECTIC FEVEE. 209 
 
 mercury may be used (if used in very small doses) -while the 
 system is as it were rapidly sinking under the pressure of' 
 hectic fever. In fact, we can hardly conceive any man, who 
 is yet able to walk two or three hundred yards, to be more 
 reduced in flesh, colour, and strength. Nor can we imagine 
 a more sharp degree of hectic fever ; nor can I recal to mind 
 any instance in which the glandular swelHngs or the 
 scrophulous enlargement of .the lymphatic glands had 
 increased more rapidly. Let this case now stand as an 
 instance of a very reduced state of health, and a very severe 
 degree of hectic fever, not forbidding the cautious use of 
 mercury. As, however, so many other remedies had been 
 used along with the mercury, it is impossible to estimate what 
 share the mercury had in effecting this very salutary change. 
 I therefore feel myself called on to produce the following 
 case as an instance of the safety with which mercury may be 
 used in a very low state of health, and how it wiU, in such a 
 condition as would almost forbid its use, effect the cure of both 
 primary and secondary symptoms. 
 
 John Yeates, a labourer, set. ann. 30, admitted into No. 11 
 ward, Dec. 17th, 1835. 
 
 On the external prepuce is a painful ulcer ; the surrounding 
 integuments are of a dark red colour : there is also a purulent 
 discharge from under the prepuce, which is much swollen ; an 
 ulcerated bubo in each groin ; through that on the left a lym- 
 phatic gland, larger than an almond, rises and projects con- 
 siderably above the level of the skin ; both tonsils are enlarged 
 and of a coppery red colour ; on the surface of the right tonsil 
 is a small ulcer : he suffers much pain in swallowing ; com- 
 plains also of pains in the shins, and along the ulna of each 
 arm ; the surface of the body is covered with a papular 
 eruption of a large size ; appetite is very indifferent ; he 
 sleeps badly; pulse 100; says that six weeks ago he first 
 perceived a small ulcer on the glans penis, and a pustule on 
 the prepuce, which inflamed and then ulcerated ; very shortly 
 afterwards a bubo appeared in each groia; about ten days 
 ago the gland in the left groin became exposed, and began to 
 protrude; three days prior to his admission he perceived 
 the eruption; thinks he felt soreness in the throat in a 
 
 p 
 
210 HECTIC FEVEE. 
 
 ■week after he perceived the chancre : he has not taken any 
 medicine. 
 
 Prom the day of his admission until Dec. 26th he was 
 directed to take repeated purgatives, generally a combination 
 of calomel and jalap ; but his bowels proved obstinate, and 
 these medicines have produced much less of purgative effect 
 than was wished for. 
 
 Dec. 26th. The symptoms being as at the time of his 
 admission, I directed for him Ungt. Hyd. Fort. gr. x. o. n. 
 
 Dec. 29th. Mouth sore, with some ptyalism ; both the 
 buboes are much improved, presenting clean granulating 
 surfaces ; the protruded gland, I think, is a little retracted ; 
 a slight mercurial erythema at the top of his thighs. Mist. 
 Cinchonae c. Tr. Opii. Omitt. Ungt. 
 
 Jan. 2nd, 1836. Erythema is now gone; chancre and 
 buboes looking healthy; the protruded gland is obviously, 
 though slowly, retiring ; throat is much better ; eruption very 
 much faded. Eepet. Mist. Cinch, c. Tr. Opii. 
 
 Jan. 4th. Eepet. Mist. Ungt. Hyd..Fort. gr. x. alt. noct. 
 
 Jan. 9th. Pergat. 
 
 Jan. 11th. Ungt. Hyd. Fort. gr. x. om. nocte. Eepet. 
 Mist. Cinch. Both tonsils are reduced to their natural size, 
 but there still remain a few small superficial ulcers on their 
 surface ; chancre is very nearly healed ; buboes are healing 
 rapidly ; gland much more retired ; eruption gone, stains of 
 it are scarcely visible ; prepuce stUl thickened, and its orifice 
 much contracted, giving exit to a purulent discharge, for 
 which I have directed the Lotio Nigra to be injected under the 
 prepuce. 
 
 Jan. 15th. He complains' most bitterly of a scalding at the 
 anus ; the buttocks on each side, where opposed to one another, 
 are covered with a thick purulent discharge ; on wiping this 
 away the surface on each side is seen excoriated to twice the 
 extent of a crown piece ; no actual ulceration ; the ulcers in 
 both tonsils appear more deep than they were some days ago, 
 and even seem disposed to open ; the chancre and both buboes 
 are improving, but now rather more slowly ; mouth is sore. 
 
 From the 15th to the 30th of January he had P. Mist. 
 Cinchonae c. Opio et Lotio Nigra for the excoriation. 
 
HECTIC FEVEB. 211 
 
 Jan. 19th. Pulse 108, as he stands out of bed ; tonsils look 
 better ; buboes and chancre have improved rapidly since 16th 
 inst. ; he appears much less feverish ; excoriation is much less 
 painful, although not yet healed in any one part. 
 
 Jan. 26th. Mouth nearly well; throat as before; chancre 
 and buboes perfectly healed ; excoriation healed in the more 
 superficial parts ; pulse 80 as he lies in bed. Eepet. Mist. 
 Cinch, et Lotio Nig. 
 
 Jan. 30th. Pulse 96 as he stands out of bed ; anus quite 
 well ; he feels the throat more sore. Ungt. Hyd. Fort. gr. x. 
 omni nocte. 
 
 Feb. 2nd. Eepet. Ungt. Sumat Pil. Hyd. gr. v. om. 
 nocte. 
 
 Feb. 6th. Eepet. Ungt. om. nocte et PH. Hyd. gr. v. bis 
 in die. 
 
 Feb. 9th. Ungt. 9 i. om. nocte et Pil. Hyd. gr. v. ter in die. 
 Mouth is not yet sufficiently sore ; ulcers of tonsils are better, 
 and he says he feels his throat better. 
 
 Feb. 23rd. Discharged cured; not having used any 
 mercury since the 10th, on which day his mouth was quite 
 sore enough. 
 
 Remarks. 
 
 In my notes of this case, taken on the 26th December, I find 
 this remark: "I think there is not another surgeon in 
 DubHn who would dare to give mercury to this man in the 
 present circumstances of his case." From which may be 
 inferred how very unpromising was his state at that time. 
 Let us now advert more particularly to his history. 
 
 We have here combined, iu the same individual, vmdoubted 
 venereal symptoms (if any symptoms deserve that epithet) of 
 the primary and secondary class ; and these too without 
 having suffered any modification from mercury, or indeed 
 from any other plan of treatment. Yet we find that these 
 clear and decided, or unadulterated venereal symptoms of each 
 class, yielded to mercurial treatment, cominenced while the 
 system was in a febrile state, and so early as on the twelfth day 
 after the eruption began to show itseK. So that here the 
 practice was in direct opposition to two rules which I believe 
 
212 HECTIC FEVEK. 
 
 are pretty generally acted on by the profession, viz., 1st, not 
 to give mercury while there is much febrile excitement; 
 2ndly, not to give mercury while an eruption is coming out, 
 and while the eruptive fever continues. I am perfectly certain 
 that had I used mercury in the ordinary doses of 5ss. or 5i. 
 of Ungt. daily, the result would have been very unfortunate 
 indeed. But by apportioning the doses to the state of the 
 constitution the result has been most satisfactory, and the 
 patient has been released from his sufferings, and has been 
 cured of his disease in a period of time shorter by one month 
 or six weeks than he would have been had he been subjected 
 to the ordinary routine of practice, and had the mercmy been 
 withheld until the fever had subsided and his general health 
 to a certain degree been re-established. Another very remark- 
 able featm'e in this case is the very short period of time and 
 the very small quantity of mercury employed in exciting 
 ptyaUsm. Ten grains of mercm-ial ointment, used for three 
 successive nights, brought the system as folly and satisfactorily 
 under the influence of mercury as could be desired. And the 
 state of the symptoms, as reported on the 11th of January, 
 viz. in sixteen days from his commencing the use of mercury, 
 shows that the effect of this mercurial treatment was as 
 favourable as is seen in ordinary cases, where mercury is given 
 in the usual doses to a patient free from fever, and in ckcum- 
 stances deemed most fitted for the use of this medicine. This 
 case presents a very striking fact, one for which I candidly 
 admit that I am not able to account. We find that ten grains 
 of ointment, used for four nights, from the 11th to the 15th of 
 January, had produced that distressing effect, xiz. a mercurial 
 excoriation about the anus. This was only ten grains more 
 than what had acted so favourably at the beginning of the 
 course. But although I do not pretend to account for this 
 effect of the mercury, I may be allowed to direct attention to 
 it ; because I look upon this as a most unerring proof that the 
 mercm-y is at this time too powerful in its action for the 
 individual. Yet surely it wUl be granted that the doses were 
 not excessive, nor were they employed for any unreasonable 
 length of time. Still as an indication that mercury is now 
 disagreeing with the system, I look upon this symptom as a 
 
HECTIC FEVBE. 213 
 
 very valuable addition to our rules of practice. Indeed I am 
 of opinion that we cannot too highly prize any effect or test 
 which will point out to us that mercury is disagreeing with 
 the system. It is curious that this excoriation did not appear 
 with the first ptyalism, but at the approach of the second. It 
 is also remarkable that this unkindly action of mercury had 
 more injuriously affected the secondary than the primary 
 symptoms. Had I been using 5i. or 5ss. of Ungt. Hydr. Fort, 
 instead of ten grains for a dose, then I might be told that the 
 dose was too large. A short time ago I could not have 
 expected such severe effects from so small a dose of mercury. 
 
 To those who are anxious to use mercury in the smallest 
 possible quantity, this case must be very gratifying, as the 
 whole quantity employed amounted only to four drachms, and 
 ten grains of ointment, with 110 grains of blue piU. 
 
 The venereal nature of this case will not, I believe, be 
 disputed. The state of health at the time that mercury was 
 first employed is described in the report in a very few words ; 
 and though the description by no means corresponds with that 
 usually given of hectic fever, yet that he was highly feverish 
 maybe inferred from my private remark at that time, viz., "I 
 think there is not another surgeon in Dublin who would dare 
 to give mercury to this man in the present circumstances of 
 his case." 
 
 I shall now adduce a case in which the symptoms were 
 considered by me, and by all the hospital attendants, to be 
 secondary venereal symptoms, and which yet did not admit of 
 a verbal description that would satisfy one, who had not an 
 opportunity of personally examining the case, as to their 
 venereal nature. The symptoms were a return of the same 
 ulcers for which he had been an the hospital for two months 
 previous to February last. — Markham, No. 12 ward. 
 
 In the history of his case he is described as having an 
 extensive ulcer covering the upper lip and the tip of the nose, 
 which has destroyed part of the septum and part of the right 
 ala nasi ; and has also a large ulceration on the fore part of 
 the left thigh, a little above the knee, and a small ulcer on the 
 back of the leg. He had ulcers in aU these places, of which 
 he was apparently cured when he left the hospital in February 
 
214 HECTIC FEVEB. 
 
 last, having undergone a full course of mercury. On his 
 return home he was much exposed to cold, and drank spirits 
 to very great excess. In two months after leaving the hospital 
 the ulcer on the nose began to re-appear, and in four months 
 more that on the thigh also broke out. 
 
 From the time of his admission (the 17th) until the 28th of 
 November he was directed to take the mineral acids. On the 
 28th he was ordered Ungt. Hydr. Fort. 9 i. o. n. 
 
 On December 1st, 5. Tinet. Acet. Ferri, ji. Hydr. Cor. Sub. 
 gr. i. M. Sumat Cochl. Minim, bis in die, e Decocti Hordei 
 Cyatho. 
 
 December 5th. His mouth is now very sore; a smart 
 ptyahsm is established. Omittatur Solutio. Curentur Ulcera 
 Ungt. Hydr. Nitr. 5i. Dilut c. Axungia §i. 
 
 On the 28th of November I made this note : — " This man 
 was under my care, and was salivated when last in the 
 hospital. He is now such a wretched-looking creature that I 
 have been afraid to use mercury with him since his admission ; 
 and I have but little encouragement to do so, as it akeady 
 failed to cure him. However, as he must die unless something 
 decisive be done, I shall venture on the use of mercury ; for 
 die he must under the ordinary treatment, without mercury. 
 No improvement whatever has taken place since his admission." 
 
 On the 13th of December I made the following note: — "It 
 is remarkable and most extraordinary how very readily 
 ptyahsm has been induced ; and it is equally remarkable how 
 very quickly and materially the ulcer of the Hps and nose, 
 and the sweUing.of these parts, have improved since the 
 mercury came into action. The mouth is still smartly 
 affected, and the cheeks swollen. The amendment during the 
 last eight or ten days has been greater than could have been 
 anticipated." 
 
 To finish the history of this case, I shall only add that so 
 speedy and complete was the healing of the ulcers of the face, 
 and so decided the improvement of the ulcers of the limbs, 
 that I did not feel myself justified in ordering any mercury 
 after that of the 1st instant ; we of course ceased at the end 
 of four days. The ulcers were retarded in healing partly by 
 the great extent, and partly by being seated on the cicatrix of 
 
HECTIC FEVEE. 215 
 
 former ulcers. He left the hospital on the 27th of February 
 cured. 
 
 I cannot readily forget the surprise depicted in the 
 countenance of the students, when they first heard me direct 
 the pupil in charge of my prescription book to write a scruple 
 of ointment every night ; indeed it was such as forced me to 
 declare " that if mercury did not cure him, I could not tell 
 what would ; and most assuredly, if this man could bear 
 mercury, there was no man who could not." I need not add 
 that the progress of the case (at least as long as under the 
 influence of the mercurial action) was most anxiously watched 
 by all the pupils. 
 
 It may not be amiss to state that during (and probably 
 owing to) the mercurial action, a lymphatic gland under the 
 chin inflamed, suppurated, and ulcerated; and it healed 
 spontaneously after the action of the mercury had subsided. 
 
 In this case one very remarkable fact should not be passed 
 over. I aUude to the cure having been accomplished by 
 such -a very minute quantity of mercury ; for the entire 
 quantity used amounted only to three scruples of the ointment 
 and one grain of corrosive sublimate ; and to use this small 
 quantity seven days were employed. 
 
 Some perhaps wiU lay hold of this one fact as an argument 
 to show that the disease could not have been venereal ; because 
 here we have a cure accomplished by a quantity of mercury 
 so infinitely less than what is universally considered as 
 sufficient for the cure of any one symptom in any stage of 
 the venereal disease. But although such objection may be 
 urged with effect, if applied to the cure of a strongly marked 
 and decided, or unsubdued symptom of syphilis, in an 
 unbroken constitution ; yet it will not hold good when applied 
 to a case of a feverish, debilitated patient, affected with 
 symptoms which had been subdued and weakened by previous 
 mercurial treatment. In support of this assertion, let me 
 bring forward the following case : — 
 
 Mr. 0. B., eet. ann. 28, contracted a venereal disease four 
 years ago, and has been for a long time under the care of Mr. 
 Peele for the cure of secondary venereal ulcers ; three or four 
 of these, on the face, are most strikingly marked as venereal ; 
 
216 HECTIC FEVEB. 
 
 a very extensive and deep ulcer of the calf of the leg is less 
 strongly marked as syphilitic, but it commenced at the same 
 time with the ulcers of the face. This ulcer had committed 
 great havoc ; it destroyed no small portion of the inter- 
 muscular cellular tissue, and had induced a sloughy state of 
 what remained between the muscles of the calf; so that, even 
 if the ulcers were perfectly healed, it was obvious that he 
 must always remain lame of this leg. I had akeady seen him 
 in consultation three or four times, at intervals of three or 
 four weeks. On each of these occasions one principal subject 
 of our deliberations was whether we should resort to amputa- 
 tion. However, in consultation on the 17th of September, 
 1833, it was agreed that he should make trial of very minute 
 doses of mercury : accordingly he was directed to take Pil. 
 Hydr. gr. v. omn. nocte. Of these he had taken two only in 
 as many nights, when his mouth became very sore, and a very 
 small ptyahsm ensued. All the ulcers, both of the face and 
 leg, healed during the salivation ; and he has since enjoyed 
 good health, and is able to go about, wearing a high heel to 
 his shoe. During the long period that this disease continued 
 mercm-y had been tried more than once, and again abandoned, 
 not having produced any decided benefit. 
 
 In this case the ulceration of the leg would have been early 
 healed, if that object could have been accompUshed by appU- 
 cations of different kinds most judiciously chosen, and these 
 applied with a degree of skill and dexterity not to be surpassed, 
 and with a zeal and attention which could scarcely be expected 
 from a very attached friend. Yet the dexterity in applying, 
 and the judgment in choosing various local applications, 
 availed but little ; nor was the use of mercury more service- 
 able, BO long as the mercury failed to excite salivation ; but 
 the moment that the mercury chanced to be apportioned to 
 the state of the system, and that it produced saUvation, from 
 that instant all the symptoms changed for the bBtter, and the 
 deep and extensive ulcers of the leg, and the disfiguring ulcers 
 of the face, hastened to heal. Here it is remarkable that so 
 very smaU a quantity of mercury could have made such a 
 decided impression on the general system; but it is quite 
 clear that, in this case at least, this medicine acted not by its 
 
HECTIC FEVER. 217 
 
 quantity, but by its having luckily taken a right direction, 
 and made vyhat I term a salutary impression on the salivary 
 system. 
 
 In each of the consultations our chief objection to the 
 proposed amputation was the apprehension that the stump 
 would be seized with the same kind of bad ulceration. I 
 really thought that the leg was scarcely worth preserving, and 
 that certainly we ought not to endanger the patient's life in 
 the slightest degree from an anxiety to preserve such an 
 useless limb. 
 
 I know many will be ready to exclaim, all this does not 
 prove that the ulcers were venereal, for we know that mercury 
 has cured many ulcerated legs where no suspicion of a 
 venereal taint could be entertained. To this I can only 
 answer, that the ulcers on the face presented to me what I 
 considered very strong characters of venereal ulcers, and that 
 they could be traced up to a venereal origin. Waving all 
 arguments on the subject of these ulcers being venereal or not, 
 what I contend for is this — that where we can trace ulcers, or 
 any symptom, to a venereal origin, we may be allowed to 
 suspect that they stiU partake of the nature of their exciting 
 cause ; and that under such circumstances we are justified in 
 resorting to mercury. Had we not in this case been able to 
 trace some connection with venereal infection, I am certain 
 that we should not have dreamed of using mercury for the 
 leg alone, so very different was the ulceration of this from 
 any thing of secondary venereal ulcers. But the ulcers on 
 the face had enough of venereal characters to call our attention, 
 and to rouse our suspicions, as to their real nature. 
 
 So very sudden was the improvement that I did not after- 
 wards see the patient until long after all the ulcers were 
 healed, and then he was going about in perfect health, but 
 obliged to use a high heel to his shoe. 
 
 A few more such instances would go far to overturn Mr. 
 Hunter's position — " The quantity of mercury to be thrown 
 into the constitution for the cure of any venereal complaint 
 must be proportioned to the violence of the disease." — Page 
 508, London edition, 8vo, 1810. 
 
218- 
 
 CHAPTEE X. 
 
 MEECUEY DURING VENEEEAL ERUPTIONS. 
 
 I BELIEVE it is a pretty prevalent opinion at the present 
 day, that when a venereal eruption is coming out we should 
 withhold mercury until the eruption be completed, lest we 
 interfere with or interrupt that process. Another reason for 
 withholding this medicine in such cases is, that the fever 
 which accompanies the eruption is considered as unfriendly to 
 the anti-venereal action of mercury. Now I am convinced, by 
 repeated observations, that this rule not only may be departed 
 from, but that it cannot he followed with advantage to the 
 patient. My observations have been both where the eruptive fever 
 was very sMght,"and also in cases where the fever was running 
 pretty high preceding the appearance of the first eruption; 
 but I imagine that that line of practice which is found safe 
 and useful in the fever attending the first eruption (which is 
 always of a more severe kind) cannot be dangerous in those 
 shghter forms of fever which occasionally usher in and attend 
 on the second or subsequent crops of eruption. 
 
 Some years ago I fijst adopted this plan of treatment in the 
 case of Mr. P., a young man who had been under my care for 
 four weeks, for cure of a chancre and bubo. Prom my anxiety 
 to get him quickly cured, I used mercury in doses too great 
 for his system, and accordingly I failed to excite ptyalism, or 
 to cure the local complaints. At the expiration of three 
 weeks the chancre was not quite healed, the bubo was red, 
 painful, and enlarging. SarsaparUla was now substituted for 
 the mercury. When he had been nearly three weeks on this 
 plan, a pustular eruption, accompanied by an eruptive fever of 
 a hectic type, with profuse sweats, began to appear — some 
 spots of it of a very large size came upon his face. This 
 made him very readily comply with my desire, that he should 
 use small quantities of mercury, notwithstanding his last 
 imfavourable experience of it. I directed Pil. Hyd. gr. iii. to 
 
MBRCUEY DURING YENEEEAL EEXJPTIONS. 219 
 
 be taken bis in die. I was delighted to see the eruption yield 
 very quickly, the large pustular spots on the face dry and 
 contract, and the crust fall off, — no new spots appeared. And 
 not only did the fever subside, but at the same time the 
 original primary symptoms, which had heretofore proved so 
 obstinate, now got well speedily and permanently. Now I 
 make no doubt that this young man was cured of aU his* 
 venereal complaints fully six weeks sooner by the course I 
 adopted, than he would have been had I deferred the use of 
 mercury until the eruption had fully developed itself, and had 
 left the systerri free from fever. Besides, he was saved from 
 some unseemly and permanent cicatrices of the face, which 
 the ulceration of this eruption so constantly leaves after it. 
 
 The same plan of treatment I adopted in the following case 
 of a venereal eruption, one very different in form from the 
 foregoing. 
 
 July 2nd. Mr. T. informed me that on. 7th May he had 
 commenced taking Calomel, gr. iii. bis in die, for cure of a 
 chancre, and continued the use of the medicine until about 
 eleven days ago ; during the entire of this time he was 
 travelling through the country in such a manner as did not 
 allow him to guard against cold or wet. He thinks his mouth 
 was made slightly sore in a week after he had begun the use 
 of merciiry ; and he endeavoured, but in vain, to keep up a 
 slight soreness of it. 
 
 At present he is free from mercurial action, and complains 
 much of sore throat ; both sides of it are of a colour too highly 
 red, and are swollen. The right tonsil is ulcerated, and a 
 white slough occupies the entire ulcer. 
 
 Sis days ago he first perceived on his forehead an eruption 
 of small copper-coloured spots, scarcely raised above the 
 surface ; these are of the sandy or measles-like eruption. 
 The prepuce, which with him naturally covers the glans, now 
 cannot be brought over it, in consequence of a dark copper- 
 coloured bump, as large as a filbert, which is seated behind 
 the frsenum, and occupies the site of the original chancre. He 
 sleeps very badly, although he has not pains of limbs, and he 
 sweats towards morning. Pulse 108. I directed soine James's 
 powder, with nitrate of kaH. 
 
220 MBRCUEY. 
 
 July 4th. Throat feels worse, and as if much swelled 
 internally ; much pain in swallowing ; fauces much inflamed 
 and thickened, especially the uvula; ulcer of right tonsil is 
 more decidedly venereal ; snuffles much in speaking. I5> PU. 
 Hyd. gr. ii. Pulv. Ant. gr. ii. Bhei gr. ii. Ft. PH. ii. mane et 
 nocte sumendse. 
 
 July 7th. Symptoms not improved, rather worse ; has had 
 gout in one foot and hand since the 5th inst., but not so 
 severe as to confine him to bed. PH. Hyd. gr. iii. Pulv. 
 Antim. gr. ii. bis in die. 
 
 July 10th. Eruption fading, and beginning to desquamate ; 
 uvula and velum are less swoUen, and have less of inflam- 
 matory redness ; voice much improved ; has a bad taste in 
 his mouth, but it is not brassy ; it makes him dislike tea, 
 of which he had been very fond ; gums little, if at aU, swollen ; 
 gout better ; pulse 84. Eepet. Pilulse ut 7th inst. 
 
 July 14th. Eruption and condition of throat stationary; 
 mouth less affected with brassy taste ; no ulceration of gums, 
 but the cheeks exhibit the impression of the posterior molares ; 
 gout has seized on right ancle. Sumat. PU. Hyd. gr. v. 
 ter in die. 
 
 July 23rd. Gums not ulcerated ; throat less swoUen, and 
 ulceration better; eruption less bright. IJ. Calomel Pulv. Antim. 
 Conf. Opiat. a. a. 9 i. PU. xii. Sumat unam ter in die. 
 
 July 28th. Eruption much faded ; skin of forehead much 
 less red; throat less inflamed ; voice perfectly re-established; 
 mouth not more affected ; appetite good ; skin temperate ; 
 pulse 84 ; sleeps for three hours, and awakes in perspiration. 
 Calomel Conf. Opiat. a. a. 3 i. Port. Pil. octo. Sumat unam 
 ter in die. 
 
 Aug. 3rd. Eruption has quite cleared away from the fore- 
 head, leaving only the discoloured pittings; ulcer of throat 
 healed; scarcely any inflammatory redness or thickening; 
 countenance much improved; brassy taste of mouth; gums 
 not ulcerated, but cheeks of a leaden colour, and impressed by 
 posterior molares; has been purged, with some pain; pulse 
 78 ; no night sweats. Eepet. Pil. ut 28th. 
 
 Aug. 9th. Mouth more affected; bowels moved once a day; 
 symptoms have disappeared. Pergat. 
 
DUEING VENEREAL ERUPTIONS. 221 
 
 Aug. 19th. Gums ulcerated; mouth sufficiently affected; 
 stomach rather weak ; no night sweats ; lump on prepuce has 
 left only some thickening ; for the last four days the skin has 
 come forward and covered the glans. Sumat PH. unam bis 
 in die. Mist. c. Sulph. Quinse et Tinct. Cinch. Comp. bis 
 in die. 
 
 Aug. 24th. Mouth is very fully and satisfactorily affected ; 
 ulceration of gums of dentes sapientise, and of the edge of the 
 tongue, corresponding with them ; strong mercurial fcetor : 
 spots on the forehead have all left discoloured pits ; prepuce 
 lies forward; when retracted, no hardness to be felt; when 
 pushed forward, some small hardness is either felt or sus- 
 pected. Omitt. Pil. Haust. Purg. et b. tepid. 
 
 Dec. 24. In excellent health ; a globular hard spot, size of 
 head of a large pin, in site of old lump, is the only vestige that 
 remains of the disease. 
 
 Bemarks. 
 
 In this case I was induced by the importunity of the patient 
 to give mercury in the eruptive fever of secondary symptoms, 
 even while only a very limited quantity of eruption had 
 appeared ; for he was obliged to be much abroad, and, of 
 course, was most anxious to get rid of the eruption on his 
 forehead as speedily as possible. I began with very small 
 doses in combination with Pulv. Antim., a supposed febrifuge 
 medicine. In addition, we observe that the gout attacked 
 him on the second or third day of using mercury. Yet, with 
 aU these disadvantages, on August 7th, when he had only 
 taken twenty grains of Pil. Hyd., there was not only a check 
 given to the symptoms, but even a marked improvement. 
 
 Now had I followed the established rule of withholding 
 mercury until the eruptive fever had ceased, what a delay 
 to his recovery, what an injury to his pursuits would he have 
 had to suffer, and possibly, in addition to this, the ulcer of 
 the throat" might have created such an aggravation of fever, 
 that it, combined with very inadequate nourishment, would 
 have made it take an unfavourable turn, and begin to slough. 
 Thus his voice might have been irretrievably injured. Or it 
 is possible that, during the exasperated stage of fever, some 
 
222 MERCUEY 
 
 spots of the eruption on his face might have ulcerated or have 
 degenerated into rupia, and thus leave him more or less dis- 
 agreeably marked. All these risks have been avoided, and the 
 entire of the disease has been removed in a period of time 
 little more than would have sufficed to get rid of the eruptive 
 fever only. So that, by following the established practice, 
 the patient would have barely begun the mercurial treatment ; 
 for at the time that he would be laying it aside, if treated 
 according to the plan pursued in this case. The duration of 
 the mercurial course might have been a week or ten days 
 shorter, had not the attack of gout prevented me from pushing 
 on with the mercury. In this case, on 23rd July, I ventured 
 to give very full doses of mercury, nearly two grains of calomel 
 three times a day. I was induced to do so because I found 
 that his mouth had not been sufficiently affected by the Pil. 
 Hyd., and I judged it perfectly safe to do so because he had 
 been for many days perfectly free from any febrile disturbance. 
 I think it a satisfactory circumstance that in this case we had 
 other symptoms than eruptions (for we know that these will 
 spontaneously improve after they have been out for a certain 
 time), particularly the hardened purple lump on the prepuce. 
 We observed this to yield in proportion as the action of the 
 mercury on the system was more fully established. The early 
 exhibition of mercury, as here recommended, will therefore 
 be found to possess the following advantages : — 
 
 1st. The patient is freed from the venereal disease in a much 
 shorter space of time. 
 
 2nd. The constitution is relieved from all the injury which 
 it must sustain by a continuance of the eruptive fever. 
 
 3rd. The local symptoms thus arrested at their very onset 
 are prevented from committing any devastation or destruction 
 of important parts, or from leaving after them unsightly 
 cicatrices. 
 
 4th. The cure of the venereal disease is effected by a 
 quantity of mercury infinitely smaller than what is -ordinarily 
 required for the removal of similar symptoms when allowed 
 to develop theijiselves fully. This, by some practitioners, will 
 be considered a great advantage. 
 
 Mr. D. applied to me with an ulcer on the glans penis, 
 
DURING VENEEEAL ERUPTIONS. 223 
 
 which I judged to be a chancre, and to be applied to which I 
 directed the Lotio Plumbi Acetatis for a few days. Being 
 confined to my bed by an attack of gout, I did not see him 
 for twenty days ; I then found the chancre with so very 
 healthy an appearance that I almost suspected I had been 
 mistaken in supposing it to be a venereal ulcer. I advised 
 him to continue the same lotion. In about three weeks more 
 he called on me ; he had now an eruption on his forehead and 
 body of a pustular character ; his appetite good ; pulse very 
 quick; profuse night sweats. Notwithstanding this febrile 
 state, I advised. May 22nd, Pil. Hyd.gr. iii. et Pulv. Antim. 
 gr. ii. 0. n. 
 
 May 26th. No visible effect from the pills; the eruption on 
 the forehead is scabbing, and has assumed a darker colour. 
 Sumat Pil. Hyd. gr. x. o. n. 
 
 May 30th. Eruption fading; bad taste in the mouth; gums 
 are not sore. Pergat. 
 
 June 2nd. Eruption is everywhere fading ; some foetor of 
 breath ;' mouth not sore ; night sweats continue. Sumat Pil. 
 Hyd. gr. x. omne nocte, et grana quitiq. mane. 
 
 June 13th. Mouth not sore ; eruption fading. Sumat Pil. 
 Hyd. gr. x. m. et n. 
 
 June 20th. Mouth not affected. I^ Calomelanos gr. ii. 
 Opii. gr. ss. Ft. Pil. mane nocteq. sumenda. 
 
 June 24th. Gums swelled and ulcerated ; some ptyalism. 
 Omitt. Pil. per dies x. dein repetantur. 
 
 July 3rd. Has been smartly salivated, although he did not 
 take any pills since 24th inst. ; eruption completely removed. 
 
 The very delicate state of his health during the first month 
 prevented me from increasing the doses of the mercury by 
 larger additions than those above mentioned ; but, finding his 
 strength and health so much improved at the end of the 
 month, I then ventured to increase the doses by very large 
 additions, and certainly with the happiest effect. Mr. D. is a 
 young man naturally of a very delicate habit ; his strength 
 and flesh were reduced very much at the time I commenced 
 the use of mercury, under all the disadvantages of very 
 accelerated pulse and profuse night sweats. 
 
 The changes which the chancre underwent before healing. 
 
224 MEKO0EY. 
 
 and the facility with which it healed under the use of so 
 simple an application as Lotio Acet. Plumbi, should teach us 
 great dif&dence in deciding on the nature of primary ulcers. 
 
 I think I can scarcely too often repeat what I consider to 
 be the grand rule for the treatment of these apparently 
 deplorable cases, that is, to apportion the doses of the mercury 
 to that weakly state of the system which is thus marked by 
 hectic fever and emaciation. If we neglect this means we 
 shall most certainly fail in our attempts at cure ; and I may 
 even add, that we shall very generally render his condition 
 worse by any other plan of treatment. A ease which I have 
 lately witnessed renders it extremely probable that the most 
 serious consequences may be quickly induced by a material 
 deviation from this plan. The facts are briefly these : — A 
 young man, by name Mooney, of apparently sound and robust 
 constitution, was received into the hospital. No. 11 ward ; he 
 was labouring under a smart degree of eruptive fever, and a 
 crop of small mercurial pimples had made its appearance on 
 the face, and was coming out on the trunk. I thought it a 
 favourable case for trying the plan of employing mercury 
 during the eruptive fever, and while the eruption was stiQ 
 coming out. Accordingly I directed that he should rub Ungt. 
 Hyd. Fort. gr. x. omni nocte; but by some mistake the 
 clinical clerk wrote down Ungt. Hyd. 5i. omni nocte. I was 
 astonished on seeing the patient again in two days ; he was 
 in a most alarming state of fever, not purely inflammatory, 
 although accompanied with very high vascular action, and 
 with very high degree of excitement and great restlessness, 
 and his face full and flushed. This alarming condition made 
 me search most anxiously to ascertain the cause; and on 
 enquiry I discovered the mistake. I need not say that the 
 mercury was laid aside, and the high degree of fever opposed 
 by suitable treatment. As soon as the fever was sufiiciently 
 moderated, I made him resume the mercury in doses of Ungt. 
 Hyd. gr. x o. n. By this his mouth became soon, though 
 moderately, affected, .and the eruption was removed ; so that 
 he was dismissed from the hospital fully one month sooner 
 than he would have been had he been treated according to the 
 established rule of endeavouring to subdue the fever, and 
 
DUEING VENEREAL ERUPTIONS. 225 
 
 allowing the eruiDtion to come out very fully before we ventured 
 upon the mercurial treatment. It is quite unnecessary for 
 me to point out how much more expeditiously this disease may 
 be treated on this plan than it could have been by subjecting 
 the patient either to the non-mercurial treatment or by 
 insisting on a long delay prior to the commencement of the 
 use of mercury. 
 
 As this practice is so much at variance with that generally 
 followed, I feel it necessary to produce further evidence of its 
 safety and advantages ; and in doing so I shall select two 
 cases of eruption which occurred at the same time, and which 
 were treated on the two different plans. By comparing these 
 together, the superiority of that which I have ventured to 
 recommend will be most clearly established. 
 
 On the 17th of September I was called upon to consult on 
 the case of Mr. K., a young man, who had in his boyhood 
 suffered severely from scrophula, which had left a permanent 
 contraction of the right elbow, and numerous cicatrices on his 
 neck. His present complaints are a pustular venereal 
 eruption, pretty numerous on the trunk, with a few on the 
 face ; four or five of those on the forehead are disposed to 
 form scabs, and to ulcerate ; one on the chin is larger, and 
 incrusted over by the concretion of the discharge among the 
 beard. Pains of the limbs, which had for some days been 
 troublesome, have ceased since the eruption appeared. He 
 complains of pain in the contracted elbow, but this is not 
 attended with swelling, heat, or redness ; pulse 72 ; coun- 
 tenance of a remarkably pale sickly hue. 
 
 I saw Mr. K. again on October the 16th, when I found the 
 spots of eruption on the face larger and more disposed to 
 ulcerate ; one especially, on the right eyebrow, seemed as if 
 it would not only ulcerate, but spread rapidly; his countenance 
 is still pale and sickly ; no night-sweats ; the pain of the 
 elbow has almost entirely ceased. 
 
 Since my first visit he has been taking Decoct. Sarsse c. 
 Acid. Nitr. Dil. 
 
 His attending surgeon this day agreed to give him Pil. 
 Hydr. gr. iij. et Extr. Conii gr. ij. bis in die. 
 
 I have not seen Mr. K., but I have learned that he 
 
 Q 
 
226 MEECUEY 
 
 bore the mercury very well, and was cured in the ordinary 
 time. 
 
 On the 22nd of September Mr. T. called on me, and 
 informed me that for three weeks past he had been troubled 
 with pains of the shoulders, which very much disturbed his 
 sleep ; but that within the last week, on the appearance of a 
 rash, these pains had been materially relieved. At present 
 the trunk of the body is thickly covered with a very minute 
 eruption, not unlike small red sand. Some patches of the 
 same eruption, collected in clusters, appear on his face ; his 
 countenance is very pale ; appetite pretty good ; pulse 112. 
 
 ^ Pil. Hydr. gr. iij. Extr. Cicutse gr. ij. Ft. Pil. mane 
 nocteq. sumenda. 
 
 September 26th. Eruption out in greater quantity. 
 
 October 1st. Colour of eruption less vivid; spots on the 
 face are inclined to desquamate ; appetite pretty good ; com- 
 plains of weakness of stomach, which he thinks arises from a 
 nauseous taste in his mouth ; no thirst, pulse 108, less languor, 
 sleeps well : no night-sweats ; no sensible mercurial effect on 
 his mouth. Eepet. Pil. Sumat Sulph. Quinse gr. ij. ter 
 in die. 
 
 October 4th. Eruption on face still more faded in colour ; 
 that on the trunk less so ; appetite good, sleeps well, and has 
 less languor in the evening. He has now taken twenty-four 
 pills ; mouth not sensibly affected ; has complained for a few 
 days past of soreness of the right side of the throat, with pain 
 passing into the ear ; right palatine arches a little swollen, 
 and of too high a red colour. Eepet. PH. et Affricetur 5ss. 
 Ungt. Hydr. Fort. sing. noct. 
 
 October 16th. Eruption has totally disappeared from the 
 face ; that on the trunk is of a very faded tint ; inner gums of 
 the lower incisors are ulcerated along the edge ; no pain of 
 the teeth, or pain from chewing, but painful aching from 
 particles of food resting on the gums ; appetite pretty good, 
 sleeps well ; pulse 108, when the finger is first applied to the 
 wrist, and 96 when carefully counted for some time. He now 
 says that the pain of his throat has moved from the right to 
 the left side, and to the left ear. On inspection the fsiuces 
 appear rather swollen, and of a colour too highly bright. No 
 
DUBING VENEEEAL EEUPTIONS. 227 
 
 ulcer to be discovered. Tlie cheeks opposite to the last 
 molars are much swoUen, and of a leaden colour. Pergat. 
 
 October 20th. Eruption completely removed; the gums 
 are universally affected by ulceration of their edges, but 
 without much swelling ; he still complains of the soreness of 
 his throat ; the swelling and redness of the fauces continue ; 
 the edge of the anterior left arch is covered with an exudation 
 of coagulated lymph, and the left tonsil is covered with the 
 same. He feels himself very heavy; pulse 108. Omit. 
 Pilulse et Ungt. Hydr. Eepet. Mist. c. Sulph. Quinse. 
 
 October 23rd. He feels his throat much better, and it is 
 much less swoUen and less red; pulse 108. Ungt. Hydr. 
 Fort 5ss. omni nocte. Eepet. Mist. c. Sulph. Quinse. 
 
 November 5th. Mercurial action has subsided, although he 
 continued to use the ointment ; and for the last four days has 
 also taken Pil. Hydr. gr. v. bis in die. I have now directed 
 for him two grains of Calomel, with three grains of Compound 
 Powder of Ipecacuanha, ter in die. 5ss. Ungt. Hydr. Fort. 
 omni nocte. 
 
 November 10th. He has suffered severely the two last days 
 from mercurial dysentery ; the gums of both rows of incisors 
 are swollen, and superficially ulcerated ; the fauces of a high 
 red colour, not unlike that attendant on scarlatina, with 
 exudation of lymph on both tonsils. The under surface of the 
 tongue is marked on each side by a narrow line of leaden- 
 coloured slough, and a similar spot on the inside of the lower 
 lip ; pulse 108, skin hot, appetite very bad. He is continually 
 spitting up foetid thick saliva, which he says comes from his 
 throat ; pulse 108. 
 
 The account of this case I shaU conclude by saying that the 
 mercurial action was kept up for one week longer, and then 
 the mercury was altogether discontinued. 
 
 I have coupled together the history of these two cases, 
 which happened to come under my observation at the same 
 time ; and I think it may be useful to compare the progress 
 of the one with the other. This comparison was instituted on 
 the 16th of October ; it will be seen that at that time Mr. K. 
 had been for one month affected with the eruption, and in that 
 period no advance towards its cure had been made ; all this 
 
228 MBBCURY 
 
 time was spent in improving the state of his general health, 
 and as it were preparing him for the use of the remedy 
 (mercury) which was to cure this eruption. His attending 
 surgeon was averse to the early use of mercury in this case, 
 although the constitution was at the time so little disturbed ; 
 for his pulse was only 72. I must observe that the pain of 
 his elbow was merely owing to an affection of the skin ; nor 
 did it appear to his own surgeon, or to me, as connected with 
 the joint. A case in which so httle of febrile commotion existed 
 appeared to me as particularly favourable for the use of 
 mercury in the early stage of the eruption. Nor is the loss of 
 time the only disadvantage attending this postponement of the 
 use of mercury; for we find that one spot on his eyebrow 
 threatened to ulcerate and to spread rapidly ; now had this taken 
 that course, it must have destroyed the growth of the hair, 
 and left a most unseemly bald spot with a silvery ground. 
 
 Mr. T., on the contrary, might be considered, on the 16th 
 of October, as more than half cured, and as perfectly free 
 from any risk of being disfigui-ed by any part of the eruption 
 going on to ulceration ; for we find that although he had not 
 commenced the use of mercury until the 22nd of September, 
 yet .now the eruption had totally disappeared from his face, 
 and that everywhere it was very much faded. His general 
 health was fully as good as when he . entered upon the treat- 
 ment, although the mercury. has now fuU possession of his 
 system, the pulse being then even somewhat slower. 
 
 Nor are we to confine our views to the mere loss of time 
 accruing from the later exhibition of mercury ; we should also 
 take into account the ravages that may be committed by the 
 disease during the time we withhold this remedy. Thus in 
 cases of an eruption which has a strong tendency to run into 
 ulceration, such of the spots as form on the face, or on other 
 exposed parts of the body, may produce ulcers which are not 
 only painful and distressing at the time, but which wiU leave 
 after them cicatrices the most unseemly, on account of the 
 extraordinary silvery whiteness which they assume, and which 
 remains through life. Besides, these cicatrices may form on 
 the eyelids, lips, or nose, in such situations as to render a 
 contraction of these parts absolutely unavoidable. 
 
DURING VENEREAL ERUPTIONS. 229 
 
 But I must not omit to mention another circumstance 
 connected with Mr. T.'s case: he was of that peculiar consti- 
 tution upon which the ordinary doses of mercury cannot be 
 made to act so as to produce a moderate ptyalism. On more 
 occasions than one he had been previously under my care, 
 and also under that of others, for the cure of primary 
 symptoms ; but never, in any instance, was a manageable 
 ptyalism induced. On each occasion recourse was finally had 
 to frightfully large doses of mercury, and these had the effect 
 of producing a most profuse and ungovernable ptyalism. By 
 adopting the very small doses of mercury in the early, and in 
 the febrile stage of the eruption, I succeeded in obtaining a 
 moderate and a controllable ptyalism ; and, taught by this 
 experience, I succeeded, on a subsequent occasion of chancre 
 in the same individual, in effecting the cure with a moderate 
 ptyalism, by employing mercury in doses considerably below 
 those in ordinary use. 
 
 These two febrile states, viz. that of hectic and exhaustion, 
 and that of the eruptive fever, require that the mercury should 
 be administered in a manner peculiarly suited to such con- 
 ditions. Were we to use mercury with these, as we do with 
 venereal patients in general, I believe we should commit most 
 serious mischief. 
 
 In these cases we should not commence with a larger dose 
 than ten gr. of Ungt. Hydr. Fort, every morning, or with an 
 equivalent of blue pill; that is about gr. iij. mane nocteque. 
 However inconsiderable such doses may appear, still we shall 
 be gratified to find that on the third or fourth day the mercury 
 is acting in the most favourable and salutary manner on the 
 system; and it but seldom occurs that these effects are 
 deferred to the sixth or seventh day. 
 
 I am satisfied, from repeated observation, that we can 
 calculate on the medicine acting in a salutary manner in such 
 cases, with much more certainty than we can when it is 
 administered to those who are in the enjoyment of more 
 robust health, and who are free from fever at the time we 
 commence the course. The benefits derived from this early 
 influence of mercury are particularly striking; for in a few 
 days we have the happiness to vritness the sudden change 
 
230 MEECUKY. 
 
 from misery and suffering to comfort and enjoyment. Sleep 
 and appetite return, night-sweats cease, pains are removed ; 
 the improved ulcerated throat now allows the patient to 
 swallow with comparative ease ; and this, together with the 
 increasing appetite, induce him to take more nourishment. 
 
 I do think that under no other circumstances shall we find 
 the secondary symptoms removed so rapidly, and made 
 entirely to disappear (at least for the time) with so small a 
 quantity of mercury. The quantity of ointment employed on 
 such occasions sometimes does not exceedthree or four drachms; 
 and not only are the secondary symptoms dispersed, but the 
 general health is proportionably improved, so that the patient 
 rapidly acquires strength and flesh. Those who are anxious 
 to have the least possible quantity of mercury introduced into 
 the system will be pleased with this mode of proceeding. 
 
231 
 
 CHAPTER XI. 
 
 ON THE TREATMENT OP SYPHILIS IN SCEOPHTJLOXJS PATIENTS. 
 
 Mr. Hunter having clearly shown that in many cases 
 venereal ulcers are kept from healing, and other symptoms 
 from being cured by mercury, in consequence of the super- 
 vention of a scrophulous action, surgeons have naturally 
 referred many instances of the obstinacy of venereal symptoms 
 to this cause. This theory has had great influence, and has 
 even reached such a length that the opinion came to be 
 generally entertained by practitioners that scrophulous 
 patients are unfit subjects for the treatment of syphilis by 
 mercury. And it has even been put forward by most of the 
 anti-mercurial writers as one of the great and peculiar 
 advantages attendant on the non-mercurial plan of treatment 
 of syphilis, that scrophulous patients could be cured safely 
 and effectually by that plan, while almost certain death 
 awaited them if their venereal disease were treated by 
 mercury. 
 
 Let us, however, appeal to facts and observation, and see 
 whether the dread of scrophula in the management of 
 venereal cases has not been carried too far, and has not 
 deprived many such unfortunate patients of a safe and 
 speedy remedy, instead of subjecting them to the slow, 
 uncertain, and too often unsuccessful line of treatment, by the 
 non-mercurial plan. To decide this question with accuracy, 
 we should first observe that venereal patients present symptoms 
 of scrophula under two very different conditions: first, a 
 patient may have had some scrophulous disease before he 
 contracted syphilis ; ex. gr., a young man labouring under a 
 scrophulous affection of the hip or knee-joint, or a scrophulous 
 ulceration of the cervical lymphatic glands, may become 
 infected with venereal disease ; and, secondly, a young man 
 who in his childhood may have had scrophulous disease, but 
 in whom it has long ceased to appear, — or one in whom 
 
232 TREATMENT OF SYPHILIS 
 
 though no traces of serophula having ever been in action may 
 appear, yet may exhibit an indolent enlargement of the 
 cervical glands, at the time that he applies for the cure of 
 some secondary venereal symptoms. On inquiry, we may 
 learn that he had not been subject to any enlargement of 
 these glands until the eruptive fever preceding the secondary 
 symptoms had arisen ; that these enlargements took place 
 either at the time that the secondary symptoms made their 
 appearance, or perhaps immediately before them— that is, at a 
 time when the general health became out of order. We 
 therefore may be called on to treat a serophulous patient in 
 whom the disease of serophula existed in action for a long 
 time antecedent to the appearance of secondary syphilis, or 
 one in whom the development of the serophulous symptoms 
 is coeval with, or perhaps induced by, the secondary venereal 
 symptoms. We shall commence with the latter, of which the 
 following are instances : — 
 
 Let us first tm-n our attention to the case of a patient who 
 has not any serophulous disease in action, and in whom we 
 are not able to discover any trace of the previous action of 
 serophula. Let us suppose that the eruptive fever which 
 ushers in the secondary symptoms in the first order of parts, 
 either sore throat or eruption, excites at the same time an 
 enlargement of a greater or lesser number of the cervical 
 glands; some of them may be clustered together into an 
 indefined mass, while others remaiu distinct. This condition 
 of the glands we may observe in some cases does not make its 
 appearance for two or three weeks after the eruption or the 
 sore throat; but sometimes it precedes them by an equal 
 length of time. How are we to treat this complicated case ? 
 My answer is, that we are to proceed exactly ia the same 
 manner as if the venereal symptoms were uncombined with 
 any such affection. The only difference to be made is, that in 
 this complicated case we should be anxious to bring on a 
 smart degree of ptyalism, and with the least possible delay ; 
 but at the same time one that we shall be able to control. 
 
 In directing the doses of the mercury we are of course to 
 be guided by the existing state of the general health, and we 
 are to suit the former to the latter. As soon as the mercury 
 
IN SCKOPHULOUS PATJENTS. 233 
 
 has produced its legitimate effect we must add to the mer- 
 curials such other treatment as is best calculated to invigorate 
 and support the general system, and this the more par- 
 ticularly if the case seems to require a prolonged use of 
 mercury. I shall now adduce some cases in support of my 
 assertion, that such serophulous affections as are ushered in 
 by the eruptive fever along with secondary venereal symptoms, 
 not only will bear mercury, but will yield to the action of this 
 medicine exactly as the syphilitic symptoms themselves yield. 
 
 And here I would refer the reader to the case of Mr. G — , 
 page 206, as a very striking instance of the safety and 
 advantage with which mercury can be given in cases attended 
 with this enlargement of the lymphatic glands accompanying 
 secondary venereal symptoms. In that case the mercury was 
 commenced under most unpromising circumstances ; and yet 
 we found that so far from these swellings being irritated and 
 injured, they were, on the contrary, removed by it, and they 
 appeared to have retired pari passu with the truly venereal 
 symptoms. 
 
 In the following case the use of mercury was commenced 
 under more favourable auspices, the general health not being 
 much impaired ; the doses of the mercury were accordingly 
 larger, and the result was equally fortunate. 
 
 March 14th, 1884. Eobert White, set. 36, was admitted 
 into the 12th ward ; he states that eight months ago he con- 
 tracted a chancre, which he attempted to cure by taking pills 
 for three weeks, while he was exposed to the weather; the pills 
 salivated him. 
 
 In December last an eruption, preceded by pain of the head 
 and limbs, appeared over his entire body ; and at the same 
 time he felt his throat sore. Two months previous to the 
 eruption, he observed a swelling of one of the lymphatic 
 glands on the left side of the neck ; this swelling did not 
 ulcerate sooner than three months after it first made, its 
 appearance. For relief of these symptoms he took, for two 
 months, a mixture given to him at the Talbot Dispensary. 
 The throat grew better, owing, as he thinks, to the use of a 
 gargle ; the eruption was not improved. At present we 
 observe on the trunk an eruption of papulae, of rather a large 
 
234 TKEATMENT OP SYPHILIS 
 
 size, sparingly scattered ; on the limbs an eruption of similar 
 appearance, but of a smaller size. The eruption on the face 
 is of the small measly kind, and did not come on until a few 
 weeks after that on the trunk and limbs. Mist. Purg. Bain. 
 Tepid. 
 
 March 18th. Ung. Hydr. Fort. 5ss. omni nocte, Pil. Hydr. 
 gr. T. omni nocte. I shall not trouble my reader with any 
 more minute details of the practice in this case than to say 
 that during the entu-e treatment, whenever mercm-y was 
 employed, the preparations used were those above-mentioned ; 
 and the doses were varied according to existing circumstances. 
 He bore the mercury very well ; ptyalism was induced without 
 difficulty, and kept up with but slight intermissions. He left 
 the hospital on the 12th of May, at which time the ulcer had 
 not entirely healed, although it was reduced to a mere line ; 
 but the skin forming the edges of this line did not adhere to 
 the surface of the granulations which they covered ; and the 
 discoloration in the vicinity of the edges had not entirely 
 disappeared. In this case it was plain that the scrophulous 
 affection of the glands had been excited, either by the 
 unguarded use of some mercurial medicine or by the mere 
 action of the venereal poison acting on a scrophulous habit ; 
 and it is- equally obvious that the presence of this scrophulous 
 condition did not prevent the mercury from acting on the 
 system as it acts on the most healthy habits, and effecting a 
 cure of the venereal with the usual readiness and certainty. 
 And surely it is not too much to add that it did not exhibit 
 any unfavourable action on the scrophulous symptoms. 
 
 August 2nd, 1834. Michael Bruton, set. 21, was admitted 
 into the 12th ward. The lymphatic glands on each side of 
 the neck are enlarged and indurated ; particularly on the right 
 side, where three or four clustering together form a large 
 irregular tumour under the angle of the jaw. On the left side 
 the glands affected are fewer in number, and smaller in size ; 
 one of them, however, is soft, and gives the feel of fluctuation. 
 The integuments covering the enlarged glands retain their 
 natural colour; no pain in the glands; he complains of night- 
 sweats and of pain in his chest, but he is not emaciated. A 
 fading papular eruption occupies the integuments of the 
 
IN SCROPHULOUS PATIENTS. 235 
 
 shoulders ; and a few scattered papulae are seen on his fore- 
 head, at the root of his hair ; he complains of nocturnal pains 
 of the shoulders and arms, and of the right wrist, where a 
 slight enlargement of the hone is felt. 
 
 Three months ago he contracted a sore on the dorsum 
 penis, which became as large as a sixpence ; for this he used 
 only a few common purges, and it healed in a month after its 
 appearance. The glands of the neck then began to swell, and 
 at the same time the pains attacked his shoulders and arms ; 
 and these, in another month, were followed by the eruption. 
 He has not taken any medicine, except a few purgative pOs. 
 
 August 9th. I put him on the use of mercury, 5ss. Ung. 
 Hydr. Fort, omni nocte, et PH. Hydr. gr. v. ter in die, and 
 find on August the 30th this report : — " The glands on both 
 sides of the neck have been much reduced by the ptyalism ; 
 that on the right side remains solid, that on the left side is 
 soft with a fluid in it, but no redness of the skin, nor sm'- 
 rounding hardness or other sign of active inflammation. 
 From the 16th of August to the 6th of September he discon- 
 tinued the use of mercury. When resuming it on the 6th of 
 of September, I directed Calomel gr. ij. Opii gr. J twice a day, 
 with the view of quickly reviving the salivation ; but in this I 
 did not succeed, for the only effect was a slight ulceration of 
 the gums, accompanied with tumefaction and angina-like 
 redness of the throat, and an increased secretion, but no 
 actual flow of saliva. 
 
 On the 25th of October he was dismissed cured. The gland 
 on the left side, which on his admission contained a fluid, had 
 been punctured on the 6th of September, and at the time of 
 his discharge from the hospital still yielded a very small 
 quantity of purulent fluid; and it looked so well that I 
 imagine it must have healed in the course of eight or ten days. 
 
 Here is a clear instance of enlargement of the cervical lym- 
 phatic glands, arising entirely from a venereal taint ; certainly 
 hot in any degree excited by mercm-y, for he had not used 
 any until after his admission into the hospital. 
 
 In a note which I made of this case, while the patient was 
 in the hospital, I find it stated — " The result has been, that 
 as soon as the mercury acted fully on the system, the glands 
 
236 TREATMENT OF SYPHILIS 
 
 began to decline pan passu with the eruption ; and that both 
 remained stationary when the action of the meremy was 
 allowed to subside, and both finally disappeared under the 
 renewed action of mercui-y. 
 
 Let me also refer my reader to the ease of Mr. G., page 
 206, where the scrophulous enlargement of the cervical glands 
 was daUy, if not houi-ly accumulating ; and I think that he 
 wiU admit that these cases fully bear out my assertions — 1st. 
 That those scrophulous symptoms which come on along with 
 secondary venereal symptoms, and which are almost a part of 
 that disease, are all to be cm-ed along with the venereal 
 symptoms, and by the very same remedies. 2nd. That those 
 scrophulous affections which had existed prior to the appeai"- 
 ance of the secondary symptoms (and which of com-se are in 
 no way connected with them) will not be benefited by a 
 mercurial com"se, instituted for the cm-e of secondary venereal 
 symptoms ; nor will they, or the constitution of the patient, 
 be in anywise injm-ed provided that the mercm-ial process be. 
 conducted with a reasonable share of skill and judgment. 
 
 It may be asked, whence then has arisen the very general 
 abhorrence of meremy for the treatment of scrophulous 
 patients when affected with syphilis ? I answer, that authors 
 have, one after another, frightened each other, and the pro- 
 fession at large, on this subject ; until at length it became one 
 of the great boasts of the non-mercuriahsts to say that then- 
 plan enjoyed this superior advantage — " That by it even 
 scrophulous subjects, who could not possibly be treated by 
 mercury for syphilis, could be cm-ed by this plan without any 
 risk of injm-ing their general health or of aggravating then- 
 scrophulous symptoms." Yet this strange, this almost 
 unaccountable aversion to using mercury with scrophulous 
 patients, does not seem to be felt by the very same practi- 
 tioners, except in venereal cases. Who of all these will 
 hesitate to give mercm-y, even with the view of exciting 
 ptyalism in a case of iritis, of peritonitis, of synovitis, or of 
 acute inflammation of any other of those membranous tissues, 
 in which mercm-y has been found so eminently useful ? Do 
 we find them very anxious, and very particular, in their 
 enquiries as to the scrophulous diathesis of a patient labouring 
 
IN SOEOPHULOUS PATIENTS. 237 
 
 under any of these diseases. Do we observe them hesitate 
 for a moment as to the medicine they should prescribe ? Even 
 in those cases where the existence of scrophula in the habit is 
 obvious, do we observe that they feel any peculiar reluctance 
 in prescribing this powerful remedy? No, the dangerous 
 nature of these diseases overpowers every other consideration. 
 
 I have no doubt that mercm-y may be administered so as 
 to exasperate already existing scrophulous diseases, or even to 
 excite new forms of it ; I mean when it is given for a length of 
 time, in what has been termed an alterative manner — viz. in 
 under-doses, such as will not produce the salutary action of 
 mercury (that is ptyalism), but such as will at length act upon 
 the system as a slow jioison ; perhaps, because its influence is 
 only allowed to reach to the nervous system. But I again 
 repeat it, that if mercury be given so as to excite a smart 
 ptyalism in a short time, it will not produce any alarming 
 symptom of scrophula, even though that ptyalism be kept up 
 for such time as may be required for the cure of either primary 
 or secondary symptoms. 
 
 We shall next advert to that class of cases in which the 
 patient, who has long been, and who is still, affeeted with 
 scrophulous disease in action, has the misfortune to become 
 the subject of secondary venereal symptoms. Does not this 
 combination, some will exclaim, forbid the use of mercury? 
 will not the result of mercm-ial treatment in such a case be 
 that the venereal symptoms will be aggravated to a dan- 
 gerous degree? Such, I imagine, is the generally-received 
 opinion — an opinion, however, which I conceive is rather 
 drawn from theoretical induction than founded on practical 
 observation. For I think I may with confidence appeal to the 
 experience of every surgeon who has had much practice in 
 the venereal disease, and ask him whether he has not treated 
 many scrophulous patients, labouring under chronic abscesses 
 and ulceration of the joints ; and whether he has not even 
 cm-ed many (who had been lamed by morbus coxae in child- 
 hood) of syphilis, by the use of mercury ; and that too without 
 being able to discover what he anxiously watched for, and 
 secretly dreaded — namely, "that the scrophulous complaints 
 had been made worse by the use of mercury." Many, I make 
 
238 TREATMENT OF SYPHILIS 
 
 no doubt, have felt a secret satisfaction at the result; and 
 some, perhaps, have ascribed their success more to chance, or 
 to some peculiar good foi"tune which has conducted both 
 surgeon and patient with safety through such apprehended 
 danger. 
 
 Out of many cases which have occuiTed in my own practice 
 I shall adduce a few instances in corroboration of the opinion 
 that such scrophulous habits as those to which I have alluded 
 do safely admit of the judicious use of mercury, for the cure 
 of their venereal disease, without prejudice to any scrophulous 
 symptoms with which they may also happen to be affected. 
 
 Joseph Bunbury, set. 26, of a full habit, was admitted into 
 No. 12 ward, on December 5th, 1834. Eight months ago he 
 had a chancre behind the corona glandis, on the right side of 
 the penis, and immediately began to use mercurial pills. He 
 had taken seventy pUls before his mouth became affected. This 
 treatment was continued for two months, and then he was 
 considered to be cm-ed ; but in a month after he was attacked 
 by pains in his shoulders and arms, and soon after a papular 
 eruption showed itself all over his face and body, and his 
 throat became sore. He was received into Sir P. Dunn's 
 hospital, was there salivated, and at the end of three weeks 
 was dismissed, the throat being well, the eruption fading, and 
 the pains much relieved, but a small glandular tumour had 
 formed on each side of his neck : these tumours have very 
 much increased in size, and now these tumours are soft ; the 
 skin covering the most prominent parts of them is of a 
 pm'plish red colour, and on each side is a small ulcerated opening, 
 through which a thin pus escapes, the edges of the opening 
 being deeply undermined and thin : he says he had many 
 such tumom-s in his childhood. His venereal symptoms are 
 several scaly spots in his eyebrows, and red patches on his 
 shoulders, with a slight swelling on each side of the liga- 
 mentum patellae, and severe pains in his shoulders and arms, 
 which prevent him from extending the forearms, and keep him 
 awake at night. 
 
 I shall briefly state the treatment, by saying that he was 
 purged, and had a tepid bath, before he began to use mercm-y. 
 
 On December the 9th he was ordered 5ss. Ung. Hydr. omni 
 
IN 8CE0PHUL0US PATIENTS. 239 
 
 nocte, et Pil. Hydr. gr. v. bis in die. The pills were omitted 
 on the 16th, and the ointment continued until the 23rd. The 
 ointment was resumed on the 30th, and continued until the 
 10th of January. Again, on the 24th of January, he was 
 ■directed Ung. Hydr. 5ss. omni' nocte, et Pil. Hydr. gr. v. ter 
 in die ; this was continued until the 31st, at which time his 
 mouth was again smartly sore. After the 10th of December 
 he took bark, in one form or other, during his stay in the 
 hospital, from which he was dismissed on the 10th of 
 February, perfectly free from any appearance of venereal 
 
 Surely this was a fair case for witnessing the effects of 
 mercury in a scrophulous habit ; for we may set down this 
 man as scrophulous, not only from the present swellings and 
 ulcers under the ears, but also from the fact that such had 
 affected him very constantly during his chUdhood. The 
 result of this treatment, in this case, has been that the 
 mercury acted rather kindly than otherwise ; that his health 
 did not, in the slightest degree, suffer from a very smart 
 action of mercury, kept up for eight and for twelve days, and 
 even then renewed — for he did not lose flesh during his stay 
 in the hospital. With respect to the scrophulous tumours 
 and ulcers, they were not benefited, nor were they in the 
 slightest degree injured by its use. In a word, the mercury 
 here acted as it does whenever it acts kindly ; the scrophulous 
 habit did not seem to have the slightest influence on its mode 
 of acting, nor did the mercury seem to exert any pernicious 
 influence on the scrophulous symptoms or diathesis. 
 
 Matthew Connor, a delicate-looking boy, set. 16, was 
 admitted on 10th June, 1834, into the eye ward, on account of 
 venereal iritis in an advanced stage. He had, on each side of 
 his neck, three or four ulcers covered with yellow scabs. 
 When the scabs were removed by poultices, the ulcers 
 presented all the character of scrophulous ulcers with fungous 
 surfaces. Having satisfied myself as to the nature of the 
 ulcers, I allowed them to scab again ; and dm-ing the time of 
 his treatment for iritis they remained untouched. For the 
 cure of the iritis, I employed calomel in doses of two grains 
 three times a day, by which a very high degree of ptyalism 
 
240 TBEATMENT OP SYPHILIS 
 
 was induced. During the long period of the ptyaUsm the 
 scabs remained unaltered in every respect. When the ptyalism 
 had subsided, I again removed the scabs by poultices, and I 
 found the ulcers still retaining the same character and 
 appearance as they had previously to the mercurial course. 
 They did not exhibit any appearance which could lead me to 
 imagine that they had undergone any change during the time 
 of the salivation. 
 
 Let us not then be too timid when certain diseases, or 
 conditions of disease, require that we should give mercury to a 
 patient, in whom we see scrophula already in action. The 
 safest rule to adopt in such ckcumstances is, in my judgment, 
 to give it so that it shall, in six or eight days, produce the 
 degree of ptyalism that we wish for. I need scarcely add, 
 that should it be deemed necessary for the cure of the disease 
 for which mercmy is being administered, to keep up a 
 lengthened action of mercury, we should support the system 
 of om- scrophulous patient by nourishing diet, by bark, and 
 by opium. 
 
 Feb. 1st, 1822. Mr. 0. (usher of a school), set. 26, has 
 been long afQicted with a severe cough, sometimes with 
 haemoptysis ; and is altogether of a very consumptive habit. 
 On Feb. 1st he applied to me for cure of a chancre on the 
 inside of the prepuce, — this is a genuine Hunterian chancre, 
 and had been discovered only a few days previously. 
 
 I advised PH. Hyd. 5ss. Pulv. Ipec. gr. octo fiant pil. octo. 
 Sumat unam sing. noct. ; but by mistake of the apothecary 
 he took, according to the label on the pill box, one pUl at 
 night and one in the morning. 
 
 Feb. 49. He states that the pills gripe him occasionally ; 
 gums are very sore, those of upper jaw being smartly 
 ulcerated ; surface of chancre clean, hardness much less. 
 Omitt. Pil. per dies ii. dein i. o. n. 
 
 Feb. 13th. Mouth more sore; chancre less hard at 
 base ; thinks his cough much improved since he began this 
 course. 
 
 Feb. 25th. Mouth sore; upper gum severely ulcerated; 
 scarcely any hardness in the site of the chancre. Eepet Pil. i. 
 om. nocte. 
 
IN SOROPHULOUS PATIENTS. 241 
 
 March 11th. Has not taken any pills since 3rd inst. ; 
 mouth is only now well; no hardness in the site of the 
 chancre ; cured. Acid. Sulph. Dil. Gutt. xv. ter in die. 
 
 Reviarks. 
 
 I felt quite disappointed when Mr. 0. told me that he had 
 been taking two pills a day instead of one, as I had directed, 
 for I was tremblingly alive to the danger of using mercury in 
 almost any quantity with him. However, as he had begun 
 with this dose, I did not like to send him back to a smaller 
 one, fearing that if I did so I should not get the mercury to 
 act favourably hereafter. 
 
 This case clearly proves that we may with perfect safety 
 use mercury in small doses, and even excite a smart xDtyalism 
 in patients whose lungs must be considered as extremely 
 delicate and tender, and therefore, according to generally 
 received opinions, very ill suited to bear the active use of 
 mercury. Had this been a solitary instance of the safety 
 with which mercury may be given to a patient with haemo- 
 ptysis, it might be said that it was an escape and not a cure ; 
 but supported as it is by many other instances in which 
 mercury was with safety and advantage given to those 
 labouring under hectic fever in full action, I have no hesitation 
 in pronouncing it a cure. Should this point be established, 
 that mercury can with safety (provided it be with caution) be 
 given to a patient threatened with hsemoptoe, so as to effect a 
 cure of primary venereal symptoms, I say if this point be 
 once established, it will enable practitioners to hold out to 
 such persons the benefit of this medicine. 
 
 At the time that Mr. 0. applied to me, I had not satisfactory 
 experience of the safety with which mercury may be given to 
 scrophulous patients; and, therefore, I directed very small 
 doses of this medicine, indeed much below what his system 
 could have borne ; but by the mistake of the apothecary the 
 dose proved better suited to the existing state of his health, as 
 he was not affected with hectical symptoms. The issue of 
 this case, however, made me reflect more upon this line of 
 practice, and induced me, in subsequent cases of scrophulous 
 patients, to administer mercury with more freedom. 
 
 R 
 
242 TREATMENT OF SYPHILIS 
 
 Had Mr. 0. been a patient in easy circumstances I certainly 
 would not at that period, and with the notions I then enter- 
 tained of mercui-y, have preferred a mercurial com'se. But as 
 his means were extremely limited, depending upon his daily 
 exertions for his daily bread, I knew that he could not procure 
 for himself that ease and those comforts which would be 
 required by a different line of practice. These considerations 
 induced me to direct a mercmial com'se, knowing that this, if 
 it succeeded, was decidedly the shortest line of treatment, and 
 one which would not materially interfere with his occupations. 
 
 The result has shown that mercury may be administered to 
 patients subject to hsemoptoe, provided it be given with caution 
 and judgment ; and also that in such the venereal symptoms 
 yield at least as quickly as they do in those of more robust 
 and more healthy constitutions. 
 
 It may naturally be asked, if scrophulous patients be found 
 to bear mercmy so well as you represent, how has it come to 
 pass that the profession have so generally entertained the 
 contrary opinion, and have been impressed with a notion that 
 mercury would aggravate all the symptoms of scrophula, 
 whUe, at the same time, the scrophulous diathesis was so 
 opposed to mercury as to prevent it from exercising its 
 salutary influence, and effectiag a cure of the venereal disease 
 in such habits ? To this I can only answer, that I suppose 
 when men's minds were first instructed, that venereal 
 symptoms in certain habits had resisted the power of mercury, 
 and were afterwards cm-ed by sea-air and sea-bathing, they 
 inferred that this was only attributable to a scrophulous 
 diathesis, — they, of course, became more guarded and reserved 
 in the administration of mercury to patients of this habit. 
 Hence it followed that they not only prescribed this medicine 
 m smaller doses, but whenever they saw it about to produce 
 ptyalism they withheld it for a time. In a word, that they 
 most cautiously watched it for the purpose of preventing it 
 from acting on the salivary system (its natui-al and salutary 
 action). By this means the constitution of the patient came 
 to be irritated, and teazed as it were, by this long-continued 
 use of mercury in under-doses ; the medicine accumulating in 
 ■the system, and not being allowed its natural action and 
 
IN SCROPHULOUS PATIENTS. 243 
 
 natm-al outlets, it came to act as a poison on the system ; and 
 thus the scrophulous habit (naturally weak) was thrown into 
 disorder, and consequently all its diseases, and tendency to 
 disease, were aggravated. What was considered as an 
 indulgence to the scrophulous habit ultimately proved to be 
 the source of the principal mischiefs which have been 
 observed when mercury was administered to scrophulous 
 patients. 
 
 Let us not, however, consider every instance of enlarged 
 cervical lymphatic glands occurring in venereal patients, 
 either simultaneously with or subsequently to the appearance 
 of secondary symptoms, as excited by the influence of venereal 
 virus. For we shall meet with some cases in which this 
 condition of the glands had been produced by the action of the 
 mercury at the time that ptyalism was commencing. That 
 the enlargement of the glands is in such instances caused 
 wholly by the action of mercury is proved by the fact that the 
 swelling subsides according as the action of the mercury 
 declines ; and that when we again reproduce the ptyalism a 
 second time, the niercurial action having been allowed to 
 subside, we shall find that the swellings will retm-n, and that 
 these can be prevented from increasing in number and size 
 only by reducing the doses of the mercury, and interposing 
 brisk . purgatives pretty liberally. When we thus know the 
 fact that ptyalism is occasionally the cause of this enlarge- 
 ment of the cervical lymphatic glands, we can easUy guard 
 against or remedy this occurrence. Whereas, were we to 
 mistake such for scrophulous enlargement excited by the 
 venereal virus, we might be disposed to persist in using the 
 same doses of mercury under an impression that the former 
 would yield to a little further action of mercury, as some 
 of the venereal symptoms had already begim to do under 
 its use. 
 
 I have lately seen two cases of this enlargement of the 
 cervical glands in patients while under treatment for primary 
 symptoms only, and these afford a still further proof that this 
 affection was occasioned solely by the action of mercury on 
 the salivary glands. 
 
244 
 
 CHAPTEE XII. 
 
 inNXJTE DOSES OF MEECDKY IK LATE AND CHRONIC B0BO. 
 
 Among those cases of syphilis which can best be treated by 
 very miinite doses of mercuiy, I must mention a rare form of 
 bubo : it is one of an indolent nature ; it makes its appearance 
 long after the chancre is healed, perhaps in foui* or five weeks. 
 The bubo in some cases is single ; in others, there is one in 
 each groin : the swelling is not of an acute inflammatory 
 nature, nor is it, during its progress, attended by severe pain, 
 unless it proceed to suppm-ation, in which case it becomes 
 very painful, particularly if the matter has accumulated 
 lai-gely and has not got vent. These buboes, to which these 
 remarks apply, are very remarkable for the severe and extra- 
 ordinary derangement of health which attends them. A high 
 degree of febrile excitement exists, and yet the fever partakes 
 very much of the character of hectic fever : a quick pulse, 
 impaii-ed appetite, urgent thirst, languor and lassitude, 
 emaciation, and night-sweats, form its leading featm-es. 
 When, after a tedious suppuration of three or four weeks, the 
 matter gets exit, the pain then diminishes; and by slow 
 degrees the health in some measm-e improves, but a long time 
 elapses before it is perfectly re-established. In some instances 
 the tumom- does not advance to suppm-ation, but having 
 arrived at a certain size it remains stationary for a short 
 time, and then slowly retires, but only to a certain degree. 
 For whether suppuration shall have taken place or not, the 
 groin is not restored to its natural state, and considerable 
 induration of an indolent nature still remains. Such ai-e the 
 symptoms which attend buboes of this class. I have been 
 consulted on cases in which the disease stood at this point for 
 a very long time ; of this the following is an instance : — 
 
 October 19th, 1835. Mr. K. six months ago had a chancre 
 on the dorsal aspect of the penis, at the junction of the pre- 
 puce with the glans ; for this he was directed, by an eminent 
 
MINUTE DOSES OF MEECURY, ETC. 245 
 
 surgeon, to use mercurial frictions : he says that he rubbed in 
 nearly one pound of mercurial ointment, and with so much 
 energy that his arms at first became quite muscular ! This 
 course he continued for six weeks ; during it he lost flesh, and 
 became unable to read or to attend to any business, but no 
 affection of the mouth was produced. Three months ago he 
 again had sexual intercourse, by which the cicatrix of the 
 original chancre was opened; this has not since healed. 
 About this time a bubo formed in each groin; these were 
 considered, by another eminent surgeon, as constitutional or 
 scrophulous buboes, and therefore they were treated without 
 mercury. During the formation of the buboes his health 
 suffered materially; he became emaciated, and had night- 
 sweats. After this last sexual intercourse the prepuce 
 became much thickened, especially on its dorsal aspect ; this 
 thickening affected the integuments of the penis more than 
 half-way towards the pubes. The ulcer, which hitherto had 
 been confined to the prepuce, has lately shown a disposition 
 to slough, and has stretched forwards, so that now it has laid 
 hold of the corona glandis. To the ulcer Mr. K. had applied 
 Acid. Nitric, within the last three days. At present the 
 prepuce and integuments half-way up the penis are red, much 
 swollen, and thickened; a hardened and knotted lymphatic 
 vessel runs along the right side of the penis ; a considerable 
 hardness and swelling exists in each groin, the integuments 
 are there also red ; a trifling discharge takes place from a 
 small opening in each bubo. His health is very much broken 
 down ; he is emaciated to an extreme degree ; pulse 130 ; 
 countenance pale and sickly, yet his appetite is good ; he has 
 no thirst ; has night-sweats ; sleeps until four o'clock a.m., 
 from which hour until the time he gets out of bed he is 
 incessantly teazed by painful erections. 
 
 On the most minute enquiry I cannot discover any secondary 
 symptom. Judging that the original venereal disease was 
 not cured by the very heavy com'se of mercury which he had 
 undergone, although his system suffered so much by it, I felt 
 no hesitation in recommending mercury, but in very minute 
 doses, which alone could be borne by him in the present 
 depressed state of his health. Accordingly I advised Ung. 
 
246 MINUTE DOSES OF MERCUEY 
 
 Hydr. Fort. gr. x. omni nocte; and, at the same time, to 
 drink from half-a-pint to a pint of sarsaparilla broth daily. 
 
 October 22nd. The swelling of the prepuce considerably 
 reduced ; the ulcer not spreading upon the glans : he says the 
 right bubo is more paiaful, yet it is scarcely (if at all) more 
 swollen ; slept well last night, not having been troubled with 
 erections, but had profuse night-sweats; the pulse is still 130; 
 he relishes the sarsaparilla broth. No sensible effect from the 
 mercury, yet he says that he feels himself stronger. 
 
 October 26th. The swelling and hardness of the integu- 
 ments of the penis much reduced ; ulcer with a tolerably clean 
 surface ; it discharges healthy pus in sufficient quantity ; the 
 right bubo, which had been very painful, is easy, and has now 
 three small openings; the hard chord-like lymphatic vessel 
 along the right side of the penis is reducing. He says his 
 health is in every respect much better : he sleeps well ; has 
 no night-sweats; erections are rare, and not attended with 
 pain ; pulse reduced to 108 ; appetite better than when he 
 was in perfect health ; some mercurial fcetor indicates a very 
 slight affection of the mouth. Eepet. Jusculum Sarsse et 
 Ung. Hydr. ad gr. x. per duas noctes, et dein augeatur dosis 
 ad 9i. sing, nocte. 
 
 I was prevented from watching the further effects of this 
 plan of treatment ; nor did I receive any account of the 
 patient until the 20th of December, when Mr. K. informed me 
 that when he had rubbed scruple doses of the ointment for 
 three times his mouth became sore, and he continued to use 
 the mercury, so as to keep up the soreness for a fortnight ; he 
 then laid aside the mercury. He has taken a great deal of 
 sarsaparilla, and now enjoys tolerable health. The glands, 
 however, in both groins are still too large; the penis is 
 healed, with a broad and deep cicatrix behind the base of the 
 glans. 
 
 September, 1836. Mr. K., about the time of the last 
 report, relinquished all further treatment ; and yet he has not 
 regained his ordinary state of health, although he has been 
 pretty actively engaged in various pursuits, at times living 
 rather freely. He is still very thin, and suffers from irregular 
 pains in his limbs. 
 
IN LATE AND CHEONIC BUBO. 247 
 
 In a word, he is not in perfect health ; he is teazed Tvith 
 the above symptoms, not one of which is decidedly venereal ; 
 and yet, all together, they excite in my mind a strong sus- 
 picion that something of a latent unsubdued syphilitic taint 
 still remains, which obstructs his restoration to perfect health ; 
 yet he declines to follow my advice, viz. that he should again 
 use mercury, beginning with scruple doses of the ointment. 
 
 Such are the leading features of this disease when confined 
 to the primary symptoms. But it does not stop here; for 
 unless it be cured at this stage we shall find that after some 
 time a fresh set of symptoms will arise, which, though not 
 strictly secondary venereal symptoms, yet lead us to suppose 
 that they proceed from a certain modified operation of the 
 venereal disease on the general system. 
 
 Thus we sometimes observe that the slight improvement in 
 the general health which takes place on the matter of the 
 buboes being discharged, does not continue unimpaired for 
 many weeks. The patient now, perhaps, suffers from one or 
 more ulcers on some part of the body or limbs. He tells us 
 that each of these began as a small boil or pimple, which he 
 scratched ; or that it arose from some very trifling hurt. 
 These ulcers seldom exceed in circumference that of a half- 
 crown piece, more frequently they are of a size intermediate 
 between that and a shilling. When fully estabhshed these 
 ulcers exhibit so much of the character of secondary ulcers 
 that almost every surgeon would say they were suspicious- 
 looking ulcers. Generally from two to four of these appear, 
 and they are healed very slowly by means of some active 
 application, for mild ones produce no improvement in them. 
 In other cases no ulcers appear, and the second set of 
 symptoms bear no resemblance to those of the venereal 
 disease ; they are such as indicate disturbed health and a 
 broken-down system, and therefore we may expect to find in 
 these an almost endless variety, depending probably upon 
 some constitutional predisposition, or excited by some acci- 
 dental circumstances ; they are such as we could not, by 
 viewing them abstractedly, imagine to be syphilitic, and yet 
 by tracing their history we are led so directly to the previous 
 venereal disease, that we can scarcely doubt their syphilitic 
 
248 MINUTE DOSES OF MEECUKY 
 
 origin. The readiness with which they yield to the operation 
 of mercury removes all doubt, and convinces us not only that 
 they arose from a venereal taint, but that they are as quickly 
 and as certainly curable by mercury as the purely secondary 
 venereal symptoms are ; and yet these symptoms are among 
 those diseases which altogether forbid the use of mercury 
 under ordinary circumstances. Let us take as an example 
 the following case : — 
 
 Dr. G., while pm-suing his studies at Glasgow, had an ulcer 
 near the fraenum, which destroyed that fold; it had been 
 brought to heal chiefly by repeated applications of Argentum 
 Nitratum. In May following, some weeks after, being in 
 London, a bubo made its appearance in his right groin, and 
 at the same time his health became much deranged, and his 
 strength and flesh were seriously reduced. He applied to one 
 of the most eminent and experienced surgeons in London, 
 who considered his case as one of scrophulous bubo, and 
 accordingly treated him principally with iodine. By his 
 advice he at length removed to Chatham, where, for a time, 
 his general health improved^ much ; but he did not long enjoy 
 this state of good health, for he was then affected with a 
 slight spitting of blood, and cough ; some difficulty of 
 breathing quickly followed, and he felt his throat sore. After 
 a little time he became troubled with palpitation of the heart, 
 and along with this a glandular swelling, as large as a plum, 
 took place between the angle of the lower jaw and the chin. 
 Such was the history of his case on 6th Nov., 1835. When he 
 was introduced to me by my friend Mr. White, he had, in 
 addition to a pretty large indurated bubo, the enlargement of 
 the glands under the jaw, palpitation, and quick respiration ; 
 he was also affected with extreme quickness of pulse, con- 
 siderable emaciation, lassitude, and a sickly pallor of 
 countenance. Upon the most mature consideration we agreed 
 to make a trial of minute doses of mercury, in the hope that 
 all his ill health was caused by a latent venereal taint. On 
 Nov. 6th, 1835, we directed for him 9ss. Ungt. Hyd. Port, 
 omni nocte. 
 
 Nov. 24th. Mr. White informs me that he is getting well 
 very fast ; the lump under the jaw has declined ; his pectoral 
 
IN LATE AND CHEONIC BUBO. 249 
 
 complaints are much improved ; in every respect his health is 
 much better ; he still uses the small doses of mercury ; he is 
 now to use doses of a scruple each. 
 
 Dec. 18th. He now appears much improved in flesh, and 
 he feels himself in excellent health ; he is free from cough and 
 difficulty of breathing ; very slight remains of the glandular 
 swelling under the jaw ; pulse quiet and natural ; he has 
 continued the small doses ( 9 i.) of ointment, by which his 
 mouth has been slightly affected ; he is ordered to repair to 
 Chatham, and is advised to persevere in the use of the same 
 small doses of mercury for three weeks longer. 
 
 The above histories exhibit to our view buboes or swellings 
 of the inguinal glands under circumstances very different from 
 those in which we commonly contemplate venereal bubo. 
 Thus, in the ordinary venereal disease, bubo appears as an 
 acute glandular inflammation ; and, when attended by fever, 
 this is of the inflammatory type. These late buboes, on the 
 contrary, exhibit all the marks of a chronic indolent disease ; 
 and these are invariably accompanied by a fever of a purely 
 hectic type. 
 
 Perhaps a surgeon, in the whole range of diseases in which 
 he may be called on to practise, cannot meet with any instance 
 in which a true diagnosis is a matter of greater difficulty or of 
 greater importance. It' is but too obvious that we cannot 
 place any reliance on the present symptoms. Some informa- 
 tion may be gained by applying our attention to the history 
 and treatment of the original primary symptoms, and par- 
 ticularly where these had been treated by mercury. We 
 should carefully inquire as to the manner in which this 
 medicine had acted on the system ; and in all such cases, if 
 the ptyalism had not been excited at the regular period, and 
 kept up for a fair length of time, then I would strongly incline 
 to the opinion that all the present symptoms arose from a 
 syphilitic source. 
 
 On collating together the history of several of these chronic 
 venereal buboes, with that indolent constitutional bubo which 
 I originally described in a paper in the Dublin Hospital 
 Eeports, vol. ii. (which paper has been transferred to page 125 
 
250 MINUTE DOSES OP MEROUEY 
 
 of this work), it will be seen that the local conditions of the 
 groin very closely correspond with each other, and that the 
 constitutional symptoms of the one cannot be distinguished 
 from those of the other. Yet in practice no more serious 
 error could be made than that of mistaking and of treating 
 the one for the other. For were we to treat by the ordinary 
 mercurial process as venereal the constitutional bubo with its 
 accompanying symptoms, we should exasperate all the com- 
 plaints, inflict a severe injury on the health of the patient, 
 and even endanger his life; while if we treated a chronic 
 venereal bubo as a mere constitutional swelling of the inguinal 
 lymphatic glands, we should only employ an imbecUe useless 
 hne of practice, leaving the cause and the root of the disease 
 untouched, allowing it to pursue its coui'se unopposed, until it 
 terminated, as it generally will do, in a slow death, except in 
 some eases, where a peculiar innate strength of constitution 
 may enable the system to produce the development of some 
 one or two well-marked symptoms of syphilis. In confirma- 
 tion of these assertions we find that one of these cases had 
 been mistaken by a surgeon of the highest character in the 
 United Kingdom. If we indulge a hope that we shall be able 
 to distinguish the venereal from the indolent constitutional 
 bubo, we must rest it on our scrutinizing with most scrupulous 
 minuteness the history of each case. By so doing we may, in 
 a few instances, acquire a well-founded confidence in our 
 diagnosis; but in the majority of cases we shall find the 
 history involved in the utmost perplexity and uncertainty. I 
 trust, however, that I have now directed the attention to a 
 perfectly safe and generally an efficient test by which our 
 doubts may, in a great degree, be dispelled, and by which 
 our practice may be guided in a safe and satisfactory manner. 
 It is merely to employ mercury in very small doses, ex. gr. 
 ten grains of the ointment once a day : by employing this 
 test in cases which are venereal we shall enjoy the satisfaction 
 of seeing some improvement in the constitutional symptoms, 
 as also some amendment in the general health in the course 
 of five or six days, before any mercurial effect can be dis- 
 cerned ; and those favourable changes will become more and 
 more manifest, in proportion as the salivary system comes 
 
IN LATE AND CHRONIC BUBO. 251 
 
 under the influence of the mercury. Should we have 
 employed the same test in a case of purely constitutional 
 indolent bubo, we shall find, on the contrary, that no amend- 
 ment takes place within the first six or eight days, but that, 
 even when the mercury acts on the mouth, the symptoms are 
 rather aggravated. 
 
 This plan of employing those minute doses of mercury can, 
 therefore, lay claim to the double merit of being the most 
 speedy as well as the safest method of treating all venereal 
 symptoms, whether primary or secondary, when attended 
 with hectic fever ; and also of affording the most certain and 
 the only safe criterion by which we can- decide in doubtful 
 cases, which are attended with hectic, whether the disease be 
 venereal or not. 
 
 Were we to employ, as a test, mercury in doses such as are 
 employed ordinarily in the treatment of the venereal disease, 
 we should inevitably injure the patient, and at the same time 
 we should not obtain the smallest insight into the nature of 
 the disease ; for mercury used in such doses, with a patient in 
 this state of debility and hectic fever, would rather overpower 
 the system than produce any improvement in the venereal 
 symptoms. 
 
 One word more on the subject of these buboes and their 
 accompanying symptoms. Here is a modification of symptoms 
 of syphilis and its consequences, which we are utterly at a 
 loss to account for ; the natural habit and previous state of 
 health will not explain it ; nor do we acquire any real insight 
 into the cause by referring it to the treatment of the primary 
 symptoms; for in one of the cases I have related mercury 
 was used in full doses, and for a very sufficient length of 
 time, while in the other no mercm-y at all was employed. 
 And I recollect other cases in which the patients used only a 
 few mercurial pills for eight or ten days, without any sensible 
 mercurial action being induced. If in the case of Dr. G. we 
 embrace the opinion that the venereal disease had been 
 modified by the constitution, we shall be fuUy as much justified 
 in supposing that in Mr. K.'s case the overpowering doses of 
 mercury induced the extraordinary deviation from the regular 
 course of the venereal disease. 
 
252 
 CHAPTEE XIII. 
 
 SYPHILIS IN INFANTS. 
 
 Perhaps there is not, in the entire range of surgical 
 diseases, any one the contemplation of which is more cal- 
 culated to arrest our attention, or to excite our interest, than 
 Syphilis Infantum. Whether we inquire into the circum- 
 stances under which the diseased parent or parents can infect 
 their offspring, or the form in which the disease affects the 
 infant, or the appearance and nature of those diseases which 
 are communicated by the infant to the nurse, or of those 
 communicated to its other attendants, and the further propa- 
 gation of disease by the nurse to her husband, and perhaps to 
 a large family of children ; I say, in investigating any one of 
 these points,. we must be struck with the fact that we find in 
 each a striking deviation from those laws which regulate the 
 venereal disease as communicated by the adult to the adult. 
 Indeed this is so much the case, that some authors have not 
 hesitated altogether to deny that these affections were 
 venereal, while others, admitting the possibility of a venereal 
 disease in infants, have yet made use of those very deviations 
 from the regular laws of syphihs to prove that in particular 
 instances the disease was not venereal, because it did not 
 strictly square with the progress of syphilis in adults. 
 
 Before I enter upon the subject of syphilis in infants, I 
 must state a fact which, though I am unable to explain it, has 
 yet been forced upon my observation by more than five or six 
 instances ; namely, that a newly married man, who is himself 
 free from every appearance of syphilis and every other disease, 
 shall yet infect his wife in such a manner that secondary 
 symptoms shall appear in her in a few months after marriage, 
 and these not preceded by any primary symptoms, or by any 
 discharge whatever from the genitals. And although among 
 these secondary symptoms some raised ulcers shall fix upon 
 the external pudenda of the wife, yet the husband shall very 
 rarely suffer in any manner from these. The husband, when 
 
SYPHILIS IN INFANTS. 253 
 
 questioned, ■will admit that at some period within nine months 
 antecedent to his marriage, he had contracted a venereal 
 disease; that he had undergone mercurial treatment, by 
 which all his symptoms were removed and that he had been 
 declared by his surgeon to have been cured. I am well aware 
 that such reports cannot always be relied on ; and as long as 
 such cases were confined to mechanics and persons in an 
 humble rank of life, I could not bring myself to believe 
 implicitly in their reports ; but when I found some occurring 
 in the higher walks of life, and when the husbands proved to 
 be men of acknowledged and known veracity, I could no longer 
 withhold my assent. I now mention one case, of the truth of 
 which I am perfectly convinced, and which is, besides, one of 
 the very few instances in which the husband seemed to suffer 
 from the diseased state of the wife. 
 
 January, 1828. In two months after her marriage, Mrs. 
 K. first noticed certain unnatural appearances on the labia 
 externa. Having, after another month, obtained an examina- 
 tion, I found a number of white moist raised tubercles on the 
 internal surface of each labium pudendum. At this time she 
 was also affected with white superficial ulceration or excoriation 
 at both angles of the lips. The tonsils appeared with whitened 
 surfaces, the snail track affection of the mucous membrane, a 
 deep copperish hue of the skin at the junction of the alse nasi 
 with the cheeks. Upon the most minute inquiry I could not 
 discover any grounds for supposing that Mrs. K. had at any 
 time been affected with primary symptoms. 
 
 At this time Mr. K. had not the slightest trace of any local 
 or constitutional disease. About ten months before marriage 
 he had undergone a full and regular course of mercury for 
 primary symptoms, and was then assured by his surgeon that 
 he was perfectly cured. Since that period he had remained 
 free from all appearances or suspicions of venereal disease. 
 
 However difficult it was to account for these appearances, I 
 considered them to be venereal, and accordingly put both 
 husband and wife under a course of mercury. For although 
 he did not exhibit the slightest trace of disease, yet it was 
 quite certain that from him Mrs. K. received her complaints. 
 By the use of blue pill her mouth was made smartly sore in 
 
264 SYPHILIS IN INFANTS. 
 
 the course of three weeks ; yet at this period the symptoms on 
 the pudenda were not improved as much as I thought they 
 should have been in that time, and they afterwards appeared 
 to yield rather to a lotion of Sulph. Zinc than to the action 
 of mercury. All the other symptoms were removed solely by 
 the influence of the mercury. This course was continued for 
 eight weeks. 
 
 His mouth was with dif&culty affected ; however, about the 
 middle of the fifth week it became slightly sore, and this effect 
 was continued until the conclusion of the treatment. In the 
 beginning of April they returned to the country, where they 
 both used sarsaparilla for six weeks following. When they 
 had been at home for three months Mrs. K. perceived a few 
 blotches in the skin of the palms of the hands, a few also on 
 the forehead near the roots of the hair, and some over the 
 scalp ; on the dorsum of the tongue there now is a small patch 
 destitute of papillse, and looking as if it had been scalded. 
 Fresh appearances have also taken place on the pudenda. 
 Prom these she suffers no uneasiness whatever ; no discharge. 
 They consist of a number of small raised brown-coloured 
 excrescences covered with a firm cuticle. 
 
 Mr. K. now told me that he was strangely affected ; for that 
 about six weeks ago he observed some strange appearances on 
 his penis. I found, on the inside of the prepuce, a brown 
 blotch of a rounded form, and a similar one of a much larger 
 size, and of oblong form, raised and with a rough surface on 
 the skin of the penis. 
 
 I now commenced another course of mercury, which was 
 carried on for ten weeks, and which proved more satisfactory 
 than the former ; for now, in Mrs. K., all the symptoms 
 yielded kindly as the ptyalism proceeded; and Mr. K. was 
 without much dif&culty brought under the influence of 
 mercury, and the brown blotches yielded in the same manner 
 as venereal symptoms usually do. 
 
 Some authors, with a view to make facts reconcileable to 
 their theories, have supposed that the infant could only be 
 infected by coming in contact during parturition with ulcers 
 in the vagina of the mother. This doctrine is at once over- 
 thrown by the following facts : — 1st, by having ascertained by 
 
SYPHILIS IN INFANTS. 255 
 
 observation that no such ulcers were in existence at the period 
 of parturition ; and, 2ndly, that many infants have exhibited 
 the symptoms of the disease actually existing at the moment 
 of their birth. 
 
 Many of those who admit that the fcetus in utero can be 
 infected suppose that this takes place only when one or both 
 parents have been affected with primary or secondary 
 symptoms at the time of conception, or that the mother has 
 been so affected during utero-gestation ; and to this opinion I 
 believe the majority of experienced practitioners, urged by 
 repeated observation, now give their assent, however irrecon- 
 cileable the fact may be with their theoretical notions of the 
 ordinary mode of propagation of the venereal disease. 
 
 But there are cases in which the foetus in utero has been 
 infected under circumstances so strange and so difficult to 
 explain, that nothing short of actual observation could induce 
 us to allow the fact. The circumstances to which I allude are 
 these : — The father of the child has had primary symptoms 
 six or eight months before his marriage ; for these he has been 
 treated by mercury ; has undergone a full course of this medicine, 
 under which his symptoms have been removed; and his 
 surgeon has declared himself satisfied with the treatment, and 
 dismissed him as perfectly cured. In six or eight months 
 after this treatment he marries. In the ordinary time his 
 wife becomes pregnant, and carries the child until the seventh 
 or eighth month, when abortion takes place, and this without 
 being preceded by any of those circumstances which in 
 ordinary contribute to its occurrence. The same fatality 
 attends on the second and third, and perhaps fourth, pregnancy, 
 in spite of every attention paid to the directions of her 
 accoucheur. At length suspicion arises in the mind of the 
 accoucheur; he examines the product of the next abortion, 
 and finds that the cuticle is loose, and that it readily peels off 
 in patches of greater or less extent ; thus is explained what 
 the midwife had termed a putrid state of the child ; he may 
 find too that the nails are not formed, and in general that the 
 chUd appears as if it had been badly nourished. It should be 
 here remarked that sometimes the child is produced alive, in 
 such a weakly but emaciated state that it does not survive 
 
256 SYPHILIS IN INFANTS. 
 
 more than a few hours; and such often bear unequivocal 
 marks of the venereal disease. Until these repeated abortions 
 shall have attracted the attention of the accoucheur there 
 has not been any one circumstance vehich could have raised 
 suspicion as to the true cause of them ; for both parents 
 continue, all this time, to live in the enjoyment of perfect 
 health; no trace of disease is to be discovered in either. 
 When the husband is questioned he candidly avows that he 
 had before marriage been affected with primary symptoms; 
 that he had been (as he thought) cured of them; and that 
 having allowed six or eight months to pass over before his 
 marriage, without perceiving any sign of a return of the 
 disease, he had concluded that it had been perfectly eradicated 
 from his system. On further inquiry it is ascertained that 
 his wife had never complained of any sensations which might 
 lead even to a suspicion of her having had primary symptoms ; 
 nor has any appearance taken place in her which can even 
 bear a resemblance to secondary symptoms. In a word, both 
 parents are pronounced (after the most minute investigation) 
 to be in the enjoyment of perfect health. 
 
 In some cases we may discover equivocal appearances of 
 disease in the father, yet so faintly resembling syphilitic symp- 
 toms that we could not think of considering them as venereal, 
 unless our suspicions came to be strengthened by some col- 
 lateral circumstances. Of this kind is one of those cases 
 related by the late Dr. Beatty, of this city, in his paper 
 entitled — " On a Species of Premature Labour," published in 
 the fourth volume of ' The Transactions of the Association of 
 the King and Queen's College of Physicians.' 
 
 Dr. Beatty, having concluded the history of one case of this 
 kind, says, " Several similar cases occurred to me from that 
 time, with similar success, which I shall pass over, as they 
 rest only on my own experience, and shaU therefore confine 
 myself to a very few, in some of which I was assisted by Mr. 
 CoUes and Mr. Todd, in their capacity of surgeons. In my 
 case-book, to which I have referred, I find that, in August, 
 1812, I attended the wife of a staymaker, who was delivered 
 of a putrid child, in the seventh or eighth month, which she 
 said was the third that she had born dead. I discovered so 
 
SYPHILIS IN INFANTS. 257 
 
 much of venereal affection, as to recommend that they should 
 put themselves under the care of some experienced surgeon 
 for the use of mercury. They applied to Mr. Colles ; and, 
 when she was pregnant in the following year, Mr. Colles told 
 me that they had not continued a sufficient time under his 
 direction to satisfy him that they were cured of their venereal 
 complaints ; which I found to be the case in July, 1813, when 
 I delivered her again of a putrid child, in the eighth month. 
 I then declared that I never would attend her again, until Mr. 
 Colles told me that he was satisfied with the result of the 
 mercury used. They again returned to him ; arid fully 
 attending to his directions, in October, 1814, I again attended 
 her, when she bore a living girl, at the full period of gestation. 
 She has had several living children since." 
 
 I can recollect that the symptoms exhibited by the husband 
 were of such a very doubtful nature that I should not have 
 thought of treating them as venereal were it not for the com- 
 munication made to me by Dr. Beatty with respect to the 
 abortions of his wife. 
 
 Although in this case there was enough in the appearance 
 to allow us to connect them with a preceding venereal com- 
 plaint, yet Dr. Beatty's experience had informed him that 
 similar unfortunate results might have taken place where no 
 visible symptom of venereal disease could be discovered in 
 either parent, for his next case, which was treated by him and 
 the late lamented Mr. Todd, was of this description. 
 
 In a few instances the child comes to its full time or nearly 
 so, but is born in such a weakly state that it ceases to live in 
 a few hours. This infant exhibits unequivocal marks of 
 venereal disease, in the copper-coloured eruption which is 
 always to be seen about the anus and genital organs, and 
 which is often spread over the entire surface of the body. 
 The countenance of such a child generally exhibits somewhat 
 the appearance of extreme old age. 
 
 But the manner in which I believe the syphilis of infants 
 more generally makes its appearance is this :— the child is 
 born, to all appearance, healthy and well-nourished, and 
 continues apparently in good health for a period varying from 
 eight days to as many weeks; then a number of copper- 
 
 s 
 
258 SYPHILIS IN INFANTS. 
 
 coloured spots appear about the anus and genitals, on the 
 inside of the thighs, corresponding to the external genital 
 organs ; these sometimes spread along the groins, and 
 degenerate into ulcers. The voice of the child is now observed 
 to change ; it has a peculiarly hoarse cry. Superficial ulcers 
 next appear at the angles of the mouth; these sometimes 
 affect more particularly the mucous membrane of the mouth ; 
 sometimes they occupy rather the external skin, and when 
 this is the case we find the cracks or fissures made to bleed 
 by the stretching of the skin whenever the child cries. The 
 tongue, palate, and throat also are affected with those white 
 and very superficial ulcerations which authors have denomi- 
 nated aphthous. The nose too begins to be more or less 
 obstructed ; a sharp thin discharge flows from the nostrils, 
 and seems to irritate (if it does not excoriate) the adjoining 
 skin ; this discharge occasionally dries, and forms a hardened 
 crust at the opening of the nostrils, which, by obstructing 
 the breathing, seems to add considerably to the sufferings of 
 the child. If the disease be allowed to proceed we find ulcers 
 or fissures in various folds of the skin, ex. gr. between the 
 chin and throat, on the back of the neck, in the folds on the 
 back of the thighs — in a word, in any or every one of the 
 folds of the skin. The voice of the child soon adds another 
 symptom characteristic of the disease; the cry of the child 
 becomes hoarse and raucous to an extreme degree. The child 
 then begins to emaciate, the skin becomes flabby, and unless 
 active treatment be employed, the unfortunate sufferer dies 
 extenuated and exhausted. Very frequently a number of the 
 lymphatic glands become enlarged, which older authors have 
 improperly termed buboes. The glands of the neck, and those 
 on the occiput, suffer in this manner, especially when the 
 eruption forms a crusty covering on the scalp ; indeed every- 
 where on the surface are the lymphatic glands occasionally 
 liable to be thus affected. But there is nothing in this 
 enlargement to be compared to the inflammatory enlargement 
 of these glands in the buboes of adults ; on the contrary, they 
 remain perfectly free from the condition of active inflamma- 
 tion, although some of them often undergo a sort of slow 
 suppuration and ulceration, similar to those processes in 
 
SYPHILIS IN INFANTS. 259 
 
 scrophulous glands. These changes in the glands, when they 
 do occui', take place only in the last stages of the disease. 
 
 It deserves to be mentioned that some infected infants (in 
 addition to the other symptoms) have a muco-purulent dis- 
 charge from the eyes. This is in such quantity as scarcely to 
 overflow the eyelids, and is accompanied with only a very 
 shght redness of the tunica conjunctiva. It bears no resem- 
 blance to the purulent ophthalmia of infants, which latter (I need 
 scarcely add) is not a symptom of syphilis. My limited 
 observation does not furnish me with a single instance of 
 purulent ophthalmia, in conjunction with truly syphilitic 
 symptoms. 
 
 The unfortunate victims of this disease generally perish 
 apparently worn out by marasmus. In a few some spots of 
 the eruption, or some of the glandular swellings, degenerate 
 into ulcers, which, becoming irritable and painful, add 
 severely to the sufferings, and hasten the death of the patient. 
 But in no instance do we oberve those destructive processes of 
 ulceration by which portions of the throat or nose are carried 
 away ; nor do we see those frightful affections of the bones 
 which too often attend the other symptoms of secondary 
 syphilis in adults. 
 
 Let it not be supposed that we are to meet with aU the 
 above symptoms affecting every infected child ; scarcely ever 
 are they all combined, nor indeed is there any regular order 
 in which they necessarily appear. In some cases the first 
 indication of the disease is a hoarseness or a snuffling ; and 
 in such the throat or the nose exhibits the first traces of the 
 disease. More frequently the eruption about the anus and 
 genitals is first in appearing ; but this remarkable phenomenon 
 we may expect invariably to witness, viz. that when the 
 throat is fij-st affected we may shortly expect to see the 
 affection of the anus, and vice versa. 
 
 I shall only further add, that sometimes the copper-coloured 
 eruption is most remarkable at the fold between the lip and 
 chin, or below the chin, and on the fore part of the neck ; a 
 coppery hue, along the joining of the lip and nose, is also 
 often a very characteristic symptom of this infection. 
 
 There is still another manner in which the infant may 
 
260 SYPHILIS IN INFANTS. 
 
 receive the infection, viz. by sucking a nm'se affected with 
 secondary symptoms of syphilis ; but I am in doubt whether 
 the diseased nm-se could infect the child unless she had 
 ulceration of the nipple ; I cannot at this moment recollect 
 an instance. The following ease, which has been very lately 
 under my care, is an instance of the infection being com- 
 municated to the infant, the nurse having, at the same time, 
 an ulcerated nipple. 
 
 Esther Warren, £et 29, admitted into the 9th ward, 23rd of 
 February, 1836, under Mr. CoUes. 
 
 In September last this woman, then nursing the child at 
 present at her breast, and having more milk than it could 
 use, was induced to suckle another infant, and continued to 
 do so untU it died, at the end of three weeks. The manner of 
 its death and the state of its body, as related by the woman, 
 leave no doubt that this infant had been affected with syphilis. 
 Previous to her reception of this chUd, she and her own 
 infant (then four months old) were in perfect health; about 
 the time of the death of the strange infant a sore appeared on 
 her breast, near to the nipple ; and not long afterwards an 
 eruption occurred over various parts of her body, preceded by 
 the customary febrile symptoms. Not being aware of the 
 natm-e of her illness she did not apply for medical advice, 
 and she has remained up to the present time without treat- 
 ment, the eruption fading in one place and then reappearing 
 in another. In the meantime her health began to decHne; 
 her appetite failed her ; she was troubled with night perspira- 
 tions ; and, from a previous state of health and strength, she 
 soon became weakly and emaciated. Her throat, also, has 
 latterly become affected ; it presents a deep red appearance, 
 but there is no ulceration to be seen ; the angles of her mouth 
 are also affected by fissures : at this period of her complaint, 
 seeing that matters were going on from bad to worse, she 
 determmed on coming into the hospital. She has had but 
 one other child, now two years of age, stout and healthy. 
 The infant, now ten months old, is not at aU emaciated, but 
 of a pale and rather sickly appearance. Several parts of its 
 body are covered by a copper-coloured eruption, shghtly raised 
 and smooth; this particularly affects the parts of generation 
 
SYPHILIS IN INFANTS. 261 
 
 and the neck; it became affected nearly at the same time 
 with the mother. 
 
 Mercury was administered to both the mother and chUd, 
 and they were dismissed cured in the course of some weeks. 
 
 I shall now mention the outlines of a case which proves 
 that the dry nurse (if labouring under syphilis) may infect an 
 infant committed to her care. 
 
 My friend Mr. Cusack says : — " The child of A. B., a year and 
 a half old, was brought to me with small superficial ulcera- 
 tions about the nates ; the dry nurse, whom I examined, was 
 at the time perfectly free from any disease. Before the 
 expiration of three weeks the nurse again called on me, and 
 showed me an inflamed spot, about the size of a sixpence, just 
 over the dorsum of the metacarpal bone of the thumb. Prom 
 the previous affection of the child I was induced to suppose 
 it venereal, and accordingly received her into the hospital. I 
 placed her under the influence of mercury, but this did not 
 prevent the occurrence of secondary symptoms, for she sub- 
 sequently suffered from pains of her limbs, general copper- 
 coloured eruption, ulcers in her throat, and iritis. During her 
 residence in the hospital, the cook from the same family was 
 admitted, labouring under very similar symptoms. On 
 inquiry, I ascertained that the cook had originally infected the 
 child, and the child had contaminated the dry nurse." I shall 
 extract from the hospital registry an account of these two 
 cases. 
 
 Mary Margrane, set. 36, dry nurse, married, and mother of 
 several healthy children, admitted into No. 9 ward, on the 
 21st of January, 1834, under the care of Mr. Cusack. 
 
 About four months ago a pimple appeared on the dorsum of 
 the metacarpal bone of the thumb, which, being frequently 
 rubbed off, was converted into a circular ulcer, which was accom- 
 panied with a slight eruption on the fore arm. She did not 
 suffer any constitutional disturbance. When she had the pimple 
 on the hand she was in the habit of washing a dehcate child, 
 affected for some months previously with sore eyes and an 
 ulcer on the buttock. The child had been weaned for five 
 months. The ulcer on the buttock of the child was healed by 
 the use of black wash. On the 15th of November, 1833, 
 
262 SYPHILIS IN INFANTS. 
 
 Margrane was admitted for the first time into the hospital ; 
 she had then a cu-cular sore on the hand and a slight 
 eruption on the fore arm. On the 25th of November she was 
 ordered PU. Hyd. gr. v. bis die, which she continued to take 
 till the 9th of December, when, being apparently quite well, 
 she left the hospital, but without being salivated. In about a 
 month afterwards a scaly eruption appeared on the face, 
 unpreceded by constitutional symptoms. 
 
 January 21st. She was admitted a second time; and the 
 eruption, which was of a scaly kind, had not extended to any 
 other part. N.B. — Was examined by Mr. Cusack, and no 
 appearance of ulcer on the genital organs. ^ . Hyd. Oxym. 
 gr. J, c. Decoct. Sarsse. 
 
 March 10th. Has continued the same medicines to the 
 present time ; is now free from the eruption, but still there is 
 some slight discoloration ; is made an external patient, and 
 to continue medicine. N.B. — She continues in good health. 
 
 Mary O'Donnell, set. 30, cook in the same family with 
 Margrane, admitted into No. 8, on the 25th of January, 1834, 
 under the care of Mr. Cusack. She always enjoyed good 
 health until the end of October last, when an eruption came 
 out all over the body, preceded by pains in the bones, palpita- 
 tions of the heart, loss of appetite, nausea, and thirst. Says 
 she had previously no ulcer in, or discharge from, the vagina ; 
 but the child, mentioned in the preceding case, was usually 
 left in her bed during the day. She got some cathartic pills 
 and woods from a dispensary, during the use of which the 
 general symptoms subsided and the eruption was fading 
 away, when, having caught cold, a fresh eruption came out, 
 about last Christmas ; she has taken no medicine since. 
 
 January 25th. Scaly eruption, of the same character as 
 Margrane's, all over the body; pains in the bones occasionally 
 at night ; tongue clean, pulse regular, appetite good. Decoct. 
 Guaiaci, Pil. Purg. 
 
 February 3rd. No fresh spots have come out ; the eruption 
 has ceased to desquamate. I^ . Hyd. Oxym. gr. J, c. Decoct. 
 Sarsse. 
 
 February 24th. Eruption gradually declining; left the 
 hospital, and was desired to continue her medicine. 
 
SYPHILIS IN INFANTS. 263 
 
 Of course we cannot say whether the infant was infected by 
 the primary or the secondary symptoms of the cook. 
 
 I had an opportunity of seeing these two women when in 
 the hospital, and I considered their diseases to be most 
 unequivocally syphilis. 
 
 Here then are two clear examples to establish the opinion 
 that secondary symptoms are capable of propagating the 
 venereal disease; for, in this case, no suspicion whatever 
 arose in the minds of any of the medical attendants that the 
 disease of the child had been derived from the parents ; indeed, 
 the advanced age of the child at the time that it first exhibited 
 any signs of the disease was quite sufficient to remove all 
 doubt or suspicion on that head. 
 
 In cases of so much danger and so much delicacy it is a 
 matter of the first importance to form a correct diagnosis. 
 No man would be so rash as to be decided in his judgment by 
 any single symptom, however strongly it may be marked. 
 Every circumstance which can throw any light upon the 
 subject must be taken into the account, viz. the history of the 
 father's health previously to his marriage, the frequent 
 abortions, the appearances of the expelled fcetus (if these can 
 be discovered), the present symptoms, their succession and 
 combination. 
 
 We sometimes meet with an infant havpg numerous spots 
 of moist button-scurvy about the anus, genitals, and inside of 
 the thighs. Should other members, also, of the family, 
 exhibit similar symptoms, we are not in much danger of mis- 
 taking these for syphilis ; because a slight attention to the 
 history of each case, and to the marked difference in the more 
 grown subjects, between button-scurvy and syphilis, will at 
 once enable us to decide ; but where the infant is the only 
 member of the family so affected, we are liable to commit a 
 mistake if we form a hasty opinion. A little attention will 
 enable us to decide correctly; for although the anus and 
 external organs of generation may present appearances pretty 
 closely resembling those of syphilis, yet we shall be able to 
 distinguish these from the latter by observing that they are 
 raised above the surface, that they are most distinct and 
 distant from each other ; and while those in syphilis begin 
 
264 SYPHILIS IN INFANTS. 
 
 •with a number of blotches pretty thickly set, these enlarge a 
 little, and then ulcerate, without being at any time raised 
 aboYe the soimd skin. 
 
 An eruption of a few copper-colom-ed spots is not unfre- 
 quently seen about the anus and genitals of infants, otherwise 
 perfectly healthy — ^these we must not hastily pronounce to be 
 venereal ; they are sometimes caused by inattention to clean- 
 liness, and sometimes by a disordered state of the alimentary 
 canal. But these spots remain the single symptom; this 
 disease is not found to make progress — it does not show itself 
 in the mouth or throat, or on other parts of the body, and it 
 soon yields to persevering cleanhness and a regulated con- 
 dition of the alimentary canal. 
 
 The anus of infants is subject to fissm-e, which, beginning 
 on the skin, extends in upon the mucous membrane of the 
 rectum. We know that such is not venereal when we find it 
 remain a single and solitary symptom ; this yields to black 
 wash and ordinary local treatment. 
 
 A superficial ulcer is sometimes found on the rugous skin 
 of the anus ; generally with one part of the edge rather deep, 
 the rest of the edge thin. This ulcer is not very painful ; it 
 is indolent, and sometimes continues for many weeks or 
 months, the general health of the chUd remaining unimpaired. 
 Strict attention to keeping this ulcer constantly covered with 
 some stimulating apphcation wUl effect its cui-e in a very 
 moderate time. 
 
 It is assei-ted by many authors that this disease in the 
 infant at the breast may be most safely and very certainly 
 cured by subjecting the nm-se to a full and regular com-se of 
 mercury. This, no doubt, is true in many instances ; but not 
 a few cases are reported to have required, in addition, that the 
 chUd itself should be subjected to mercui-ial treatment. In 
 my opinion the cure, if not more certain, will be more speedy 
 by subjecting both nm-se and infant to the use of mercm-y. 
 Indeed, in some instances it is absolutely necessary to give 
 mercm-y to the infant, as well as to the nurse, as in the 
 following case : — 
 
 Eliza Eedmond, aet. 35, an unhealthy-looking woman, of 
 spare make and dark complexion, with her child (aged five 
 
SYPHILIS IN INFANTS. 265 
 
 months and a half), admitted into No. 7 ward, under Mr. 
 Colles, September 3rd, 1836, gives the following history of 
 herself : — 
 
 She lives in the country, and was married in November, 
 1832 ; she states that in seven weeks afterwards she perceived 
 a sore on the right labium pudendum, which spread to the 
 size of a sixpence, accompanied with ardor urinse, and a 
 discharge per vaginam, great heat, and swelling of the parts. 
 For this she took seven pills ; her mouth became sore, and 
 she discontinued the medicine. She was not aware of her 
 husband having any sore, but he also took pills, and was 
 similarly affected. On salivation being produced in her, the 
 sore healed, and all her other symptoms disappeared, except 
 a slight discharge. In two months from the date of the sore 
 healing, an eruption broke out on both herself and her 
 husband ; this was attended with pains in the large joints, 
 particularly the shoulders and ankles. The eruption con- 
 tinued, off and on, for five or six weeks, but finally disappeared 
 without her taking any medicine, but leaving her much broken 
 in health. The husband's symjjtoms went off similarly. 
 
 In June, 1883, she states that a sore appeared on the same 
 place, and of the same character with the first, attended by 
 gonorrhoea, &c., &c. She again had recourse to the pills ; 
 took six, and, being exposed to much cold, a profuse salivation 
 was produced. The husband also took pills. Her sore 
 healed, and the discharge gradually went off; but she com- 
 plained of general ill health, with loss of appetite, and 
 occasional pains at night. No eruption or sore throat 
 followed this attack, in either herself or husband. With 
 these symptoms she went on to the period of her becoming 
 pregnant (in the summer of 1835), the first time since her 
 marriage. About the eleventh week she miscarried, caused, 
 she supposes, by fright. There was no foetor, or marks of 
 putrescence of the foetus. 
 
 On the 20th of March, 1886, she was confined of this child, 
 a girl, which she suckled herself ; healthy to all appearance, 
 and it remained so till the ninth week, when she perceived a 
 number of copper-coloured spots, the size of from a pea to a 
 sixpence, on the neck, face, and body of the child; these 
 
266 SYPHILIS IN INFANTS. 
 
 symptoms were attended with fits of screeching and a remark- 
 able alteration in the voice. In twelve days from this, the 
 child getting worse, she applied for advice — got pills, seven of 
 which affected her mouth. The child at this time improved 
 a little ; it got no internal medicine, but had medicated baths. 
 Shortly after this the child's mouth became sore at the 
 angles and along the red margin of the lips, appearing first 
 in the form of whitish blisters, running into one another, and 
 afterwards extending to the inside of the mouth ; the spots 
 gradually disappearing, the voice and mouth remaining much 
 the same. The child sucked well. 
 
 June, 1836. About three months ago sores began to appear 
 on the pudendum of the infant, cleft of the nates, and the 
 angles of the body generally, coming on in the latter places in 
 the form of fissures. The child's health became much worse ; 
 it was much wasted and constantly crying. 
 
 August. Three weeks ago she came to town, and, under 
 the care of a surgeon, took ten pills, and eight rubbings, 
 herself ; the child received no treatment, and evidently became 
 worse ; the mercury did not affect the mother. 
 
 September 3rd. Came into the hospital ; child is extremely 
 emaciated and weak, has a pale sickly look, its eyes dull and 
 heavy, takes no notice of anything, is constantly crying — in a 
 word, is in a deplorable and almost hopeless state ; its voice 
 is of that peculiar croaking hoarseness characteristic of its 
 state, and its whole aspect bespeaking disease ; its lips, and 
 the mucous membrane of its mouth and tongue, are covered 
 with white spots, and small superficial ulcers interspersed ; 
 at the angles of the mouth are superficial ulcers with white 
 margins ; at the cleft of the nates, opposite the front of the 
 coxse, and not engaging the anus, there are two ulcers ; their 
 edges are red and well defined ; in the centre of each there is 
 a small spot, about the size of a pea, standing up like an 
 island, unaffected by the disease. The rest of the sore is 
 covered over with a layer of greyish white tenacious matter, 
 without any appearance of pus ; the whole of the ulcer lies 
 beneath the surrounding integument. There is an ulcer of 
 similar character, but not so marked, across the throat ; also 
 in each hand, and the marks of others in the folds of the 
 
SYPHILIS IN INFANTS. 267 
 
 skin of the thighs ; one on the pudenda is healed ; there are 
 also slightly discoloured marks of the spots on different parts 
 of the body, but no appearance of desquamation. 
 
 The mother has no symptoms of disease, except slight wan- 
 dering pains and general weakness ; her nipples are perfectly 
 sound, and have not been at any time sore. She was ordered, 
 on September the 3rd, Calomel gr. ij. opii gr. J, bis in die ; 
 and the child, Pil. Hydr. gr. ij. in Syrupi si. bis in die ; and 
 black wash to all the sores. 
 
 September 8th. The mercury has disagreed with the 
 mother, and caused a purging ; it was discontinued, and she 
 had an oil-draught. The child is greatly improved since its 
 admission ; it is more lively, takes more notice, its eyes have 
 lost the dull look, its voice is much improved, it cries less, and 
 when it does it is much stronger than before. The sores are 
 all better, and those about the anus are losing the elevated 
 margin, and have thrown off the white tenacious coating ; are 
 clean red, and the surface is coming on a level with the skin : 
 that on the neck is nearly healed ; the mouth is cleaner — the 
 white coating has peeled of, the ulcers are healed, leaving the 
 tongue redder than before. It sucks and sleeps well ; ordered 
 to continue the Pil. Hydr. and the wash. The mercury has 
 not been resumed with the mother : she complains of weak- 
 ness, and loss of rest and appetite ; mouth slightly sore. 
 Ordered a gargle, and cardiac mixture. 
 
 September 11th. Mother much the same ; child continues 
 to improve ; the mouth better, and the sore contracting and 
 healing both from the edges and the central sound spot. 
 
 She is not aware of her husband having any symptoms of 
 disease since June, 1833. 
 
 This case pretty clearly proved that mercurial treatment of 
 the mother was not sufficient to cm-e the infant ; for while the 
 mother was treated by a surgeon in Dublin with mercury (no 
 medicine being, at the same time, administered to the child), 
 the latter was not at all benefitted ; indeed, its state was all but 
 hopeless on its admission into the hospital. Again, when the 
 child was put upon mercury it rapidly improved, although 
 at this time the mercury had not made any salutary 
 impression on the system of the mother ; indeed it had 
 
268 SYPHILIS IN INFANTS. 
 
 acted on her, at this time, rather as a poison. Vide Eeport 
 of September 8th. 
 
 The ulcer near the anus of the infant resembled, in a degree, 
 the secondary ulcer of an adult when it is about to heal ; for 
 we often find the latter to heal in the centre, while the edges 
 show no disposition to do so. I merely notice this fact, because 
 I think we cannot be too particular in noticing every fact in 
 those diseases which are not well understood ; and I imagine 
 that we are as yet but little acquainted with the syphilis of 
 infants. 
 
 It is unnecessary to enter into particular rules as to the 
 treatment of the nurse ; this must be conducted as in ordinary 
 cases of secondary syphilis. 
 
 For the child we may employ either the Ung. Hydr. in very 
 minute doses, Gr. v., or Gr. iij. semel in die ; or Pil. Hydr. 
 gr. ij. may be given daily, suspended in mucilage ; or we may 
 give Calomel, gr. ^, combined with sugar, once or twice a day. 
 
 It is quite in vain that we look to the state of the mouth and 
 gums as an index to point out the action of the mercury on 
 the child's system. No man, in the present day, requires to 
 be told that mercury never does produce ptyalism, or swelling 
 and ulceration of the gums in infants. The morbid affection 
 of the mouth and throat may be attended with profuse flow of 
 saliva, before any mercury is employed ; but this excessive 
 flow is actually found to decline in proportion as the medicine 
 acts in a kindly manner on the system. We have no better 
 proof of the wholesome and efficient action of mercury 
 on the system of the child than our witnessing an improve- 
 ment in the condition of the symptoms, especially of those 
 which are not treated by any topical applications. When the 
 mercury begins to act the bowels may be deranged, or even 
 dysenterically affected ; but I have not yet seen any instance 
 of mercurial erythema in an infant. In one case, which I 
 was treating with frictions of mercurial ointment, on the 
 second day of visible amendment of the symptoms, the child 
 was seized with a convulsive fit, in which it expired. I ascribed 
 the death, in this case, to the first impulse of mercury upon a 
 highly sensitive system, for I could not discover any other 
 probable cause of it. 
 
SYPHILIS IN INFANTS. 269 
 
 The amendment, once begun, proceeds with greater rapidity 
 than we observe in cases of similar symptoms in the adult. 
 
 Here, as in adults, the disappearance of symptoms is not 
 always the cure of the disease ; for it occasionally happens 
 that the symptoms return after an interval of one or two 
 months, and require us to resort again to the use of mercury. 
 
 In some cases we see one symptom linger for weeks, and 
 even months, after all the rest have disappeared ; and this, 
 although such symptoms may enjoy the additional advantage 
 of a topical application. This remnant of a solitary symptom 
 would seem to be merely a local affection ; for it may be 
 removed by changing the topical remedy for another possessed 
 of similar qualities, though perhaps not of superior activity. 
 I believe that under these circumstances we need not resume 
 the use of mercury. . 
 
 From the commencement of the treatment we employ topical 
 remedies for the relief of the external ulcerations, wherever 
 seated; those around the genitals and anus imperatively 
 demand them, as they add so severely to the sufferings of the 
 patient. The black wash will be found of inestimable value ; 
 it soothes the irritability of the ulcers, and improves their 
 appearance and condition, even before the mercury can have 
 acted on the system. When a larger spot of ulceration at the 
 anus proves obstinate, and seems stationary, even after all the 
 other symptoms have disappeared, we should then apply some 
 other topical means — perhaps the Ung. Hyd. Nitr. one part, 
 with eight parts of lard, will then be a good substitute for the 
 black wash. I am not acquainted with any remedy which 
 can be with advantage applied to the ulcers of the lips, palate, 
 and throat ; the very act of applying anything to these irri- 
 tates the ulcers, and causes them to bleed, so that I have 
 imagined they did fully as much harm as good ; and, on that 
 account, I have long since relinquished their use altogether. 
 I am not aware of any local treatment for the swellings of the 
 enlarged lymphatic glands ; they yield readily to the consti- 
 tutional influence of mercury. The slight purulent discharge 
 of the eyes is benefitted by a mildly astringent coUyrium. 
 
 Should the parents, from ignorance of the nature of the 
 disease, have wasted time in unavailing efforts to cure it, and 
 
270 SYPHILIS IN INFANTS. 
 
 have allowed the child to be so far reduced that a diarrhoea 
 has set in, and the countenance has assumed that confirmed 
 appearance of old age, we must consider the case as in the 
 last degree dangerous ; however, by using the ordinary means 
 to check this discharge, while at the same time we use om* 
 best efforts to bring the system imder the influence of mercury, 
 we afford some chance of hfe to the unhappy little sufferer. 
 
 The Appearance and Nature of those Diseases which are commu- 
 nicated hy the Infant to the Nurse. 
 
 In some days, or at least in a very few weeks, after the 
 nurse has observed the venereal symptoms appear on the 
 child, her sufferings commence. She is first affected with 
 what she terms a sore nipple. On inquuy it will be found 
 that one or two pimples, or pustules, ha^e appeared near the 
 nipple ; these soon degenerate into an ulcer, which presents 
 the characters of a secondary rather than of a primary 
 venereal ulcer ; this becomes exquisitely sensitive. A slight 
 enlargement and tenderness of some of the axillary glands 
 quickly follow, but these glands do not betray any strong ten- 
 dency to run into suppuration ; on the contrary, I must say 
 that I have not seen one single instance in which this occurred. 
 In two or three weeks more the nurse complains of sore throat, 
 or of an eruption ; and not unfrequently these two symptoms 
 appear almost simultaneously. An eye accustomed to view 
 the secondary symptoms of syphilis does not discover any 
 difference between these and the venereal sore throat and 
 eruption which follow a primary ulcer in the adult. The 
 pudenda of the infected nurse are very generally beset with 
 small raised ulcers which discharge copiously ; these are to be 
 seen perhaps in every case where a general eruption of the 
 skin exists, but not unfrequently they may be found accom- 
 panying the superficial white ulceration of the throat where 
 no general eruption exists, and where the skin remains free 
 from a geaieral venereal eruption. I have occasionally seen 
 venereal iritis also attack the nurse. What other symptoms 
 might arise, or what course the disease would follow, if longer 
 unattended to, I cannot pretend to say, because I have scarcely 
 ever seen any case in which the course of symptoms might 
 
SYPHILIS IN INFANTS. 271 
 
 not have been disturbed and deranged by the exhibition of 
 mercury. But many of those infected nurses to whom mercury 
 was administered became affected with very obstinate ulcera- 
 tions of the throat, and with pains of the bones and joints. 
 And in the greater number of these the disease appeared very 
 obstinate and intractable. Indeed we have instances recorded 
 in which the nurse has suffered the loss of the bones of the 
 nose, and a few in which the disease terminated fatally. I 
 am, however, disposed to think that these severe symptoms 
 of the disease might be traced to the injudicious and excessive 
 use of mercury employed for the cm'e of the early symptoms, 
 without due consideration of the nature of those symptoms 
 and of the reduced state of the system, which at this time is 
 often debilitated by nursing. I am inclined to think that in 
 most of these cases we should commence with under-doses of 
 mercury. The following fact appears to me very deserving 
 of notice : — I have never seen or heard of a single instance in 
 which a syphilitic infant (although its mouth be ulcerated), 
 suckl'ed by its own mother, had produced ulceration of her 
 breasts ; whereas very few instances have occurred where a 
 syphilitic infant had not infected a strange hired wet nurse, 
 and who had been previously in good health. 
 
 It is a curious fact that I never witnessed nor ever heard of 
 an instance in which a child deriving the infection of syphilis 
 from its parents has caused an ulceration in the breast of its 
 mother. The following case when received into the hospital 
 appeared to form an exception, but on closer inquiry this 
 proved not to be the case. The particulars are transcribed 
 from the hospital registry. 
 
 Anne CuUen and child, admitted into No. 9 ward, on the 
 19th of March, 1834, under the care of Mr. Cusack. 
 
 The child is about three months old. The extremities, 
 the parts of generation, the anus, and the chin, are covered 
 with copper-coloured spots slightly raised and smooth. The 
 child is pale but not emaciated, its bowels are rather relaxed. 
 At birth it was healthy and well-looking, and continued so 
 until it was about a month old, at which time the body became 
 covered with those spots, which were of a brighter red colour 
 than they are at present. The mother of this infant was 
 
272 SYPHILIS IN INFANTS. 
 
 admitted a patient into the hospital about foui* years ago for 
 syphilis. The only symptoms she had then were pains in the 
 bones ; but about six months before that, while suckling her 
 own child, when it was half a year old, she got a sore on the 
 breast, near the nipple, which was soon after followed by an 
 eruption. She stated that other women occasionally suckled 
 her child. In a short time after the sore had appeared on her 
 breast, she observed that the child's mouth was sore ; an 
 eruption afterwards came out all over its body ; two other 
 children, and a girl that attended them, became similarly 
 affected — namely, with eruption and sore throat. They were 
 all admitted at that time into the hospital ; were all salivated, 
 and discharged cm"ed. After this she had two children ; the 
 first about two years since. When this child was a month 
 old an eruption came upon its body, and in two or three weeks 
 afterwards it died. The other child, now three months old, is 
 (with herself) a patient in the hospital. She herself says 
 that she never enjoyed better health than at present : her 
 husband also is perfectly healthy. 
 
 Rema7-ks. 
 
 In this case there was a very strong presumption that the 
 infant was infected by some of those women who were allowed 
 occasionally to suckle her child ; that, from the child, she and 
 all the other members of the family also were infected, except 
 the husband, who was probably infected by the mother. I 
 say there is a presumption that this is the manner in which 
 the infection was conveyed, because as yet I have not seen any 
 instance in which an infant infected by the mother commu- 
 nicated a venereal ulcer of the nipple to her. This case shows 
 that parents, who are not at all conscious of any derangement 
 of health, may yet produce a child which shall, in a few 
 weeks, exhibit the genuine characters of venereal disease, 
 necessarily derived from one or both parents. 
 
 With respect to the treatment- of the nm'se and child, I 
 believe that very little difference of opinion is to be found 
 among authors or practitioners. All agree that it is desirable 
 (even though the child alone show signs of the disease) to 
 bring the nurse under the influence of mercury ; and many 
 
SYPHILIS IN INFANTS. 273 
 
 assert, that this alone is quite sufficient to effect a cure of the 
 disease in the child. To the latter part of this statement I 
 have seen some exceptions, and I am certain that I have seen 
 a good many cases in which the child appeared to be daily 
 growing worse until mercury was daily administered to 
 it. Of this much I feel assured, that the cure of the infant 
 will be more speedy if it be subjected to the use of mercury 
 at the same time with its nurse. I am also disposed to think 
 that in the treatment of the nurse we shall succeed better with 
 small doses of mercury than with large ones. I am disposed 
 to ascribe to over anxiety of the surgeon, and consequently to 
 too vigorous treatment, the frequent failures, and still more 
 frequent tedious cures, of nurses infected by syphilitic infants. 
 
 The disease, as it appears in the syphilitic infant and the 
 infected nurse, seems to differ very little, if at all, from the 
 secondary symptoms which result from this disease of adults, 
 as contracted by impure sexual intercourse. But if we proceed 
 to trace further the consequences of this infection in the nurse 
 and in the infant, we shall discover some striking particulars 
 in which the diseases propagated by them materially differ 
 from the ordinary forms of syphilis. 
 
 With respect to the nurse, we find that very frequently her 
 husband becomes affected with ulcerations on the genitals ; 
 and these, in a short time, are attended by superficial ulcera- 
 tions of the throat and mouth. If we have an opportunity of 
 examining the nurse, at the time her husband first complained 
 of ulceration of the genitals, we shall find a greater or smaller 
 number of small raspberry-like, moist, raised excrescences, or, 
 as some term them, ulcers on the genitals, and insides of the 
 top of the thighs of the nurse, and this while there is no 
 eruption on the general surface of the skin. Every one con- 
 versant with the appearances of the venereal disease in females, 
 knows that when they are the subject of general venereal 
 eruption their genitals are beset with them, and that all those 
 on the genitals, or on the skin in contact with them, assume 
 that raised moist condition above-mentioned. But in the 
 instance of infected nurses we shall sometimes find that 
 this condition of the genitals is an attendant on the affection 
 of the throat, without the intervention of a general eruption 
 
 T 
 
274 SYPHILIS IN INFANTS. 
 
 of the skin. And here we must remark, that while spots of 
 ordinary venereal eruption so generally fix upon the pudenda 
 of the female, and there degenerate into those moist raised 
 ulcers above mentioned, we see very few spots of venereal 
 eruption on the male organs of generation, and those which 
 are found there retain the characters of the general eruption, 
 and indeed, we may add, are usually of the scaly nature. 
 
 The ulcers which are seen on the genitals of the husband 
 very closely resemble those on the pudenda of the woman ; 
 but they are not so much raised, do not yield as much dis- 
 charge, and give us the idea that they are in a less moist 
 structure or tissue. In a short time after the appearance of 
 these ulcers on the genitals of the husband, he begins to com- 
 plain of soreness of the throat, or of the lips and tongue. On 
 inspecting these parts, we do not find the truly syphilitic 
 ulcer ; we see generally the palatine arches pretty extensively 
 covered with a very superficial ulceration, with broken patches 
 of whitish lymph on and around the really ulcerated spots ; 
 a similar appearance, but more in the form of pretty large 
 circular superficial ulcers, may be seen on the inside of the 
 cheeks and lips. The tongue, if affected on the sides, presents 
 appearances similar to those on the cheeks ; but if the dorsum 
 be affected we observe a smooth patch, perfectly bald and 
 polished, as if the papillas had been carried off from this spot. 
 The common occurrence of ulcerations in the throat of the 
 nurse being attended with ulceration of the pudenda, and, on 
 the other hand, the ulcerations of the genitals of the husband 
 being so constantly attended with affections of the throat, 
 seem to point out some sympathetic connection between these 
 parts which have hitherto been overlooked. But when we 
 come to examine more closely the circumstances under which 
 this apparent sympathetic connection takes place, we shall 
 find reason to call in question this solution. For we find that 
 such sympathy between the throat and parts in the vicinity of 
 the anus never takes place when the former is affected with 
 any other form of ulceration, except that which is distinguished 
 by the milky-white state of the mucous membrane of the 
 throat ; so that, after the most strict investigation, we are 
 obliged to adopt the conclusion that this apparent connection 
 
STPHILIS IN INFANTS. 275 
 
 is caused rather by something peculiar in the morbid condition 
 of the part affected than in any natural or morbid sympathy 
 between those remote parts, the seats of co-existent disease. 
 And, in corroboration of this opinion, I observe that in every 
 instance of such superficial white ulceration of the throat, I 
 always enquire, and generally discover the corresponding 
 affection of the anus ; while, on the other hand, when the 
 patient complains of the soreness of the anus, and that we 
 there find the superficially ulcerated or excoriated state of this 
 part, I immediately enquu-e for the corresponding affection of 
 the throat ; and this latter I have not unfrequently discovered 
 when the patient was not conscious of its existence, so little 
 inconvenience was he suffering from it. I readily admit that 
 we may meet with instances where only one of these parts are 
 thus affected at the time of our examination ; but if we closely 
 attend to the progress of the case, we shall seldom (if ever) 
 find any which, at one period or other, either in its earlier or 
 its later stages, has not had the other accompanying it. 
 
 I must here remark that my observation does not supply 
 me with an instance of the husband having contracted the 
 disease by sexual intercourse, except when ulcers had formed 
 on the pudenda of the nurse. 
 
 Having traced the propagation of this disease from the 
 parents to the infant, from the infant to the nurse, and from 
 the nurse to her husband, let us now attend to the manner in 
 which it may be made to contaminate every other member of 
 the same family. If we suppose, as frequently happens, that 
 the child is suckled in the house of the wet nurse, and that 
 she has a numerous family of children, to one of he'r daughters 
 (more particularly) is assigned the care of dressing and carrying 
 about this infant ; this is the child which first suffers from 
 the contamination. The whole family being completely igno- 
 rant of the nature of this disease, this girl sleeps as usual 
 with the rest of her brothers and sisters ; for among the lower 
 orders of Irish that family is considered to be in comfortable 
 circumstances which can afford a separate bed for the parents, 
 whUe aU their numerous progeny are huddled together in 
 another bed ; the discharge from the ulcers about the anus 
 and vagina coming in contact with one of her brothers or 
 
276 SYPHILIS IN INFANTS. 
 
 sisters will produce a simUar ulcer on their persons, and in 
 this manner, obviously, a number of the family contract the 
 disease. 
 
 The readiness with which this disease is communicated by 
 contact cannot be exceeded in this property by any other 
 disease with which I am acquainted ; I look upon it as equally 
 infectious with the itch itself. Another manner in which this 
 disease is made to spread through the family is by the use of 
 the same spoon, and drinking out of the same vessel with 
 another of the family, to whose mouth the disease may have 
 spread. Those who are acquainted with the verj^ scanty fur- 
 niture of an Irish cabin will readily comprehend with what 
 facility and rapidity the disease can be propagated in this 
 manner ; but to others it may be necessary to say that the 
 family are quite satisfied with the possession of one single 
 spoon, and the stock of cups and cans is nearly as scanty. 
 Exposed thus to the double risk of contracting this infection 
 when sleeping or taking nourishment, we cannot be surprised 
 at finding three or four, in a family of six children, all at the 
 same time infected. I shall adduce two cases to show the 
 readiness with which the disease is communicated. 
 
 August 5th, 1834. Mr. D., a respectable mechanic, and 
 his wife, had (about two years before) been under my care, on 
 account of secondary venereal symptoms, of which I supposed 
 them both to have been cured, although Mr. D. had not con- 
 fined himself to the house while using mercury. Previously 
 to this treatment Mrs. D. had many miscarriages, but I could 
 not learn any particulars of the appearance of the abortions. 
 She now applied to me on account of her child, which is five 
 months old : when two months old an eruption appeared, of 
 large copper-coloured blotches on the thighs and in the folds 
 of the hams ; the latter have degenerated into ulcers. Around 
 the arms the skin is infected with venereal ulcers, from 
 which, however, the child does not seem to suffer much un- 
 easiness. On the lips and at the angles of the mouth there 
 are white superficial ulcers ; no affection whatever of the nose. 
 Both parents appear to be in the enjoyment of perfect health, 
 and the child has all the appearance of a fine thriving child ; 
 no symptom of disease in the mother. The mother says that 
 
SYPHILIS IN INFANTS. 277 
 
 the eruption on the child has been improved by washes, and 
 some internal medicines, which she got from her apothecary 
 in the country. The child does not seem to be fretful, or 
 suffering any pain. I advised Hydr. c. Greta for the infant, 
 and directed both parents to commence a course of Pil. Hydr. 
 
 As the parents lived thirty miles from Dublin I had but few 
 opportunities of witnessing the progress of the disease. I did 
 not see the child again until the 28th of August, 1834, when 
 the symptoms of the infant appeared much relieved. The 
 mother was sensibly (if not fully) under the influence of 
 mercury ; the father very slightly affected. 
 
 They now introduced to me another patient, a young country 
 girl, about thirteen years of age ; she is their servant, and has 
 had very much the care of the child. She has a superficial 
 white ulceration of the throat, stretching low down on the 
 right arch and tonsil ; the body and limbs covered with an 
 eruption of copper-coloured spots, very thickly set; on the 
 legs these spots are smaller, and of a much darker hue ; on the 
 thighs they are larger, and more distinctly of the copper hue ; 
 she has no soreness or ulceration about the anus or pudenda. 
 Sumat Pil. Hydr. gr. iv. mane nocteque. 
 
 Neither eruption, ulcer, nor any other symptom, is discover- 
 able in the mother. 
 
 October 2nd. The eruption on the child is scarcely visible ; 
 ulcers of the mouth healed ; the skin of each buttock, close to 
 the anus, is superficially ulcerated, presenting pretty strong 
 characters of venereal ulcers. 
 
 The servant girl is affected by the mercury ; eruption faded 
 a good deal ; throat free from ulcers, but those ' spots which 
 had been ulcerated retain too high a colour. She now com- 
 plains of a superficial but venereal-looking ulcer, which 
 occupies the adjacent sides of the third and fourth toes. 
 
 December 12th. The child is now free from every symptom 
 except the ulcers at the anus ; these appear very little im- 
 proved, but they do not give much uneasiness ; the marks of 
 the eruption are still of too high a colour. Lotio nigra ulceribus 
 apud anum. Sumat Hydr. c. Greta gr. ij. alternis noct. 
 
 The servant girl appears quite free from disease ; the ulcers 
 of the throat, and that of the toes, have healed ; both she and 
 
278 SYPHILIS IN INFANTS. 
 
 the mother of the child have had their mouths smartly affected 
 with mercury for the last six or seven weeks. 
 
 The father's system has been, in a slighter degree, under 
 the influence of mercury for ten weeks past ; I have therefore 
 concluded that the parents and servant are well, and have 
 desired the mercury to be discontinued. 
 
 May 16th, 1835. The father informs me that his wife and 
 the servant maid are both well, and have not had any return 
 of the symptoms. 
 
 The child was weaned a month ago ; it appears in excel- 
 lent general health, and the ulcer on one side of the anus is 
 healed, the other is still very little improved. I^ . Ung. Zinci 
 gss. Ung. Hydi-. Nitr. 5ss, ft. Ung. ulceri applicand. Eepet. 
 Pulv. Hydr. c. Greta alt. noct. 
 
 June 30th. The ulcer of the anus was healed in three weeks 
 by the use of the ointment. The child is in excellent general 
 health, and is now a year and a quarter old. Omitt. medicamenta. 
 
 February 18th, 1836. The child is in excellent health ; no 
 retm'n of any symptom. 
 
 The mother was delivered of a fine child six weeks ago ; the 
 infant continues very healthy. 
 
 In this ease it is perfectly obvious that the servant girl 
 received the infection from the infant ; it would seem to have 
 first affected the mouth and throat. The ulcer between the 
 toes was so strongly marked as a superficial venereal ulcer 
 that I had no hesitation in considering it as part of the same 
 disease ; and here let it be observed that the mother had not 
 in any degree, or in any way, suffered from the disease of the 
 child ; she had not received any infection from her own child, 
 yet the disease was capable of infecting the servant girl. This 
 child's health was in all probability upheld, and the venereal 
 complaints kept at bay, by the medicines which were given to 
 it before the parents brought it to town ; and it is not very 
 unreasonable to suppose that mercury formed one ingredient 
 in its medicines, when we consider how very generally Hydr. 
 c. Greta is given to children. I do not, however, suppose that 
 the apothecary was aware of the real nature of the ease, as he 
 did not even hint any suspicion of this sort to the parents. 
 
 The ulcer near the anus, when it appears in a late stage of 
 
SYPHILIS IN INFANTS. 279 
 
 syphilis of infants, is generally very slow in improving, and 
 requires that the internal use of mercury should be assisted 
 by some stimulating mercurial application locally. Indeed 
 I have some doubts whether this ulcer could be healed by the 
 mere action of mercurial medicines on the general system. 
 
 Michael Swain, set. 60, admitted into No. 3 ward, under Mr. 
 CoUes's care, November 9th, 1829. He states that about ten 
 weeks since a fissure formed in the left angle of the mouth, 
 and at the same time the inside of the lip became excoriated ; 
 since that time the disease has been increasing. At present 
 there is a fissure, with indurated edges, in the part before- 
 mentioned ; the gums are soft and red ; the lower lip, the 
 posterior part of the palate, and the pharynx, are studded over 
 with superficial ulcerations. Between the root of the tongue 
 and the arches of the palate, on the right side, are fissures 
 resembling that in the comer of the mouth ; all these parts 
 are of a bright red colour, spongy-looking, studded with 
 whitish eminences, and harder than natural ; the parts so 
 affected are but slightly painful; the secretion of saliva is 
 profuse, and that fluid is turbid. 
 
 A few days since sores of the same description formed around 
 the verge of the anus. 
 
 He asserts that he had not exposed himself to venereal 
 infection by any illicit intercourse ; but believes that a woman 
 and child, lodging in his family, had the disease, and he and 
 his children used the same spoons with them. He has taken 
 some pills given him by an apothecary, and used a lotion for 
 the mouth, but he is ignorant of the nature of these remedies. 
 
 November 10th. I^. Decocti Hordei gvi. Spt. Terebinth 
 5i. Vitell Ovi. Ft. Gargarisma. 
 
 14. Eepet. Gargarisma. Utatur lotio nigra ulceribus 
 circa anum. 
 
 21st. Ulcers round the anus are nearly well. Eepet. Garg. 
 et lotio. 
 
 27th. Excoriations on the inside of the lips and on the 
 palate are more healed ; the back of the pharynx and side of 
 the tongue are much improved ; those around the anus are 
 quite well. Eepet. Gargarisma. 
 
 December 5th. Nearly well; slight redness of the soft palate 
 
280 SYPHILIS IN INFANTS. 
 
 and pharynx alone existing at present, with very superficial 
 ulcers at the bases of the palatine arches. Eepet. Gargarisma. 
 
 26th. Discharged ; free from all complaints. 
 
 Dorah Swain, set. 10, and Margaret, set. 8, daughters of 
 Michael Swaine, admitted into No. 9 ward on the 18th of 
 November, 1829. Dorah has numerous excoriations on the 
 covering of the hard palate ; the uvula and tonsUs in the 
 same state, the latter organs being much enlarged ; on the 
 dorsum of the tongue, near the base, are two large circular 
 patches, elevated, and much resembHng condylomatous ex- 
 crescences, as they appear near the anus : the pharynx also 
 is excoriated, and covered with viscid matter ; the parts in 
 the immediate vicinity of the sores are of a colour too highly 
 red ; the diseased parts are not very painful ; deglutition is 
 very slightly affected. 
 
 There are several condylomatous excrescences on the inside 
 of the labia pudendi. This girl was attacked with sore throat 
 about one week after her father. Ordered Lotio Nigra. 
 
 Margaret Swaine has large superficial excoriations engaging 
 the posterior part of the dorsum of the tongue, in the centre 
 of which is a slight furrow ; the gum surrounding the last 
 molar tooth in the upper jaw of the right side, and all the 
 soft palate, tonsUs, and pharynx, present an uniform red and 
 excoriated surface ; there are also several ulcerated spots on 
 the inside of the cheeks : she has also condylomatous excres- 
 cences on the inner surface of the labia pudenda. 
 
 Both these children were exposed to the disease in the same 
 manner as the father ; they also used the same remedies. — 
 Extracted from the case books of Stevens's hospital. 
 
 I shall now give the hfstory of this disease spreading through 
 an entire family, all of whom were previously healthy, and to 
 whom the infection was brought by a servant girl, who was 
 dry-nursing a syphilitic infant in another family, the infant 
 having died of the disease. The servant girl was received 
 into Stevens's hospital; and the history of her case and 
 reports of the treatment, are as follow : — 
 
 Margaret O'Eeilley, set. 23, an unmarried country girl, 
 admitted on the 18th of December, 1836, into No. 9 ward, 
 under Mr. Colles. On the right side of each lip, near the 
 
SYPHILIS IN INFANTS. 281 
 
 median line, and within the red border, exists an aphthous- 
 lookiag sore, with a whitish surface, irregtdar edge, and indu- 
 rated base, a little raised above the level of the surrounding 
 parts ; that on the upper is about twice the size of a split pea, 
 while that on the lower is something larger ; they are placed 
 directly opposite each other. At the angle of the mouth is 
 the raised and soft cicatrix of a former ulcer ; on the left side 
 of the tongue, near its apex, there is an oval-shaped ulcer, 
 about the size of a sixpence, possessing the same characters as 
 those on the lips, but the surface appears more elevated, and 
 the upper edge more regular and defined ; she only feels pain 
 in these ulcers while eating, and is not annoyed by a constant 
 flow of saliva into the mouth. The dorsum and remaining 
 sides of the tongue are fissured irregularly where former sores 
 had existed, but which are now healed. Beneath the chia 
 four or five glands can be felt enlarged, firm, but not very 
 hard ; the central one is a little painful when pressed on. 
 Two or three small depressed bluish cicatrices mark the 
 situation of former openings there. She complains of occa- 
 sional pains in the shoulder, which come on accompanied 
 with some stiffness, generally towards evening ; is sometimes 
 affected with paiu in the head, and with pyrosis ; her appetite 
 is good, sleeps well at night, and general health imimpaired ; 
 pulse 86. 
 
 She states that six months since, while nurse-tending a 
 child which had a sore mouth and some spots of eruption on 
 the body, and the nurse of which had a sore on the nipple, 
 she became affected with a sore at the angle of the mouth and 
 inside of the cheek of the left side ; in a fortnight after it 
 began to affect the tongue on the same side, and she has con- 
 tinued to be affected on different parts of the mouth at different 
 periods ; the sores healing up in one place and breaking out 
 in another, but never being completely free from disease since 
 its first commencement. The present sores have existed for 
 the last six weeks, and have never been touched with any 
 caustic applications, which the others had frequently applied 
 to them. The pains in her shoulder came on about three or 
 four weeks ago, accompanied with some soreness of the throat, 
 which she ascribed to cold ; she had also some slight soreness 
 
282 SYPHILIS IN INFANTS. 
 
 about the anus ; the pains were so violent as to prevent her 
 working, but they had remitted a few days before her admission. 
 
 The swellings under the chin have been there these two 
 years past, and did not subside after suppuration had occurred, 
 nor are they larger since the.present disease made its appear- 
 ance. It is worthy of remark that, seven or eight weeks after 
 the commencement of the sores, she went to the house of one 
 of her relatives (Hogarty), and ha^dng remained there for 
 more than a month several of the family caught the disease 
 from her. 
 
 December 20th. The sore on the tongue is much smaller 
 since the last report, and several red patches are appearing 
 through its white surface ; that on the lower Hp has spread 
 in a small patch near the gum. 
 
 26th. The sore on the upper lip has almost healcl ; that 
 on the lower is smaller, except where the new spot had 
 appeared, as mentioned on the 24th. The ulceration on the 
 tongue is now distinctly striated red and white ; had the 
 pains in her shoulder last night. 
 
 March 10th. Ung. Hydr. 5ss. et Pil. Hydr. gr. v. 
 
 19th. Eepet. Eemedia. 
 
 22nd. Eepet. Eemedia. 
 
 26th. Bal. Tep. Ung. Hydr. 5ss. 
 
 29th Eepet. Omnia. 
 
 April 2nd. Ung. Hydr. 5ss. 
 
 5th. Pergat. 
 
 9th. Pergat. 
 
 12th. Olei Eicini gss. c. Tinct. Opii. gtt. xx. Pulv. Dover, 
 gr. X. 
 
 16th. Vesicatorium Nuchse. Pulv. Dover, gr. x. 
 
 19th. Bal. Tep. Mist. Purg. 
 
 26th. Nitratis Potassae gr. x. ter in die. 
 
 30th. Mist. Purg. 
 
 May 3rd. Bal. Tep. Mist. Purg. 
 
 14th. Gargarisma Astr. 
 
 Discharged on the 22nd of May cured. 
 
 In this case a variety of remedies were used before recourse 
 was had to mercury ; and she passed through a severe and 
 tedious fever, shortly after her admission into the hospital. 
 
SYPHILIS IN INFANTS. 283 
 
 If we attend carefully to the history and to the course of 
 this case, we cannot but be convinced of the greater danger of 
 infection which those run who are exposed to contact with that 
 person who is only one degree removed from the infected child. 
 
 Hogarty and Family. 
 
 December 15th, 1835. The disease was most positively 
 introduced into this family by the servant girl, Margaret 
 O'Eeilley, who was hired to dry-nurse the youngest child 
 while weaning. The mother asserts that this girl when she 
 came to live with her had (in addition to the symptoms men- 
 tioned in O'Eeilley's case) sores on the pudenda, similar to 
 those on the inside of the lips. 
 
 The infant is reported to have taken the infection first in its 
 mouth ; after some few weeks it appeared on the genitals. 
 Next the mother took it ; in her it appeared first in the mouth 
 and then in the genitals ; she says that in the latter situation 
 it appeared like small buttons. The genitals are now free 
 from any appearance of it, but she has a patch of superficial 
 ulceration, accompanied with a slight swelling, on the inside 
 of the lower lip, a superficial ulcer at each angle of the mouth, 
 and two white ulcers, or rather blisters, under the apex of the 
 tongue. 
 
 The daughter, twelve years old, had it first on her mouth, 
 where now only a too high state of redness is to be seen. Her 
 mother said that it was on the pudenda of the daughter, but 
 on examination I could only discover on the external labium 
 one raised spot, exactly resembling the cicatrix formed by 
 button scurvy. 
 
 The father says it first appeared on him as a sore on the 
 penis ; this has healed without leaving any mark : it next 
 appeared at the anus : at present there is on each side of the 
 groove leading to the anus two small circular copper-coloured 
 spots ; the surfaces of these are constantly moist, yet one only 
 of them can be said to be ulcerated ; on the under-surface of 
 the tongue, near to its apex, is a small white raised spot ; 
 on the right anterior arch of the palate is a superficial white 
 ulceration, or rather rugose patch ; a long white ulcer is seen 
 on the inner surface of the right cheek. 
 
284 SYPHILIS IN INFANTS. 
 
 I directed each of the females to take Pil. Hydr. gr. v. om. 
 nocte, and the father to take a similar dose night and morning. 
 
 February 8th, 1836. None of the family used the medicine 
 for a longer period than three or four days. They have now 
 come into town (a distance of seven or eight miles), and their 
 present symptoms are — 
 
 The father : the small ulcers on each side of the anus are 
 as described on the 15th of December last ; on the right tonsil 
 is a distinct ulcer, not deep ; on the left anterior arch is a 
 pretty broad excoriation ; a superficial ulcer on the red border 
 of the lip. 
 
 Wife : her symptoms have scarcely altered since December ; 
 so little that the difference could not be described by words. 
 
 The daughter has now no trace of it in the mouth, but she 
 has a slight swelling, with superficial ulceration, on the labia 
 pudendi and on the preputium of the clitoris. 
 
 One spot on the mother's lip is exactly the same as the spot 
 on the lip of the servant girl O'Eeilley. 
 
 I rubbed Sulph. Cupri to the diseased spots in the mouth of 
 the mother, and gave a wash of Acet. Cupri to be applied to 
 the ulcers at the anus of the husband and the pudenda of the 
 daughter. 
 
 September 22nd, 1836. Father — general health very good '> 
 his mouth is well, except one white spot on the right side of 
 the tongue. 
 
 The mother says that she had an ulcer on the inside of the 
 lower lip for five months previously to her confinement, but that 
 since that occurrence she has been well, and now nurses her 
 infant. The infant is three months old and perfectly free from 
 any symptom of the disease. 
 
 The daughter died a fortnight ago of scarlatina; I am 
 informed by her mother that she had one sore spot in her 
 mouth at the time she was seized with scarlatina. 
 
 The child, which was the first of the family infected, was 
 brought to me this day. It is now three years old, and, 
 apparently, in robust health. It was one year and four 
 months old when it was first infected, the disease commencing 
 in its mouth and throat. 
 
 I have had an opportunity of seeing the members of this 
 
SYPHILIS IN INFANTS. 285 
 
 family to-day, not because they wished to consult me on 
 account of this extraordinary disease with which so many of 
 its members had been afHicted, but that I should prescribe for 
 the father, who had received a very slight wound of the 
 cornea from a splinter of stone which struck it while he was 
 at his work of a stone-mason. The family living at the 
 distance of seven or eight miles from Dublin, and being poor, 
 could not be induced to come into Dublin more frequently 
 than above represented ; of course I had no opportunity of 
 watching the effects of remedies, and I wished rather to watch 
 the progress of the disease undisturbed by treatment than to 
 direct any particular plan which I well knew would not (and , 
 indeed, could not) be followed with punctuality by persons in 
 their condition. Their sufferings were not so severe as to 
 oblige them to seek for admission into an hospital. The 
 small quantity of mercury which any one of them used was so 
 very inconsiderable that it may be left out of the account 
 altogetlier. 
 
 The history of this disease, propagated by an infected 
 infant, would be incomplete if I did not add that sometimes 
 one or more of the soft raised ulcers will be found in the 
 axillae, and occasionally, though more rarely, in the folds of 
 the groin. 
 
 That this disease is derived from lues venerea, I think has 
 been clearly shown ; and yet it does not in every respect 
 resemble the lues of adults, but possesses some characters 
 peculiar to itself. And, first, it appears to be infinitely more 
 contagious ; for very rarely do any escape who are for a short 
 time exposed to its infection; this is not the case with the 
 syphilis of adults, for we know that very frequently men 
 escape, though exposed to infection under circumstances cal- 
 culated to render the parts highly susceptible, and to facilitate 
 the introduction of the poison. And here I would remark, 
 that in the very remote parts of Ireland the poor people are 
 so strongly impressed with the notion of the very infectious 
 nature of the venereal disease, that if they be told that a 
 stranger whom they had lodged in their house for a night had 
 this disease, they would instantly burn the straw seat upon 
 which he had been sitting. I may be told by some that men 
 
286 SYPHILIS IN INf'ANTS. 
 
 may contract syphilis by sitting in a public privy ; to this I 
 can only answer that I have never witnessed a single instance ; 
 nor did the late Mr. Obre, who had been for many years most 
 extensively engaged in treating the venereal disease ; for on 
 asking him if he believed that the disease was propagated in 
 this manner, he shrewdly answered, that it sometimes was 
 the manner in which married men contracted it, but unmarried 
 men never caught it in this manner. 
 
 Secondly. The symptoms of this disease bear a most exact 
 resemblance to each other, in every individual affected by it ; 
 neither age nor sex, nor difference of temperament, seem to 
 make it differ in its characters, even though it may have 
 existed for some months. Now we know that syphilis in 
 adults is subject to very considerable varieties, modified 
 perhaps by peculiarity of constitutions ; ex. gr., the various 
 forms of eruption, the great varieties in venereal ulcers of the 
 throat, &c., &c. 
 
 Thirdly. This disease, in the third remove from the 
 original syphilitic infection, appears to be permanently fixed 
 to the parts it first seizes, and to be of a much milder nature 
 than the corresponding symptoms of pure syphilis. Thus we 
 do not find that in the throat it ever assumes that destructive 
 form of ulceration which too often attends venereal sore 
 throat of adults. I have never yet seen an instance of loss of 
 substance caused by this disease, even though it may have 
 existed for more than twelve months. 
 
 Again : I have never seen this disease produce ozssna or 
 iritis ; I have not known it in any case affect the bones or 
 joints ; nor, in men, affect the testes. 
 
 Fourthly. This disease appears to become less virulent as 
 it becomes farther removed from the fountain head ; of this 
 we become assured, by observing the greater facility with 
 which the cases of more remote infection are cm-ed. Thus 
 we find that when the disease originates with the infant, the 
 use of mercury is absolutely necessary for the cure of the 
 infant ; unless this be employed, the child dies The nurse 
 infected by this child must undergo a course of mercury for 
 the cure of her symptoms ; the husband also must undergo a 
 mercurial course, to effect a cm-e of his symptoms. Such of 
 
SYPHILIS IN INFANTS. 287 
 
 the attendants as contract the disease by immediate and 
 direct contact with the ulcers of the child will also require 
 mercury for their cure. But such other members of the 
 family as receive the infection from the attendant thus 
 affected, these may all dispense with the use of mercury. 
 These positions are many of them borne out by the history of 
 Hogarty's family; for the servant-giii, O'Eeilley, who was 
 infected directly by the diseased infant which died, could not 
 be cured without mercury. The length of time that she 
 remained in the hospital, and the number and variety of other 
 medicines which she in vain employed, are sufiicient to 
 establish this fact. Nor was the disease removed, even tem- 
 porarily, by a very smart attack of fever, which continued for 
 three weeks and upwards. Yet neither Hogarty's child, which 
 was contaminated by this servant-girl, nor his wife, who 
 received the infection from her own infant, required mercury 
 to cure them ; the infant appeared to have been cured by a 
 medical practitioner in their neighboui-hood, who employed 
 washes of different kinds, and a few j)Owders internally. The 
 disease of the mother seems to have been eradicated by par- 
 turition, although it had resisted various local applications 
 irregularly employed, and had continued to afflict her for a 
 period of many weeks. The disease of the father may be 
 considered as cured, as he had only one small white spot on 
 the tongue. 
 
 One fact well deserving our attention is this : that a child 
 born of a mother who is without any obvious venereal 
 symptoms, and which, without being exposed to any infection 
 subsequent to its birth, shows this disease when a few weeks 
 old ; this child will infect the most healthy nurse, whether she 
 suckle it or merely handle and dress it ; and yet this child is 
 never known to infect its own mother, even though she suckle 
 it while it has venereal ulcers of the lips and tongue. 
 
 The foregoing chapter will be admitted to be one of the most valuable 
 as regards original observation in CoUes's work. In it he — 
 
 1st. " Bstabhshes the opinion that secondary symptoms are capable of 
 propagating the venereal disease." 
 
 2ndly. While showing that a child may receive the infection of syphihs 
 " by sucking a nurse affected with secondary symptoms of syphilis, he 
 
288 SYPHILIS IN INFANTS. 
 
 cannot recollect an instance in wliicli the diseased nurse infected the 
 child, unless she had an ulceration of the nipple." 
 
 3rdly. It is iq this chapter that he more than once very clearly 
 announces the fact which is in truth the basis of the important generali- 
 zation which Mr. Jonathan Hutchinson has very well named " OoUes's 
 law." 
 
 His observations go to show that those who have once suffered from 
 syphilis have raore or less immunity from the disease afterwards. But 
 more than this, he adduces facts which lead to the belief that when a 
 mother acquires syphUis by blood contagion from the foetus, she gains 
 an immunity without suffering herself from any severe form of disease. 
 
 As regards the former of these propositions we have the following 
 remarkable pronouncement : — 
 
 He states a fact which has been forced on his observation by more than 
 five or six instances — namely, that a newly married man, admitting that 
 he has had syphilis within nine months before, yet who is himself free 
 from every appearance of syphilis and every other disease, shall yet infect 
 his wife in such a manner that secondary symptoms shall appear in her 
 in a few months after marriage, and these not preceded by any primary 
 symptoms. And although among these secondary symptoms some 
 raised ulcers shall fix on the external pudenda of the wife, yet the hus- 
 band shall very ra/rely suffer in any manner from these. 
 
 As regards the immunity of the mother, he says : — " The following 
 fact appears to me very deserving of notice : I have never seen or heard 
 of a single instance in which a syphilitic infant (although its mouth be 
 ulcerated), suckled by its own mother, had produced ulceration of her 
 breasts ; whei'eas very few instances have occurred where a syphiUtic 
 infant had not infected a strange hii-ed wet-nurse, and who had been 
 previously in good health. 
 
 " It is a curious fact that I have never witnessed nor ever heard of an 
 instance in which a ohUd, deriving the infection of syphiUs from its 
 parents, has caused an ulceration in the breast of its mother.'' 
 
 The concluding paragraph of this remarkable chapter reiterates the 
 same statement even more strongly, with the addition of the fact, the 
 importance of which is so justly dwelt on by Mr. Jonathan Hutchinson, 
 that the mother may all the while be without any obvious venereal 
 symptoms. 
 
 In order to give their true value to these observations of OoUes, we 
 must carry ourselves back to the period at which he wrote. We must 
 remember that Hunter had denied the contagious character of secondary 
 lesions, that Ricord still in a great degree upheld the doctrine of Hunter 
 on this subject, and that the results of the unjustifiable inoculations of 
 Wallace were as yet unpublished or little known. 
 
 That neither the husband who had had syphilis got it back again from 
 his wife, nor the mother from her own child, although the wet-nurse 
 became infected by the same child, seem justly to be regarded as the 
 
SYPHILIS IN INFANTS. 289 
 
 great fundamental observations on wMoli is based the dogma that as a 
 rule syphilis " is not doubled " — is not taken a second time by the same 
 individual. 
 
 Lastly. There is reason to beheve that a mother may become diseased 
 by infection from the foetus without the intervention of any chancre, and 
 without the appearance of any symptom recognisable as secondary 
 syphilis. Yet such a mother may give birth to a child, itself infected 
 with syphilis, capable of infecting the wet-nurse, its own mother having 
 gained. an exemption from the possibility of infection. 
 
 I am not acquainted with any observer who has so fully laid hold of 
 the importance of these facts as Mr. Jonathan Hutchinson. 
 
 I may be allowed, therefore, to give his views in his own words : — 
 
 " If," he says, " Colles's law be one which has no exceptions, it follows 
 that all women who bear syphilitic children contract syphihs ; for how 
 else can they obtain immunity ? And, since it is notorious that women 
 under such circumstances scarcely ever show secondary symptoms, it 
 follows, further, that we have here a form of syphilis which is protective, 
 but which is unattended by any cutaneous outbreak. Thus, syphilis 
 acquired by blood-contagion from the foetus would appear to be, for the 
 mother, a parallel with vaccination in regard to smallpox : she gains 
 immunity without suffering from any severe form of disease. The 
 botanist will at once suggest that probably in both cases the explanation 
 is to be found in heteromorphism or alternation of generations on the 
 part of the fungus. To him the clinicist might aptly rejoin, that really one 
 might almost have expected it ; for, when the mother gets syphihs from 
 the foetus, she obtains it from fluids in which the plant-life is evidently 
 under some very special restraint ; for in the foetus itself, as a rule, no 
 development of it takes place during the nine months of intra-uterine 
 life. We have only to suppose that the same condition of the yeast which 
 existed in the foetus is perpetuated in the mother, and the thing is done. 
 "We had no right to suppose that infection by inoculation of soUds (or 
 chancre-contagion) would be exactly the same in its results as direct 
 imbibition by the blood. 
 
 " As we may call vaccination developed yet protective variola, so we may 
 consider syphilis, derived from the foetus, as an undeveloped yet protective 
 form of that disease ; and we have here another most interesting point of 
 analogy between syphilis and the exanthems. 
 
 " Before, however, we accept as probable such a possibihty as that just 
 hinted at, it is desirable to look at the facts with the utmost incredulity. 
 Let us doubt unsparingly at every stage of the reasoning. First, is Colles's 
 law true ? I cannot see any escape from the conclusion that it is. It 
 was announced in 1837, and has received, I believe, the assent of every 
 authority who has written on the subject since. It has attracted attention 
 both at home and abroad, and I am not aware that a single exception to 
 it has been recorded. We have all of us seen chancres on the nipples, of 
 wet-nurses. They are, indeed, not very infrequent. We have, however, 
 
 U 
 
290 SYPHILIS IN INFANTS. 
 
 none of us seen such on those of the mothers of infected children. Let 
 us remember that it is very unusual to put a syphilitic infant out to wet- 
 nurse, — a thing which no prudent surgeon would ever permit, — and that, 
 probably, for one so nursed a hundred are suckled by their mothers ; and 
 we shall appreciate the weight with which this entire absence of proof 
 that mothers ever suffer bears. It amounts, I think, to all but proof that 
 they are absolutely insusceptible. It is as strong in that direction as is 
 the rarity of smallpox within short intervals after successful vaccination. 
 We must remember also that these mothers of syphilitic infants not 
 only suckle them, but handle them, dress their sores, and in various 
 ways through long periods expose themselves to risk. If it be granted 
 tliat it is proved that these mothers — a very numerous class — ^liave really 
 in some way had syphilis and acquired immunity, I do not think there 
 can be much dispute as to the next fact, that they do not during preg- 
 nancy show any of the usual symptoms of the disease in its secondary 
 stage. This is a matter of evei-yday experience. There remains, how- 
 ever, the possibility that the syphilis may have been gone through prior 
 to pregnancy ; and I am well aware that the few remaining writers who 
 teach that syphilis can be inherited only from the mother will hail this 
 confirmation of CoUes's law as a strong support for their opinions. Here, 
 however, again I must appeal to everyday experience. Is it not the fact 
 that women bear syphihtic children without having ever themselves, 
 either before or during pregnancy, had any symptoms, either primary or 
 secondary, of that disease ? If this happened only once or twice, we 
 might reasonably doubt the histories given us. But it is not so ; it is 
 in hundreds of cases ; and few, I think, of much experience, can doubt 
 that, as a rule, syphilis is inherited from the father ; and that the mother 
 never shows any external signs of the malady.'' 
 
291 
 
 CHAPTEE XVI. 
 
 PSEUDO SYPHILIS. 
 
 There is no class of complaints in which we may not 
 occasionally meet with instances in which the distinctive 
 characters of the disease are but faintly marked, and in which 
 the symptoms of some other disease are more or less closely 
 imitated. The venereal disease does not form an exception to 
 this assertion ; on the contrary, it is among those which are 
 most subject to this irregularity ; and this remark applies to 
 each symptom separately, as well as to the combination and 
 to the order of succession of its symptoms. 
 
 In the present state of our knowledge I think it is impos- 
 sible to lay down any rules by which our judgment can be 
 correctly guided in deciding on the nature of those simulating 
 cases ; for surgeons now no longer acquiesce in the opinion of 
 Mr. Hunter, page 439 : " The venereal matter, when taken 
 into the constitution, produces an irritation which is capable 
 of being continued independent of a continuance of absorption, 
 and the constitution has no power of relief ; therefore a lues 
 venerea continues to increase. This circumstance is perhaps 
 one of the best distinguishing marks of the lues venerea, for 
 in its ulcers and blotches it is often imitated by other diseases, 
 which, not having this property, will therefore heal, and 
 break out again in some other part. Diseases in which this 
 happens show themselves not to be venereal; however, we 
 are not to conclude, because they do not heal of themselves, 
 and give way only to mercury, that therefore they are 
 venereal, although this circumstance, joined to others, gives a 
 strong suspicion of their being such." Nor do surgeons agree 
 with Mr. Abernethy, in admitting that those simulating 
 diseases are not venereal, "because they got well without 
 mercury." On the contrary, I should think that there are 
 few surgeons of the present day, who have read the statements 
 published by several military surgeons of Great Britain, of the 
 
292 PSEUDO SYPHILIS. 
 
 appearance and progress of syphilis as it appeared in the late 
 Peninsular war, who do not believe that the symptoms of 
 syphilis occasionally disappear without the use of mercury ; 
 and there is no surgeon extensively engaged in this branch of 
 the profession who has not ia his own practice repeatedly 
 observed that the venereal disease, both in its primary and 
 secondary forms, will sometimes be made worse by the use of 
 mercury, and yet at some future period this very same ease 
 will yield to and be cured by mercury, and by mercury alone. 
 We now no longer entertain the opinion that mercury is a test 
 of the syphilitic or the non- syphilitic nature of any particular 
 case. I think that, in deciding on primary ulcers, there is 
 one source of doubt and difficulty very deserviug of attention, 
 and yet it is one which I believe has been very generally over- 
 looked ; I mean the discharge from those excrescences on the 
 genitals of females which attend on venereal eruptions, and 
 on some forms of venereal sore throat. This discharge is 
 capable of producing an ulcer on the genitals of the male ; 
 and this ulcer, though in appearance and character very 
 unlike the true chancre, is yet capable of contaminating the 
 general system, and of inducing secondary venereal symptoms. 
 The confusion which may arise from our overlooking this fact 
 does not stop here ; for by watching the progress of the 
 secondary symptoms consequent on this form of primary 
 ulcer, we shall soon discover that these also differ, in many 
 material points, from the corresponding secondary symptoms 
 which follow an Hunterian or a true venereal chancre. By 
 referring to the chapter on the Syphilis of Infants we shall 
 see these positions clearly illustrated and amply proved. 
 
 The next circumstance which tends to embarrass our judg- 
 ments, in deciding as to the true nature of primary symptoms, 
 is the variety in the effects of mercury, according to the 
 manner in which it has been employed, and according to the 
 influence which it has exerted on the constitution. Ihus the 
 appearances exhibited by a chancre or bubo, when mercm-y 
 has been administered in doses so large as to have induced a 
 general febrile irritation, will be very different from those 
 changes which a legitimate ptyalism will effect. And even the 
 appearance produced by this injudicious exhibition of mercury 
 
PSEUDO SYPHILIS. 293 
 
 will be different, according as this medicine has been early 
 discontinued or has been obstinately persevered in for a 
 length of time. I believe few will hesitate to admit that inor- 
 dinate and unsuitably large doses of mercury alter the appear- 
 ance of primary symptoms, and often derange the succession 
 of the secondary. But I fancy it is not so generally known 
 that moderate and suitable doses of mercury may be mis- 
 managed, so as to be productive of less serious mischief to the 
 system in general, but of equal or even greater perplexity to 
 the surgeon who is to decide on the nature of local symptoms. 
 I mean when these moderate doses have been so employed 
 that the patient was made to desist from their use the moment 
 even a slight approach to ptyalism was perceptible, and was 
 desired to resume them again when all tendency to ptyalism 
 had subsided ; when by repeatedly resuming and relin- 
 quishing mercury, without allowing it ever to act on the 
 salivary organs, the general system comes to be irritated into 
 a sharp degree of fever, and to be acted on by mercury as if 
 by a poison. I imagine that many surgeons indulge the hope 
 that moderate doses of mercury can do no harm ; but they 
 do not seem aware that when employed in this very timid 
 manner it may alter materially, though not cure, the 
 symptoms ; and may as completely, though more slowly, 
 break down the constitution, as when it is^ exhibited in ex- 
 cessive doses and for a shorter period. This error in the 
 administration of mercury I look upon as a very fertile source 
 of those derangements or irregularities in the appearance and 
 in the order of succession of the various symptoms of the 
 venereal disease. 
 
 Now, while I admit that some ulcers of the genitals and 
 some affections of the inguinal glands are occasionally met 
 with, which, though not venereal, yet strongly resemble the 
 primary symptoms of that disease ; and while I freely declare 
 that I have repeatedly met with a combination of symptoms 
 which were with difficulty to be distinguished from secondary 
 venereal symptoms, yet I cannot believe that the number of 
 those diseases which resemble or simulate syphilis is so great 
 as many authors would lead us to suppose. And, indeed, I 
 must say that the attempt to form a new class of diseases, 
 
294 PSEUDO SYPHILIS. 
 
 designated " Pseudo Syphilis " or " Cachexia Syphilitica," has 
 only tended to embarrass our practice and to divert our 
 attention from the real causes of those irregularities. Instead, 
 therefore, of any attempt to point out the distinctive characters 
 whereby we are to discriminate between the true syphUitic 
 and the pseudo syphilitic case, I should rather recommend 
 to apply ourselves sedulously to search out the natm-al history 
 of the venereal disease, and to become acquainted with all 
 those (probably minute) circumstances which influence the 
 effect of mercury on the general system, and on the particular 
 symptoms of the venereal disease. In the meantime, I do 
 not apprehend that much mischief is likely to arise from our 
 occasionally treating as venereal another disease resembling 
 it, provided that the mercury be given with due caution, and 
 regulated by sound judgment. Mr. Abernethy nimself makes 
 the following admission : — " The effect of exciting a mercurial 
 affection of the constitution in diseases resembling syphilis is, 
 as far as my observation enables me to determine, very 
 various. It sometimes cures them very suddenly, and very 
 differently from the gradual amendment which it produces in 
 truly venereal diseases. Sometimes, however, these diseases 
 yield more slowly to its operation, and are cured permanently. 
 Sometimes the diseases recur in the same parts, after a severe 
 course of mercury; sometimes mercury merely checks the 
 disease, and can scarcely be said to cui-e it ; in which case it 
 seems important to support the strength of the constitution, 
 and to keep up that mercurial effect which controls the 
 disease, and can be borne without material derangement of 
 the constitution for a great length of time. Sometimes, also, 
 the use of mercury aggravates these diseases." 
 
 Now it appears to me that, unless in some few instances 
 which involve the moral character of the patient, it is not 
 material by what designation we mark the disease, provided 
 that we do but cure it. The patient will not be the less 
 grateful for the favour; though his disease may have been 
 misnamed, he will be quite satisfied if it have not been mis- 
 managed. I suspect that a frequent cause of our failures in 
 the treatment of such cases, — whether those broken down cases 
 of syphilis with their distinctive characters very much 
 
PSBUDO SYPHILIS. 295 
 
 impaired, or those cases of general cachexia which assume some 
 characters of syphilis, — I say the cause of our failing to cure 
 such has been an over-anxiety to push the mercury to such 
 an extent as to afford a security against a return of symptoms 
 which had previously eluded the action of this medicine. If 
 we lay it down as a rule of practice in such cases to use mer- 
 cnry in very moderate doses, suited to the condition of the 
 general health, and to support the strength of the patient 
 during the influence of a mild ptyalism, I imagine that our 
 success in these hitherto deplorable cases will be most grati- 
 fying; and, assuredly, by such a line of conduct we shall 
 avoid all those mischiefs and dangers which have followed in 
 such cases from the too large use of mercury. 
 
 Prom the records of the hospital I shall extract the fol- 
 lowing case, which is headed " Cachexia Syphiloidea " by the 
 clinical clerk, a young but a very intelligent surgeon. 
 
 Anthony Brady, set. 32, a shoemaker, greatly emaciated, 
 admitted into No. 3 ward, 12th of December, 1835. 
 
 He states that he was first subject to the influence of mer- 
 cury eleven years ago for the cure of a gonorrhoea ; and again, 
 three months afterwards, for a bubo, unaccompanied by any 
 sore on the penis. 
 
 Ten years since he contracted an ulcer on the penis, 
 together with a gonorrhoea, for which he was salivated : the 
 sore had scarcely healed when he was attacked with pains in 
 the larger joints, followed by emaciation, febrile symptoms, 
 and an eruption of pustules, which degenerated into small 
 ulcers covered with scabs. He was now admitted, for the first 
 time, into a London hospital, where he again used mercury ; 
 the spots of eruption healed ; their white and smooth cicatrices 
 are still evident on the face and arms. He left the hospital of 
 his own accord two months from the time of his admission, 
 and returned again with a second eruption of the same kind, 
 and more debilitated than ever ; one of the spots in each ham 
 assumed the phagsedenio character, became larger than any 
 of the others, and were very painful; but he got rid of all 
 these symptoms in nine weeks, without his mouth having 
 been affected by mercury. Pains in his joints were now the 
 only symptoms remaining, which continued to affect him for 
 
296 PSETJDO SYPHILIS. 
 
 a year and a half; -when, after exposure to cold, lie was 
 attacked with iritis of the left eye, was admitted into the 
 hospital, and again salivated. About the same period the 
 right testicle began to enlarge, became very hard, but not 
 painful : the treatment not seeming to produce any good 
 effect, he was recommended to have it removed ; but before 
 he was strong enough to bear the operation, an abscess formed 
 in its substance, which was opened, and a fungus soon after 
 protruded, but was removed by caustic applications and 
 alterative doses of mercury. He was discharged, to go to the 
 country, three months from the date of his admission, the 
 testicle remaining enlarged, and the situation of the fungus 
 not quite healed. The ulcer, however, soon after cicatrized, 
 and the testicle finally wasted away to its present size. He 
 returned again in six months afterwards, with pains in his 
 bones, and nodes on his forehead and shins, and two spots of 
 phagsedenic venereal eruption on the hip and thigh of the left 
 side ; he also had sore throat and ozcena. The node on the 
 forehead was opened ; no bit of bone ever came away from it, 
 though a depression exists there, marking the loss of sub- 
 stance. He had exfoliations from both tibite, and lost several 
 of the nasal bones and the greater part of the septum. 
 
 His mouth was made sore twice while he remained in the 
 hospital, from which he was discharged one year and nine 
 months from the time of his admission ; and the ulcers on his 
 legs, where the bone had exfoliated, were not yet healed. 
 
 It is now six years since that time. Debility, emaciation, 
 night-sweats, pains, and loss of rest, were then his principal 
 symptoms ; for which latter he was obliged to take laudanum 
 to procure sleep, and which he has continued to do ever since. 
 When he went to the country he became somewhat stronger, 
 and gained flesh ; the pains, however, continued ; his knees 
 became stiff, so that they were kept constantly in the semi- 
 flexed position, and a year afterwards he was admitted into 
 another hospital, where, after remaining in bed for three 
 months, and using some medicine which did not affect his 
 mouth, he was again able to move about. The ulcer on the 
 right leg was also healed, but broke out again immediately on 
 getting up; some swelling, which had existed in the right 
 
PSEUDO SYPHILIS. 297 
 
 knee, had likewise disappeared. Prom this time, though not 
 quite free from the pains, he was able to move about, and 
 work at his trade, until about six months ago, when he got 
 cold, and the pains were increased, which have ever since 
 kept him almost constantly confined to bed. He accidentally 
 hurt the left testicle about four months ago, which became 
 swollen and painful soon after ; the pain subsided, but the 
 enlargement continued to increase. 
 
 His knees have again become stiff these last three months, 
 and his body more emaciated than ever. 
 
 The left testicle and epidydimis, which can no longer be felt 
 distinct, are enlarged to the size and shape of a turkey's egg, 
 even and uniform on the surface ; they have a firm and solid 
 feel posteriorly, while anteriorly the swelling is tense and 
 elastic ; there is some effusion into the tunica vaginalis, but 
 not in sufficient quantity to render the tumour transparent. 
 He has not the least pain in the testis, but he feels a sensation 
 of weakness in his loins when it is allowed to hang. The 
 spermatic chord is very slightly enlarged; the vas deferens 
 possesses its natural size ; the scrotum moves freely over the 
 testicle, and is not discoloured. The opposite testicle is only 
 half its original- size. 
 
 The liver appears to be enlarged, but from the tense state 
 of his abdominal muscles it is impossible to examine it 
 accurately with the hand. There is also an enlargement of 
 the glands of the groin, but none of those of the axilla or 
 neck. 
 
 He has pains in his shoulders and knees, which latter are 
 kept permanently semiflexed, and cannot be extended; the 
 left one is very tender to the touch, with some effusion into the 
 joint. The ulcers on the legs, where the bone exfoliated, 
 present a very irregular appearance ; that on the right leg is 
 situated at its upper and outer part, sinks between the bones, 
 ,its margins are uneven and of a purplish colour, and its 
 surface covered in some places with a whitish matter that 
 cannot be wiped off. That on the opposite limb is lower 
 down, smaller, and deeper, and a probe, passed to its bottom, 
 detects a portion of the bone to be in a carious state. A soft 
 node exists above the outer ankle of this side. The legs are 
 
298 PSEUDO SYPHILIS. 
 
 attenuated to the last degree, not the slightest appearance of 
 the calf; they certainly answer to the description of being 
 only skin and bone. 
 
 He complains of languor, debility, and constant lowness of 
 spirits ; his sleep is broken and disturbed, scarcely ever more 
 than two hours at a time, though to procure it he is obliged 
 to take half an ounce of laudanum every night ; and, when 
 omitted, his condition is most miserable and the pains are 
 dreadfully severe. His appetite is bad, tongue clean, and 
 bowels regular ; pulse 76, soft, and weak. He complains of 
 an occasional fluttering about his heart and coldness of his 
 extremities, especially if he did not take his usual dose of 
 opium ; the sounds of the heart are however perfectly healthy. 
 No perspirations at night. 
 
 Soon after his admission he was put on hydriodate of 
 potash, which was stopped in consequence of its disagreeing 
 with the stomach and bowels. Since that time he has been 
 taking sarsaparilla and quinine. 
 
 February 13th, 1836. Appetite has improved, but he has 
 not gained flesh or strength since admission ; the pains in his 
 shoulders have disappeared, but are still present in the knee- 
 joints at night ; the fluid effused into the right one has been 
 absorbed. 
 
 The dose of tincture of opium has been dimished to three 
 drachms every night. Pergat cum Quinse Sulph. Vini Bubri 
 §iv. o. d. 
 
 February 22nd. No further change; the soft node has 
 disappeared. Ung. Hyd. gr. x. o. n. genibus affricanda. 
 
 28th. Has rubbed in five times; pains in the knees are 
 somewhat better, and he is able to extend them a little. 
 Pulse 80 ; other symptoms continue. Pergat. 
 
 March 6th. His mouth is beginning to be affected by the 
 mercury ; the pains in his knees have disappeared, and he is 
 able to stretch them further than at the last report. The 
 ulcer on the left leg has assumed the healing aspect, and its 
 surface is clean and granular ; the one on the opposite limb 
 still presents a whitish sm-face. The effusion into the tunica 
 vaginalis is less, and the testicle is smaller; appetite im- 
 proved; bowels regular; pulse 84. The dose of tincture of 
 
PSEXJDO SYPHILIS. 299 
 
 opium has been diminished to two drachms every night. 
 Pergat. 
 
 8th. Mouth sore. Omitt. Ung. Hyd. 
 
 10th. The saHvation continues; he feels much stronger; 
 he is now able to extend the knees better, but not yet perfectly; 
 the fluttering at his heart has disappeared; the swelling of 
 the testicle has decreased ; he sleeps better at night ; pulse 84. 
 Simple dressing to ulcers. 
 
 15th. The ulcer on the right leg is almost healed ; that on 
 the left has extended, and its surface is whitish; discharge 
 thin, and in some quantity ; he sometimes feels stings of pain 
 in it. His appetite is now good; pulse 88; strength in- 
 creasing. Tinct. Opii 5ss. o. n. 
 
 18th. The sore on the left leg has improved in appearance, 
 is red and granular, and discharges healthy pus. He looks 
 much better, and is beginning to gain flesh. Pergat et Lotio 
 Nigra Ulceri, et Tinct. Opii 5iss. om nocte. 
 
 25th. Sulph. Quinse gr. ij. ter in die, Tinct. Opii 5j. o. n. 
 
 April 2nd. He has gained flesh and become much stronger 
 since last report ; his appetite is very good ; he has no pains, 
 and he sleeps almost as well, after taking 5ss. of tincture of 
 opium at night, as he did before when his usual dose was half 
 an ounce, but is very easily awakened; tongue clean; pulse 84. 
 
 The ulceration on the left leg is beginning to fill up with 
 granulations, and is now not larger than a sixpence; the 
 discharge from it is diminished ; the one on the opposite limb 
 has healed. 
 
 He is not yet able fully to extend the legs, nor can he bear 
 on them from weakness ; he feels no pain in the knees, but is 
 often annoyed at night with starting in them, extending down 
 to the soles of the feet. He now walks about the ward with 
 the help of a walking-stick. 
 
 The left testicle is now only a little larger than natural ; 
 but remains hardened, though the induration is not so great 
 as on admission. Lint. Camph. genibus affricand. Sulph. 
 Quin. gr. ij. ter in die. 
 
 This man felt himself so much improved that he quitted the 
 hospital about the middle of April, having continued to 
 improve daily. 
 
300 
 
 PSEUDO SYPHILIS. 
 
 In my opinion we often meet with cases of cachectic 
 patients whose health is much more quickly restored by the 
 use of very small closes of blue pill, or some other mild mer- 
 curial, combined with such other medicines as the circum- 
 stances of their case may require. The mischief occasioned 
 hitherto by giving mercury in such cases seems to me to have 
 arisen from its having been employed in the ordinary doses, 
 instead of doses extremely minute. 
 
301 
 
 CHAPTEE XV. 
 
 ON THE NON-MERCUEIAL TREATMENT OF SYPHILIS. 
 
 I SHALL not, with my limited experience of this plan of treat- 
 ment, attempt to enter into a detailed account of its application 
 to particular symptoms ; I shall only offer a few general remarks . 
 When this plan first attracted the notice of the surgeons of 
 Great Britain both my colleagues and myself adopted it in 
 our hospital. In general we confined this treatment to men 
 who had not used any mercury; but as in Dublin it is 
 extremely difficult to meet with venereal cases in hospital who 
 have not applied to some apothecary, or received medicines 
 at a dispensary, we could not adopt it as the general practice 
 of the institution. However, we tried it until we all became 
 convinced of this fact— that it was not suited to patients who 
 were obliged to earn their bread by labour; for we saw 
 that after they had left the hospital and got into employment 
 they generally found themselves weak, and unequal to their 
 usual labour ; and often, at the end of two or three months, 
 they returned emaciated, pale, and enfeebled, in consequence 
 of the hectical form of fever which was about to usher in a 
 new series of venereal symptoms. Their stay in the hospital 
 also proved in general very protracted; so that they then 
 became impatient of this treatment, especially when they saw 
 others with similar symptoms in the same ward have their 
 complaints more quickly cured by the use of mercury. In 
 private practice, also, I employed it for a time; but not 
 finding it superior in point of quickness of cure, or of security 
 against a relapse, and observing that these relapses were more 
 frequently reiterated, in a short time I ceased to employ it, 
 except at the express sohcitation of the patient. But I had 
 many opportunities of witnessing the results of the practice 
 of some of my brethren who adopted it more fully. Of course 
 I could not know much of those cases in which this practice 
 was successful ; but in many of those who suffered from 
 
B02 ON THE NON-MERCUBIAL 
 
 secondary symptoms, and from relapses of the different series 
 of secondary symptoms, I had melancholy proof that this 
 treatment was too often unequal to remove syphilis. No 
 doubt fewer of the non-mercurial patients complained of 
 affections of the bones than those who had been ineffectually 
 treated by mercury ; but I saw instances of closed pupil and 
 opaque lens, produced by iritis which had been neglected, not 
 having been considered as venereal symptoms. I have seen 
 many cases where the soft parts of the throat had suffered 
 severe mutilations ; and, above all, I had too many opportu- 
 nities of watching the very slow and silent, but sm-e inroads 
 which the often-repeated attacks of secondary symptoms made 
 on the constitutions of the patients ; of witnessing this pheno- 
 menon — that the venereal disease, from year to year, showed 
 itself with less striking characteristics, while other diseases 
 appeared to spring up ; so that, for some months before the 
 death of such patients, it would require a close examination 
 to discover the one or two slightly-marked symptoms of 
 syphilis which remained ; and also required close research to 
 trace the symptoms of apparently the last and fatal disease 
 to its true source, the infection of syphilis. But on tracing 
 the state of health, from the primary ulcer down to the final 
 and fatal disease, I could clearly see that at no period was the 
 unhappy sufferer altogether free from the venereal disease ; 
 so that both the patients and their friends, in many instances, 
 lost sight of the original syphilitic disease, and referred the 
 death to some other apparent cause, such as ascites, or some 
 disease of the lungs. Nor is it to be wondered at that non- 
 professional persons should form such an erroneous opinion, 
 seeing that the course of some of these fatal cases had occu- 
 pied a period of four or five years between the appearance of 
 the primary ulcer and the fatal event. In a word, after the 
 experience of one year's full trial of the non-mercurial plan, 
 we have since, in om* hospital practice, only employed it 
 rarely, and generally in very mild slight cases of primary 
 symptoms. 
 
 But we must acknowledge that the profession is indebted to 
 those who have lately introduced the non-mercurial plan of 
 treatment ; for we have now not only acquired a second line 
 
TEBATMENT OF SYPHILIS. 303 
 
 of treatment for venereal cases, but, what is of the highest 
 value, we have been released from an inveterate and deep- 
 rooted error^rom an unfounded conviction that the venereal 
 disease could not be cured by the innate powers of the 
 system, unless aided by mercury. I need not add, that all 
 the opinions and practices consequent on this prejudice have 
 been subverted. 
 
 I think it must, however, be admitted, that the non- 
 mercurial plan has not fully answered the expectations of its 
 early admirers. All will allow that many cases of syphilis 
 have resisted this treatment, and were afterwards cured by 
 mercury. Let us revert to the history of its introduction. 
 It was introduced at a time when (in Great Britain) mercury 
 was rather in disrepute ; and when in the Peninsular army 
 the venereal disease, treated by mercury, was making frightful 
 havoc among the soldiery. It was tried on a scale beyond 
 that of any other medical experiment, and under circumstances 
 the most favourable ; the patients being subjected to military 
 discipline and restraint. In civil life it would naturally obtain 
 a preference from both patient and surgeon ; the former would 
 be relieved from all the horrors of a mercurial course, the 
 latter find in it a line of practice simple, plain, and safe ; one 
 that required not any extensive observation of the venereal 
 disease, or any nice and accurate judgment in the employ- 
 ment of the remedies. Yet it has not superseded the mer- 
 curial plan of treatment; on the contrary, it seems now, 
 after a trial for twenty years, to have fewer and less warm 
 admirers. This may possibly be fairly accounted for by 
 observing that this plan subjects the patient, especially when 
 the symptoms are of an inflammatory character, to the most 
 rigid quiet, even continued confinement to bed, to repeated 
 bleedings both general and local, to the long-continued use of 
 nauseating medicines, to frequent purging and very low diet. 
 So that, during the treatment, the patient is subject to all 
 this severe discipline, and, after it, suffers a proportional 
 degree of weakness ; and, to all this, I am disposed to add 
 relapses more frequently repeated, although less severe than 
 those which follow after the mercurial treatment. 
 
 Still I trust that this line of treatment will not be hastily 
 
304 ON THE NON-MEECURIAL 
 
 giYen up. And here I may be allowed to express a sincere 
 hope that those surgeons who continue to employ it will 
 direct their attention to the following points, viz., for what 
 symptoms or combination of symptoms, or conditions of the 
 general health, is this line of practice best fitted ? whether it 
 be preferable in warm weather, or in what seasons it is most 
 likely to succeed ? But, above all, I trust that they will turn 
 their attention to the natural history of the venereal disease, 
 and thus furnish the profession with what is so great a desi- 
 deratum, and one so difficult to attain, as long as the 
 mercurial treatment alone is employed. Let not the sph'it 
 of enquiry be biassed by any rivalry between the two plans of 
 treatment. Let not the non-mercurialists try to advance 
 their cause by depreciating the mercurial treatment. Neither 
 plan is entitled to the praise of cito, tute, etjucunde. Further 
 observation is required to improve each and give them some 
 claim to the above character. 
 
 While the non-mercurial plan appears to have rather retro- 
 graded of late in public estimation, I am yet aware that 
 equally strong objections may be urged against the mercurial 
 treatment ; for it may be said that this medicine has been 
 employed in the cure of syphilis more universally than any 
 other medicine for ages past, and yet at this day it must be 
 admitted that many _ cases have resisted its use, — and still 
 further, that often where it did not cure, it considerably 
 aggravated the sufferings of the patients ; and this, although 
 mercury has obtained the title of a specific for the venereal 
 disease. But I think much may be said in vindication of 
 mercury. 
 
 Hitherto, and indeed at this very day, surgeons have been 
 very unreasonable in their expectations of the powers of 
 mercury. No doubt many weak minds, misled by a name, 
 have thought, if they administered mercury, which is consi- 
 dered a specific, they must cure the venereal disease. Yet it 
 is strange that men have dealt more justly with other specifics : 
 thus Peruvian bark is looked upon as a specific for the cure of 
 intermittent fever ; and it will, if judiciously administered, 
 succeed in a great majority of cases of this disease ; but still all 
 must allow that this specific may not only not cure, but may 
 
TREATMENT OF SYPHILIS. 300 
 
 aggravate this disease, and even induce others of a more 
 dangerous nature — if, for instance, it he given when the 
 stomach and howels are loaded ; the same unfortunate result 
 will also follow its use if it be given at an improper period, 
 ex. gr., during the paroxysm. Or, again, if it be directed in 
 doses unfit in point of quantity, it must be acknowledged that 
 it has failed ; thus if given in very small doses it will prove 
 unequal to arrest the progress of the disease ; or if given in 
 excessive doses it will derange the stomach, so that this organ 
 can no longer retain it. I need not add that this specific must 
 also fail if it be administered when the constitution has been 
 much broken down, and when a material derangement of 
 structure, in any important viscus, has been induced by the 
 long continuance of the intermittent fever. Now, when we 
 come to recollect that the intermittent fever is a disease 
 pursuing a single and regular course, we must see how much 
 more easy it is to lay down plain and simple rules for its 
 treatment than we could do for a disease so complicated as 
 syphilis is. Again, although Peruvian bark, is in intermit- 
 tent fever and some few other diseases, an useful and effective 
 remedy, yet we know that it is not possessed of such active 
 powers over the animal body as mercury is ; and, therefore, 
 that when mismanaged it will not be productive of as much 
 mischief. Let us not impute to mercury more evils than 
 those which really belong to it ; let us draw a distinction 
 between the judicious use of this powerful medicine and the 
 mal-administration of it. When we recollect how very uni- 
 versal the venereal disease is, how very numerous its 
 symptoms in every one of the stages of this disease, how 
 strangely these symptoms are modified by the habit of the 
 patient, or by accidental circumstances — ex. gr., by inflam- 
 mation ; when we call to mind the astonishing powers of this 
 medicine over the animal economy ; and when, in addition to 
 all these considerations, we reflect upon the immense number 
 of injudicious, ignorant, uneducated persons who fearlessly 
 and constantly venture to undertake the treatment of syphilis 
 by mercury, surely the wonder should be that it has not done 
 infinitely more mischief in such hands. Surely mercury is 
 not chargeable with all the mischief done by the ignorant 
 
 X 
 
306 
 
 TREATMENT OF SYPHILIS. 
 
 who presumed to direct so powerful an engine. We see every 
 man who has the slightest connection with medicine, from 
 the hospital and dispensary porter up to the presidents of the 
 College of Physicians and of Surgeons, prescribing mercury 
 for the cure of lues venerea. 
 
 In my opinion nothing can more clearly establish the claims 
 of mercury to be considered as a specific for this disease than 
 the frequent instances of cures made by it in the hands of 
 those who must employ it at random, and very frequently on 
 patients as careless and incautious as the prescriber is igno- 
 rant and pretending. It is wonderful that an engine so 
 very powerful could have been so long wielded by the hands 
 of the inexperienced, the injudicious, the uneducated and 
 unprincipled, and yet should not have committed much more 
 havoc than it has done. Mercury is either a valuable medi- 
 cine or a dangerous poison. I trust that hereafter the 
 profession, at least, will no longer be misled by a name, and 
 suppose, because the remedy they employ is entitled a 
 specific for syphilis, that on that account they have only to 
 exliibit it in certain doses, and that they must thereby effect 
 a safe and permanent cure. Let the actions of this medicine 
 on the system at large, and on the various parts of it, be 
 diligently studied ; let the very earliest indications of its 
 agreeing or disagreeing with the system be investigated and 
 made known; let the doses and forms of this medicine 
 be suited to the state of the symptoms and to the conditions 
 of the general system ; and then I am convinced that this 
 medicine will rank high among those which restore to man 
 the invaluable blessing of health. Should mercury, when 
 administered according to the above suggestions, be afterwards 
 subjected to the same obloquy which it has lately experienced, 
 I would then think that Mr. Hunter was correct in saying, 
 " Nothing can show more the ungrateful and unsettled mind 
 of man than his treatment of this medicine." 
 
307 
 
 PAET 11. 
 
 ON THE TSE OP MEBCUEY IN AFFECTIONS OF THE 
 NERVOUS SYSTEM. 
 
 EvEEY surgeon who has been engaged in the practice of his 
 profession during the last twenty years cannot fail to have 
 remarked the following fact, viz., that during that period mer- 
 cury has been applied much more frequently to the cure of 
 certain diseases than it formerly was, although its powers over 
 these had not been previously acknowledged. How to account 
 for the increasing partiality to this medicine for the cure of 
 other diseases, while its use in venereal complaints, for which 
 it had so long been considered a specific, has within the same 
 period of time been by many practitioners objected to, and by 
 some totally abandoned, is a problem not easily to be solved. 
 This, which is almost a paradox, I cannot attribute to mere 
 fashion or caprice : were I to offer any conjecture upon this 
 point, I should say that in the treatment of the Walcheren 
 fever this medicine evinced such salutary effects and such 
 superior efficacy to any other of the various remedial measures 
 that w'ere resorted to during the prevalence of that severe, and 
 too often fatal, epidemic, that some surgeons became dis- 
 posed (almost unconsciously) to ascribe to it some very 
 peculiar and very superior powers, and were thus prompted to 
 employ it in the treatment of those diseases in which it had 
 not hitherto been used, at least to any extent, and in which 
 the various remedies in ordinary use had been generally found 
 ineffectual. 
 
 It is not my intention at present to treat of the application 
 of mercury to those acute diseases in which it now is, and 
 long has been, freely and successfully employed ; for example, 
 in iritis, and in acute inflammations of various membranes, 
 peritonitis, pleuritis, synovitis, &c. The concurrent experience 
 of all practitioners has so fully justified the high reputation of 
 this medicine in these acute complaints that I shall not dwell 
 
308 ON THE USE OF MERCURY 
 
 upon this point, nor attempt to enforce by any examples a 
 truth which is now so generally admitted. 
 
 I now merely wish to report the result of my own experience 
 as to the efficacy of mercury in some classes of disease, in 
 which, as far as I know, it has hitherto been but seldom, and 
 even then but sparingly, employed. I allude to certain 
 derangements of the brain and nervous system, sometimes 
 accompanied with more or less of paralysis of the voluntary 
 muscles. In these diseases I consider mercury, when actively, 
 and at the same time judiciously, administered, to be a most 
 invaluable medicine. 
 
 This position, I think, I can best establish by a brief state- 
 ment of a few cases which I have selected out of several that 
 have fallen under my own immediate observation. 
 
 Case 1. — In the year 1810 I was requested by a respectable 
 apothecary in this city to visit a young gentleman, a near 
 relative of his, who had been attacked about three months 
 previously with hemiplegia. I attended him every fourth day 
 during three weeks ; his complaints were becoming rapidly 
 worse, and indeed his condition was most alarming. He was 
 reduced to a state of great debility ; he could not stand ; he 
 passed the entire day in the recumbent posture on the sofa. 
 He burst into tears whenever he was spoken to ; his urine 
 and fceces passed involuntarily and unconsciously. I scarcely 
 thought he could survive many days, unless some successful 
 effort were made for his relief. 
 
 I suggested to his relative a trial of calomel, to be adminis- 
 tered so as quickly to induce ptyalism. This plan was put 
 in execution, and in four days he was in a state of salivation. 
 In less than a week from this he was able to walk with the 
 assistance only of one crutch. The bladder and rectum 
 regained their retentive faculties. In the course of a fort- 
 night he considerably improved in every respect ; his intellects 
 and strength of mind were perfectly restored. 
 
 I may add that he still lives and enjoys perfect health and 
 happiness in the midst of a young family. The hemiplegia, 
 however, still, and I conclude will remain to the end of life. 
 
 Case 2. — In April, 1834, I was called into the country to a 
 near and very valued relative who was seized with hemiplegia. 
 
IN AFFECTIONS OF THE NERVOUS SYSTEM. 309 
 
 a gentleman about sixty years of age, and of a very full habit 
 of body. He had been always very temperate in regard 
 to drink, but he had indulged very fully a remarkably good 
 appetite, and he used but little exercise. For some weeks 
 previous to this attack he had the usual premonitory symp- 
 toms : before I had seen him he had been bled largely and 
 purged freely. I recommended the use of calomel, with the 
 view of exciting ptyalism ; in three days this effect was 
 accomplished, and it was maintained for nearly three weeks ; 
 by this time the powers of the limbs were gradually restored ; 
 and, at present, the recovery is so far complete that no eye 
 could discover the slightest paralytic affection of the leg. He 
 can walk with as firm and quick a step as ever. The 
 upper extremity also seems to have regained its wonted 
 power ; he can employ it in any vigorous exertion or laborious 
 occupation as effectively, and with as little fatigue, as 
 the other arm ; but still one defect remains in it, namely, he 
 is not always certain of catching or of holding a small object, 
 such as a pin or needle. However, as far as regards all the 
 ordinary business of life, both limbs may be pronounced re- 
 covered and well. No paralytic affection of the face remains ; 
 no distortion or twitch can be observed in laughing, or in the 
 expression of any emotion of the mind ; his intellects too are 
 perfectly clear, as some late productions from his pen on 
 political subjects abundantly testify. 
 
 Case 3. — December 19th, 1833. I this day saw (in consul- 
 tation with Mr. Corr, a sm'geon in this city) Mr. H., who had 
 been within a few days attacked with paraplegia. Mr. H. 
 was a young man of intemperate habits. The paralysis was 
 recent, and was rapidly increasing ; he could not stand 
 steadily for any time without support ; nor could he walk even 
 from one side of his bed to the other without the greatest 
 difficulty, and without clinging to the bed-posts. 
 
 Mr. Corr and I agreed to try the effects of mercury, given 
 so as to induce a speedy salivation. We therefore directed 
 him one grain and a half of calomel every fourth hour. 
 
 December 24th. Mr. Corr informs me that Mr. H. is now 
 in a sort of salivation ; and that he is so much improved as 
 to be able to walk through his bed-room without assistance, or 
 
310 ON THE TJSE OF MEECUKY 
 
 without laying hold of any object within his reach. He was 
 now directed a blister to the nape of the neck, and the ptyalism 
 to be maintained. 
 
 In the course of a short time Mr. H. recovered the perfect 
 use of his limbs without any other remedies, except occasional 
 purgatives. 
 
 He is now in excellent health, and a remarkably active 
 man, and even practises certain feats of agility, such as, 
 holding his hands behind his back, jumping upon a sofa and 
 down again in rapid succession, and without turning his 
 person round. 
 
 Case 4. — The following case was in Stevens's Hospital, and 
 excited so much interest and attention that I feel ceiiain the 
 pupils of that day cannot readily forget its particulars. 
 
 Mooney, a young woman, admitted during the winter 
 
 of 1835, labouring under almost total paralysis of every hmb. 
 She was scarcely able to stand, and totally unable to walk ; 
 her upper extremities also were in the same useless and help- 
 less condition. She states that a few weeks previous to her 
 admission into this hospital she had been in the Whitworth 
 institution for a severe fever ; that she left that hospital in a 
 very weakly condition, and in a very delicate state of health ; 
 she then went into uncomfortable lodgings, where she was 
 necessarily exposed to many privations, and where she found 
 not only her general health to decline, but she also expe- 
 rienced a sense of numbness, and a peculiar weakness and 
 loss of power in all her limbs ; these sensations have daily 
 increased to the present date of her admission. 
 
 I immediately resolved to try the active mercurial treat- 
 ment in this case ; and directed calomel in such a manner 'as 
 to induce a speedy and a smart degree of ptyalism. The 
 effect of this treatment in this case was most striking : 
 ptyalism was induced in the course of three days ; and, coin- 
 cident with it, there was observed a great improvement in all 
 the symptoms ; the limbs, in particular, were benefitted ; the 
 sense of weakness and loss of power in and control over 
 them were speedily diminished; her strength returned, so 
 that she was soon enabled to walk, feebly and unsteadily no 
 doubt. 
 
IN AFFECTIONS OF THE NEEVOUS SYSTEM. 311 
 
 The ptyalism was maintained, steadily and prudently, for 
 some time. Her head was directed to be shaved, and rubbed 
 with tartar-emetic ointment : this application she, from her 
 anxiety to recover, used too freely, and for too long a time ; 
 in consequence of which, sloughs formed in different parts of 
 the scalp, and the ulcers caused by these were slow and 
 difficult to heal. When the ptyalism had been continued for 
 about a fortnight, it was allowed to subside ; and although all 
 paralytic symptoms had disappeared, yet as some peculiar 
 debility as to particular motions, or in some particular 
 muscles, still remained, strychnine was prescribed. Under 
 this medicine, and afterwards tonics and generous diet, she 
 was gradually restored to strength, and was discharged in 
 perfect health. 
 
 Case 5. — October 3rd, 1836. Mrs. B., of Eathmines, ffit. 50. 
 For nearly the last two years this woman has suffered many 
 severe family afflictions, and considerable loss of property ; in 
 consequence of which, as she thinks, she has become subject 
 to what she terms " great confusion in the back of the head," 
 which of late has extended to the right side of the head also. 
 She has latterly avoided all society, and has sought for soli- 
 tude. At the same time she observed a failure of memory, 
 which, within the last six weeks, has increased considerably, 
 so that now she cannot find words to express her ideas. If 
 she chance to lay a key, or any other thing, out of her hand, 
 she cannot, in a minute after, recollect where she had placed 
 it. She is unable to read, as the attempt instantly brings on 
 the "confusion in her head;" if she attempt to recollect any 
 thing, it all ends in the same confusion; nor can s^e even 
 attempt to do any needlework, as this would be followed by 
 the same distressing sensation. Her temper has become 
 extremely peevish and ii-ritable ; she suffers from a constant 
 sickness of stomach, like sea-sickness. When she attempts to 
 walk she staggers, as she says, in consequence of a dizziness 
 in her head, yet she can walk in a dark room ; nor is she 
 alarmed by looking down from a height. Her appetite is 
 good; the bowels are very costive; she sleeps very heavily; 
 there is no emaciation ; pulse 96. 
 
 I determined, in this case, to try the effect of ptyalism ; and 
 
Sl2 ON THE USE OF MEECUEV 
 
 having premised a strong purging draught, directed " Calomel 
 gr. iij. bis in die." 
 
 October 7th. She has had a slight attack of mercurial 
 dysentery yesterday, with some soreness of the mouth and 
 gums; she describes what she terms "the confusion" in the 
 back of the head as being much less ; there is a decided 
 improvement in her memory ; she can now much more readily, 
 and more constantly, find the words to express her ideas. 
 She has some sickness of stomach, but different from that 
 kind of sickness she has so long suffered. 
 
 October 10th. She can now read and attend to figures, and 
 can even cast up an account, which she could not previously 
 attempt to do ; but still she feels she would become confused 
 if she attended to them beyond a very short time. Habeat 
 " Mist. c. Quin. Sulph. gr. ij. ter in die." 
 
 October 18th. Whenever she stoops, or turns about her 
 head suddenly, she feels a sense of confusion, and then a pain 
 in the head. Her sleep is less heavy, and much more re- 
 freshing ; she can now read as much as twenty pages of a 
 book at once — she takes an interest in it, and can recollect 
 what she has read. Says she feels as if some great weight 
 had been lifted off her ; ptyalism was still maintained by 
 occasional doses of mercury. Habeat Ung. Ant. Tart. Vertici 
 Capitis. 
 
 October 24th. Pustules have been produced by eleven 
 applications of ointment. She can iiow stoop, and, look up 
 suddenly, without any unpleasant sensations ; her memory 
 and spirits are improving ; she can now attend to her house- 
 hold affairs, and can recollect what she has to do. 
 
 November 3rd. She now reads with interest, and recollects 
 what she has read a week before; her temper is still very 
 irritable, especially if hurried ; her spirits are much better 
 in the latter part of the day ; in the morning she feels very 
 nervous ; jolting of the car makes her head still feel a little giddy. 
 
 November 13th. She feels much improved in every respect ; 
 she becomes fidgetty and uneasy at 10 p.m., before she goes 
 to bed; this is the principal nervous uneasiness she now 
 experiences. She feels her temper much improved since the 
 scalp has healed. 
 
IN AFFECTIONS OF THE NERVOUS SYSTEM. 313 
 
 November 16th. She walked from Eathmines to my house, 
 upwards of a mile, this day, and feels no inconvenience, 
 exceiDt a very slight giddiness. Her sleep is now refreshing 
 and natural ; her temper much improved ; she now does not 
 suffer from confusion when she is hurried. 
 
 I observed that during the entire treatment her bowels 
 required very active purgatives, the uneasy feelings in her 
 head uniformly becoming aggravated by costiveness. 
 
 Case 6. — On May 12th, 1836, I received from my friend 
 Mr. Pierce, surgeon of the King's County Infirmary, a letter 
 relative to the state of health of Mr. Elcot, which was handed 
 to me by the patient himself. In this Mr. Pierce mentions 
 that this man's habits of living had been irregular, his occu- 
 pation as a farmer and cattle-dealer having obliged him to 
 attend fairs at great distances from home ; and there, from 
 exposure to wet and cold, Mr. E. said he could not avoid 
 often resorting to the use of ardent spirits, as he fasted during 
 the entire day, from an early hour in the morning till late at 
 night. He applied to Mr. Pierce on account of anasarca, 
 accompanied with diseased liver. By the use of calomel, 
 digitalis, and squills, pushed so far as to induce a shght 
 ptyalism, these complaints were removed. In a very few 
 weeks afterwards he again applied to Mr. Pierce, with the 
 following symptoms : "an unsteady gait when he walked into 
 the room : a considerable inclination of his body towards the 
 left side ; aiid, in progression, a deviation towards the left 
 from the course he wished, or which I desired him to take ; 
 along with this, a most striking alteration in his countenance. 
 The left eye seemed as if sunken in the orbit, with ptosis of 
 the lid ; a languid and vacant cast of countenance ; added to 
 which was an obvious inattention to and neglect of personal 
 cleanliness ; he was inclined to remain always in bed ; his urine 
 was passed frequently, with difficulty, and in small quantities." 
 
 Such was the state of this man when he called upon me 
 with Mr. Pierce's letter, some days after it had been written ; 
 and then I observed that his intellects had in some degree 
 suffered; his memory was much impaired, and he seemed 
 almost perfectly indifferent to everything around him. I 
 feared he was likely to fall into a state of fatuity. 
 
314 ON THE USB OF MEECXJEY 
 
 I advised that mercury should again be applied, and pushed 
 so as quickly to induce a smart ptyalism ; that then the top 
 of the head should be rubbed with tartar-emetic ointment; 
 and on the subsiding of the ptyalism that he should take 
 strj'chnine. 
 
 In August, 1836, I had an opportunity of learning, by a 
 letter from Mr. Pierce, the result of this plan, and of again 
 seeing Mr. Elcot. From Mr. Pierce's letter I learned that 
 ptyalism had been induced in the course of seven or eight 
 days ; that the symptoms appeared to show some improve- 
 ment as soon as ptyalism was established ; that on the 
 subsiding of the ptyalism he was directed to take one-twelfth 
 of a grain of strychnine three times a day, and to have tartar- 
 emetic ointment rubbed on the top of the head ; and that the 
 effects of the strychnine were most satisfactory, a most 
 decided improvement having taken place in his limbs, his 
 intellects, and countenance. 
 
 I must say that I seldom enjoyed more pleasure than in 
 seeing Mr. B. walk into my study, and finding him give such 
 a satisfactory account of the improvement in his health. 
 Still he admitted that his urinary complaints distressed him a 
 good deal ; that he frequently suffered from incontinence of 
 urine, although he was able to pass half-a-pint of urine at a 
 time. 
 
 I also learned from his sister that he was still inclined to 
 remain in bed all day, and that he had a great aversion to 
 walk or to use any kind of exercise. On examining his 
 abdomen, I felt the bladder distended, and as hard as a foot- 
 ball immediately above the pubes : I drew off the urine ; and 
 repeating the operation again, after an interval of three days, 
 I found that the bladder had now regained the power of 
 emptying itself completely. His sister remarked a very 
 decided improvement in his habits from the day I first drew 
 off the urine; that he walked out every day since, and re- 
 mained for a considerable time in the open air each day. 
 
 The three succeeding weeks he passed at the sea-shore, near 
 Dublin, and he improved considerably in every respect. 
 
 Since his return to the country I find his improvement has 
 been equally progressive, as in a letter from Mr. Pierce, of the 
 
IN AFFECTIONS OF THE NEEVOUS SYSTEM. 315 
 
 11th of September last, he states, " I should have written to 
 you before relative to Mr. Eleot, who, I am happy to say, 
 continues to improve in health and strength. He is, I am 
 credibly informed, this very day attending the fair of Banaghar, 
 which is a distance of seventeen miles from his residence." 
 
 Case 7. — John Brady, set. 30, a publican, admitted into 
 No. 3 ward on the 26th of October, 1833, under the care of 
 Mr. CoUes. 
 
 His right lower extremity is paralysed ; the left is very 
 weak, and bends under him ; he has a sensation of coldness in 
 it, and a stinging pain shooting up from the instep and foot. 
 The urine flows from him involuntarily when in bed ; but 
 whenever he sits up, and tries to make water, he experiences 
 great pain just before doing so — a sensation as if the bladder 
 was over distended ; and he has to force very much : there is 
 a white powdery sediment in the urine. He has also a feeling 
 of -weakness and pain in the small of the back. His appetite 
 is pretty good ; he has no thirst ; he perspires very much at 
 night; pulse 100. 
 
 He states that on the 1st of September last, after exposiure 
 to cold and wet, by sitting up for seven successive nights to 
 protect his tent in Donnybrook fair, he was attacked with a 
 profuse diarrhoea; after which he had a sensation of being 
 stung with nettles in the lower part of the body and in the 
 thighs ; then a numbness in the right leg, which was growing 
 weak, so much so that on the 15th of September, three 
 weeks from the commencement of the attack, he was obliged 
 to use a stick in walking ; and he felt a slight pain shootmg 
 from the foot up the right leg ; also a weakness in the loins, 
 and pain, which prevented him from stooping. He had also a 
 difficulty and delay in making water, which gradually in- 
 creased, and amounted to a complete retention of urine on 
 the 20th of September, when the water was drawn off for the 
 first time. He was now received into Sir P. Dunn's Hospital, 
 when he was given some pills, during the use of which he was 
 enabled to make water ; he was also acupunctured, but without 
 benefit. On the 15th of October he got incontinence of urine; 
 and about a week before admission into this hospital he had 
 completely lost the use of the right leg. 
 
316 ON THE USE OF MEECUBY 
 
 ^Vhen admitted into Stevens's Hospital the incontinence of 
 urine continued unabated ; he had lost the power of both lower 
 extremities, so that he was unable to stand at the bed-side 
 unless he were held up by a strong man ; but he said that the 
 right leg was weaker than the left. He has a sensation of 
 coldness, and stinging pain shooting up the limbs from the 
 feet ; he also complains of weakness and pain across the loins. 
 His appetite is pretty good; has no thirst; he sweats pro- 
 fusely at night ; pulse 100. 
 
 November 1st. I^. Calomel gr. iss. Pulv. Doveri; Pulv. 
 Jacobi, aa. gr. ij. ft. Pil. ter die. 
 
 6th. He is now able to retain his water, but has still diffi- 
 culty and forcing in making it. ^. Cal. gr. ij. Pulv. Jacobi; 
 Pulv. Ipecac, aa. gr. ij. ft. Pil. ter die. 
 
 9th. Has retention of urine : the left leg does not now 
 bend under him when he rests upon it. Kep. Pilula. 
 
 12th. He has no longer retention of urine ; the power of 
 motion is returning in the right leg ; his gums are sore, and 
 salivation is established. Omitte Pilulas. 
 
 26th. His urine has gradually become clear, and he has 
 now no difficulty in making it. He can walk without assist- 
 ance. Discharged. 
 
 September 29th, 1836. This man has continued to enjoy 
 very good health, although he still follows the business of a 
 publican, and drinks rather too freely by his own admission. 
 He called on me this day, and walked into my study with a 
 firm step, not exhibiting the slightest trace of any paralytic 
 defect. 
 
 Case 8. — My dear Sir, — I have great pleasure in sending 
 
 you the case of Mr. . Mr. is now about 30, of a 
 
 fair florid complexion, with light hair. In childhood he was 
 very subject to severe attacks of croup : during boyhood, and 
 until he entered college, he was seldom free from headache, 
 for which Dr. Cheyne was consulted, and which were only 
 relieved by repeated cuppings on the back of the neck and 
 leechings. During his college life he enjoyed good health, 
 and a perfect immunity from head complaint ; he became very 
 full and corpulent, and was remarkably strong and athletic. 
 Some time after he obtained his degree ho had frequent 
 
IN AFFECTIONS OF THE NERVOUS SYSTEM. 317 
 
 attacks of slight fever, with headache, which generally con- 
 fined him to bed for three or four days, and always ended with 
 profuse ijerspiration ; still his general health was good, and 
 his habit full and iDlethoric. In the September of 1832 he 
 was suddenly attacked, while walking, with a severe epileptic 
 fit ; this was his first : the only treatment he then received 
 was a general bleeding, aperient medicine, and a more ab- 
 stemious regimen, with regular and constant exercise. He 
 went on well for some months ; but in February, 1833, he had 
 another epileptic seizure ; after which, by the advice of Mr. 
 Crampton and Dr. Marsh, a seton was put in his neck, and 
 he was ordered the nitrate of silver, which he took for eight 
 weeks, to the amount of two grains three times each day ; 
 regimen and exercise were more strictly observed, and he was 
 particularly enjoined to sleep very little. After this he con- 
 tinued without any return of absolute fit for twelve months ; 
 but he became more subject to those attacks of feverish cold, 
 attended always with headache, and, he remarked, he found 
 it very difficult to keep his bowels open. The seton was then 
 taken out of his neck, and there was no particular symptom to 
 create alarm until the winter of 1834, when, after being ex- 
 posed to fatigue and cold, he began to complain of his limbs 
 becoming numbed and stiff; he found a difficulty in getting 
 upstairs : he could not run or leap ; his right leg was weaker 
 than the left ; he felt, when on horseback, that his legs, from 
 his knees down, were numbed, and that he had no power over 
 them ; for this he was ordered friction, warm baths, blisters to 
 the sacrum, cupping on the spinal canal, and an issue in the 
 nape of the neck, and electricity, from all of which he derived 
 little or no benefit ; his limbs became weaker, he found a 
 difficulty of passing water, and an inability of emptying his 
 bladder, and his headaches came on at shorter intervals. 
 
 In the summer of 1834 he had another epileptic fit ; and in 
 the autumn of that year his symptoms were an evident drag 
 in the right leg, and great weakness of both ; inability to walk 
 more, or so much as, one mile; occasional loss of vision, 
 amounting, in some instances, to total blindness for days ; 
 slight squinting ; complains of a constant pain and weight in 
 the vertex ; occasionally of suddenly losing the use of his right 
 
318 ON THE USE OF MERCURY 
 
 hand and arm, and recovering it again after some time ; mic- 
 turition more dif&cult. At this time it was agreed, in 
 consultation with Mr. Crampton, Dr. Marsh, and Dr. Golles, 
 to put him fully under the influence of mercury ; for, although 
 he had often taken it partially as a purgative, he had never 
 taken it so as to affect his system. He commenced, early in 
 December, taking two grains of calomel, with one of Dover's 
 powder, three times each day, and continued it for three weeks 
 before it had produced active ptyalism ; from that period he 
 lost all headache, never complained of any defect of vision, 
 his spirits (which before had been gloomy and desponding, 
 with a great dislike to reading, study, or any exercise of his 
 memory whatever) became after that very good; had less 
 inclination to sleep in the evening, was fond of reading, found 
 his memory again quite restored, and he began the study of 
 German, preparatory to his travelling in the ensuing summer. 
 His limbs still continued weak, and he had not lost the di-ag 
 in the right leg. 
 
 In the summer of 1836 he went up the Ehine, and found 
 great improvement in his limbs by the baths at Baden; and 
 since ttha, he writes to say, he has been into Italy, by Swit- 
 zerland, and has travelled seven hundred miles, over bad 
 roads, most of which he has walked. 
 
 Such, dear Sir, is his case ; exhibiting, I should think, in 
 the strongest hght, the beneficial effects of mercury in cerebral 
 disease. 
 
 From an impartial consideration of these cases I think it 
 may be fairly deduced that mercury is entitled to be classed 
 amongst our most powerful and valuable therapeutic agents, 
 in those morbid affections of the nervous system which admit 
 of any remedy or relief from the healing art ; I say admit of, 
 for it must still be conceded that of all complaints that come 
 under the notice of the practitioner none are more obscure in 
 their nature and uncertain in their issue, and generally none 
 are more obstinate in resisting every remedy that is applied 
 for their relief , than those in which the functions of the nerves 
 and muscles are deranged. 
 
 I shall refrain from offering any theory, or attempt at 
 
IN AFFECTIONS OF THE NERVOUS SYSTEM. 319 
 
 explanation, of the modus operandi of mercury in this class of 
 diseases; jjartlj because we are totally unable to do so in 
 reference to other diseases in which its influence is still more 
 marked and obvious, and in which its power over disease is 
 almost certain and unerring, or specific ; but, principally, I 
 abstain from offering any theoretical observations whatsoever, 
 because the class of diseases to which I have alluded are, as 
 regards their pathology, involved in deep obscurity. Even at 
 the present day we possess but little exact knowledge of the 
 structure or function of the various parts that compose the 
 nervous system ; how then can we venture to theorize as to 
 the nature or the cause of its diseases? How are we to 
 discriminate between a functional derangement in its myste- 
 rious powers, or an organic lesion in its delicate and (as yet) 
 unexplored tissue. 
 
 No doubt, in many instances, the impaired function may 
 depend on some organic change in the nervous fibre, or in 
 some of the effects of inflammation in its investing membranes, 
 and a suitable treatment be hereby indicated ; but I fear that 
 in a vast majority of cases no such connection can be ascer- 
 tained as that between cause and effect ; and that we must 
 remain contented to pursue a mode of practice, which, though 
 it be empirical, inasmuch as it rests on no just reasoning, is 
 yet sanctioned by analogy and fortified by experience. 
 
 I shall not trouble the reader with any detailed account of 
 the benefits derived from mercury in cases where derange- 
 ments of the stomach are dependent on organic diseases of 
 that or of some neighbouring viscus. 
 
 The following case of gastrodynia, which was one of the 
 most severe I had ever witnessed, shows the great benefits to 
 be derived from the use of this medicine, in a case where the 
 most strict and repeated examination could not detect any 
 organic affection of any of the abdominal viscera. The 
 subject of it was a farmer, eet. 34, in rather comfortable cir- 
 cumstances, of full habit and florid countenance, with every 
 appearance of perfect health. He was received into the 
 hospital on the 24th of September, 1836 : he stated that he 
 was a man of temperate habits, but, from his occupation, was 
 much exposed to wet and cold. This disease commenced 
 
320 ON THE USE OP MEECURY 
 
 about twelve years ago. Whenever he used any green 
 vegetable food for dinner, he was attacked on the following 
 morning with a peculiar squeezing pain in the stomach, as if 
 (to use his own words) the stomach was squeezed between 
 two roUers ; this pain gradually increased for an hour, when 
 it at length became almost intolerable ; he then vomited, and 
 threw up sometimes a greenish thin fluid, of very acid taste ; 
 at other times a whitish fluid, like the white of an unboiled 
 egg. The difference in the quality of the fluid vomited did 
 not depend upon any particular kind of food. After the 
 vomiting, he felt quite relieved and perfectly well. As the 
 disease advanced, he found that salted meats and eggs pro- 
 duced the same effects ; and that the pain came on much 
 earlier after the meal : at this time he remarked that change 
 of air agreed with him, and that wet and cold greatly aggra- 
 vated his sufferings. He next found that when the pain 
 seized him he was not able, by a natural effort, to discharge 
 his stomach ; and with the view of relieving himself from the 
 pain, he would then excite vomiting by thrusting his finger far 
 down into his throat : this expedient after some time failed him, 
 so that he could not, even by these means, provoke vomiting. 
 He now discovered that he could still excite this act, if he 
 first drank large quantities of boiled milk, so as to over- 
 distend the stomach, and then introduced the finger in the 
 manner before mentioned. The milk thrown up was com- 
 pletely changed into a curd. He says that the quantity of 
 milk he used on these occasions generally amounted to two 
 gallons; and this he always had boiled before he used it. 
 Within the last two years the pain has increased greatly in 
 severity, and comes on after any kind of food ; but he thinks 
 it more severe after eating vegetables or eggs. Pressure on 
 the stomach procures some slight mitigation of the pain ; and 
 he has sometimes !ound relief by lying on his back upon the 
 cold pavement. 
 
 He handed me the following communication from Mr. 
 Cane, a very intelligent surgeon, practising in the city of 
 Kilkenny : — 
 
IN AFFECTIONS OP THE NERVOUS SYSTEM. 321 
 
 " Sept. 20, 1836. 
 
 " Sir, — The bearer, Mr. Walshe, was a patient of mine 
 about twelve months since for gastrodynia of the severest 
 character I have witnessed. Since then I had nearly lost 
 sight of him, until this day, when he applied to me to state 
 in writing what I had then done for him, as he wished to 
 consult you, for he is still suffering as severely a^s ever. I 
 have no notes of his case, but have a tolerable recollection of 
 his very great sufferings, and the remedies applied. 
 
 " He was cupped repeatedly, rubbed with the tart. ant. 
 ointment, and blistered over the epigastric region ; he got 
 calomel and blue pill occasionally, and the carbonate of soda 
 in inf. quassias daily. Cupping gave temporary relief; the 
 other remedies none. He was then put upon sedative treat- 
 ment ; he got the acet. morphiae, and had a belladonna 
 plaster over the stomach : these failed ; he afterwards took 
 the muriated, and then the acetated tincture of iron daily, 
 with gentle aperients at night ; all which failing, prussic acid 
 was tried, and this with as little good effect ; creosote 
 increased his sufferings. At length he grew tired of medicine, 
 and the restrictive diet which accompanied its use, and with- 
 drew from my care. Since then, he says, his sufferings have 
 been rather increasing ; and he expresses the agony he now 
 endures to be so great that he desires death. 
 
 I have the honour to remain. Sir, 
 
 EoBEET Cane. 
 
 To A. Colles, Esq., M.D., &c." 
 
 September 24, 1836. I ordered for him I^ . Aq. Calcia §vi. 
 Magnesias 5ss. Spt. Amm. Arom. 5ij. m. Sumat gi. ter in die. 
 Alternis nootibus Sumat Pil. Aloeticas duas. 
 
 October 4th. He passed the three first nights, after com- 
 mencing this medicine, perfectly free from pain; but has 
 since passed three or four nights of most severe suffering. 
 ^. Pil. Hyd. gr. iv. Ext. Hyosciami gr. i. fiat Pilula ter in 
 die sumenda. Eepet. Mist. c. Aq. Caleis, &c. 
 
 October 9th. Eepetantur Pilulte et Mist. I^ . Tinct. Acet. 
 Opii Gutt. XX. Aq. Font. 5vi. m. ft. haustus urgente dolore 
 sumendus. 
 
322 ON THE USE OF MEECUEY 
 
 October 18th. His mouth has been smartly affected the 
 two last days. Omitt. Pilulse ; Eepet. Alia. 
 
 October 28th. He has not had any return of pain for the 
 last ten days ; appetite very good ; mouth is yet slightly sore. 
 He imagines himself perfectly cured, as he has had such a long 
 immunity from pain. He is most anxious to return to his 
 farming business, and cannot be prevailed on to remain longer 
 in the hospital. 
 
 Being anxious to learn whether this man continued free 
 from this severe affliction, I wrote to Mr. Cane, who was so 
 kind as to favour me with the following communication. 
 
 " November 18, 1836. 
 
 " Dear Sir, — I have seen Walshe, and he has furnished me 
 with the following particulars : — The night he left the hospital, 
 and the following day, when he travelled outside upon the 
 coach to Kilkenny, he felt some slight return ; since leaving 
 Dublin he has had no attack by day ; but is attacked, very 
 slightly, however, about twice a week, but at night only. He 
 has had vomiting but once, and that after having eaten of 
 stewed goose. He complains of some uneasiness in the region 
 of the stomach, occurring after even slight exercise ; and, also, 
 that his nights are restless. He has a clean tongue, good 
 countenance, pulse 78, and regular ; has no tenderness upon 
 pressure over the epigastric region. On the whole he is, he 
 says, well, comparatively to what he was, and that the pain he 
 now suffers ocasionally is quite trifling, and not at all to be 
 compared to his former agony. He uses no vegetables, his 
 bowels are free, and he continues to take the medicine which 
 you prescribed for him — Mist. aq. Oalcis c. Mag., &c. 
 
 " There is no question that he has derived great benefit 
 from your treatment, though he says ' he was near losing his 
 teeth by it.' He is much better than I had hoped ever to see 
 him. It will afford me much pleasure at any time to reply to 
 any inquiries which you may be desirous to make concerning 
 him. — I remain, dear sir, yours truly, 
 
 "EoBEET Cane." 
 
 In case of obstinate ulcers of the extremities, where no 
 
IN AFFECTIONS OP THE NERVOUS SYSTEM. 323 
 
 suspicion of venereal taint could be entertained, I have occa- 
 
 . sionally at length effected a cure of the ulcers by administering 
 
 mercury, so as to excite ptyalism, using still the same dressings 
 
 which had been for a long time previously employed in vain. 
 
 I deem it unnecessary to mention here, what every prac- 
 tising surgeon must be familiar with, viz., that mercurial 
 fumigations, applied directly to ulcers, often prove a ready 
 means of causing them to heal, although they may have 
 previously resisted a great variety of topical remedies. I 
 shall only beg leave to record my experience of the superiority 
 for such purposes of the Sulphuretum Hydrargyri Eubri, and 
 beg to refer the reader to page 75 of this work, where a most 
 satisfactory and manageable mode of employing this article 
 for fumigating any part is fully described. 
 
 The following case will prove most satisfactorily that mer- 
 cury may be employed with the greatest benefit in some cases 
 of ulceration which had long resisted almost every other 
 treatment. 
 
 August, 1835. In the beginning of this month I was con- 
 sulted by Mr. S. on account of an ulcerated tongue ; his 
 speech was by it rendered very indistinct ; he had a flow of 
 saliva from the mouth ; he suffered but little pain, and was 
 apparently in good general health. Besides the affection of 
 his tongue, he also complained of epiphora of the right eye, 
 with an obstruction in the right nostril, from which, by blowing 
 the nose, hardened crusts, of amber colour, were occasionally 
 thrown out. On the back of his neck was a pretty large ulcer, 
 not very deep, and having callous edges. He informed me 
 that he had laboured under ulceration of the throat, &c., for 
 many years ; and that, in April, 1832, I had seen him, his 
 throat being ulcerated, and the ulceration having extended to 
 the tongue ; and reminded me that I had paid him two visits 
 at the time the tongue was first attacked ; that I had directed 
 for him at that time pills of calomel, which he did not take 
 for more than five or six days. On referring to my notes I 
 found that I had seen him at the time he alluded to ; that I 
 had directed for him the mercurial pills, and that he did not 
 seem satisfied when he learned the description of the medicine 
 I ordered. Since that period he has been treated by different 
 
324 ON THE USE OF MERCURY 
 
 sm-geons with Corros. Sublim., and with almost every other 
 kind of medicine : topical remedies, without number, many 
 of them caustics, have been applied to the tongue. He 
 informed me also that, shortly prior to my first visits to him, 
 in 1832, his wife was delivered of a child, which has been 
 remarkably healthy. He has not had any eruption or pains 
 in the bones, but his throat was a long time severely attacked. 
 On looking into it I observe, on the right side, the velum 
 adhering to the back of the pharynx, and the cicatrix bears 
 evident marks of a former very severe ulceration of the fauces. 
 I ordered him Pil. Hyd. gr. v. sing. noct. Ung. Hyd. Portis 
 3 i. om noct. 
 
 August 13th. Mouth slightly but uniformly affected by the 
 mercury ; the flow of saliva much reduced ; the right nostril 
 more comfortable ; epiphora less ; the ulcer of the tongue has 
 made considerable advances towards healing ; the swollen 
 edges of the ulcer less elevated ; his general health is undis- 
 turbed by the action of the mercury. 
 
 August 19th. His articulation is much improved; the 
 swelling and hardness of the tongue, in the vicinity of the ulcer, 
 much reduced. The ulcer now does not exceed the size of a 
 split pea. The eye and nostril much better ; mouth pretty 
 sore. Eepet. Pil. et Ung. 
 
 September 5th. The tongue is quite healed, but it is in 
 some degree confined in its movements by the cicatrix, which 
 connects it to the floor of the mouth ; the flow of saliva has 
 ceased ; there is not the slightest weeping of the right eye ; 
 he feels the nose better, but still some crust of hardened mucus 
 is blown down every day ; the mouth not too much affected. 
 
 He did not desist from mercury until the beginning of 
 October, at which period I considered him as perfectly cured. 
 
 Few surgeons, extensively engaged in practice, have escaped 
 meeting with cases of this chronic or scrophulous ulceration 
 of the throat ; and all know that this may exist singly, or it 
 may be combined with a similar affection of the mucous mem- 
 brane of the nose, which is by no means a case of rare 
 occurrence. In more rare instances the ulceration spreads 
 forwards along the tongue. 
 
 The case above detailed is an instance of a combination of 
 
IN AFFECTIONS OP THE NEEVOUS SYSTEM. 325 
 
 all these affections at once, and exhibits the disease as con- 
 tinuing for a period of at least eight or nine years. When I 
 first advised mercury for the cure of the throat, which had 
 long been ulcerated, and of the tongue, which had only been 
 recently attacked, I deemed the case much more favourable 
 for its use than I found it on his last application when the 
 disease had obviously spread to the nose ; for I need not say 
 that, even in venereal ozsena, mercmy is generally not capable 
 . of preventing most serious havoc being made in that organ ; but 
 in the present case it has succeeded to the utmost of my wishes. 
 
 A few days ago I saw Mr. S., and found him in excellent 
 health, and very much improved in flesh and complexion. He 
 assured me that he then enjoyed a degree of good health to 
 which he had for many years been a stranger. The tongue 
 and throat remained perfectly healed, and not the slightest 
 trace of any affection of the nose could be discovered, or even 
 suspected. 
 
 Whether we consider or call this disease a scrophulous ulcer- 
 ation, or merely an obstinate ulcer, one thing is plain, that it 
 was cured by a moderate ptyalism, although it had for eight 
 or nine years previously resisted, I believe, every other mode 
 of treatment, both local and constitutional. By adducing this 
 case as an instance of the value of mercury in causing obsti- 
 nate ulcers to heal, I do not mean to say or insinuate that it 
 will in all cases of this ulcerated state of the throat or nose be 
 equally efficacious ; for I am well aware that, in a great pro- 
 portion of such cases, we have to contend with a very morbid 
 state of the general system, — one which is not likely to be 
 remedied by mercury. But this much I will say, that in cases 
 of this description, where ulceration is spreading to, and 
 threatening the destruction of important parts, we may fall 
 back upon mercury as our last resource. I think, too, that 
 the local application of mercury directly to the ulcers may be 
 of superior advantage, especially if used in the form of fumi- 
 gations ; but on this subject I sp^ak from a very limited ex- 
 perience. 
 
 I should, when enumerating the various remedies formerly 
 employed in this case, have remarked, that he had repeatedly 
 taken mercurials, especially Hyd. Corros. Sublim. 
 
326 ON THE USE OF MEKCUEY 
 
 I am well aware that many cases of this chronic ulceration 
 of the throat have been treated, both by regular practitioners 
 and by empirics, with solution of corrosive sublimate ; and 
 that, in some instances, the practice has been attended with 
 success — more frequently, I believe, when the doses of the 
 medicine have been very small. But, if I can judge by the 
 cases which have come under my observation, this treatment 
 has been much more frequently unavailing than successful. 
 
 If what I have said of the use of merem'y in scrophulous 
 habits prove to be well founded, we shall then with some 
 degree of confidence resort to mercury, pushed to ptyalism in 
 obstinate cases of this affection of the throat, even when 
 accompanied, as it sometimes is, with enlargement of the 
 cervical lymphatic glands. I need not add that we should, 
 in such cases, strictly observe the rule to apportion the doses 
 of the medicine to the state of the general system of each 
 patient, avoiding as most dangerous the error of administering 
 it in doses too great for the constitution of the individual. 
 
 We not unfrequently meet with chronic tumours in the 
 abdomen, varying in size from that of an orange to that of a 
 foot-ball ; these tumours are movable, and are generally 
 productive of some uneasy sensations, or of some slight de- 
 rangements in the function of digestion. These tumours often 
 continue in an indolent state for years together ; but at times 
 they may be affected with some degree of uneasiness, and even 
 of painfulness. When these tumours get into this state we are 
 called upon to use the most active means for removing it, 
 and restoring tliem to their original quiescent state. General 
 blood-letting, where it can be borne, and, in more delicate 
 habits, local bleeding, should precede all other measures. 
 Having premised this evacuation, the employment of mercury, 
 in such manner as to induce a moderate ptyalism in the 
 course of six or eight days, will be found of the most signal 
 service. As soon as the salivary system acknowledges the 
 action of the mercury, instantly does the pain begin to sub- 
 side, and after a very few days ceases entirely. When I say 
 that if we do not quickly subdue this painful state of the 
 tumour, we shall see it speedily produce considerable enlarge- 
 ment of the tumour, and consequent increase of the preceding 
 
IN AFFECTIONS OF THE NERVOUS SYSTEM. 3^7 
 
 distress, which, in most instances, are attended by dropsy, 
 or by irritative fever, diarrhoea, and death ; I say, when we 
 contemplate these results, we shall at once be able to appre- 
 ciate the value of mercury used in such cases. Yet it must 
 be.,admitted that mercury has no influence in reducing the 
 size of the tumour while it remains in the indolent state. The 
 same remarks apply to that painful condition which occasionally 
 affects ovarian tumours. For here the use of mercury, pre- 
 ceded by general or local blood-letting, not only relieves the 
 patient from present pain, but also prevents the very rapid 
 increase of the tumour, which would otherwise immediately 
 attend this painful state. 
 
 I have with success employed mercury, both as a local 
 application and a constitutional remedy in some other diseases 
 in which its use has not been generally adopted; but I 
 decline to submit an account of these trials to my professional 
 brethren, as the cases in each disease have been too few to 
 justify us in founding on them any rule of practice. 
 
328 
 
 PART 11. 
 
 SELECTIONS FROM MINOE WOEKS AND ESSAYS OP 
 ABEAHAM COLLES. 
 
 The following short essay on the operation of Lithotomy is selected 
 from Colles' " Treatise on Surgical Anatomy," an unfinished work, 
 the first part only of which was published in 18H. Although since then 
 eoUpsed by far superior works of the same kind, it, like the admirable 
 work of Burns on the surgical anatomy of the head and neck, published 
 in the same year, marks an epoch in the progress of surgeiy. Mr. CoUes' 
 treatise embraces a series of essays on the anatomy of inguinal, crural, 
 and umbilical hernia, on the anatomy of the abdomen, the thorax, the 
 neck and throat, the pelvis and the organs of generation, and the 
 perinseum, concluding with observations on passing the catheter and the 
 operation of Lithotomy. 
 
 ON THE OPEEATION OF LITHOTOMY. 
 
 In no other operation in Surgery is a knowledge of anatomy 
 of more essential service to the surgeon than in that of 
 Lithotomy. Let us now consider how it will guide him through 
 the different steps of this hazardous operation. 
 
 The patient should be laid on a higher table than that 
 ordinarily used for the purpose, as this will allow greater 
 freedom of motion to the surgeon's hand, and lessen the 
 dangers attendant on some of the most difficult steps in the 
 operation. The staff should be of as full a size as the 
 urethra can well admit — should have the handle made rough, 
 which will enable the operator to hold it firmly without much 
 difficulty. Having introduced the staff, now hold the handle 
 of it firmly with the thumb and two forefingers of your left 
 hand; this hold will enable you more sensibly to feel the 
 point of the knife when it first enters the groove of the staff, 
 and (which is of much consequence) will facilitate one of 
 the most difficult and important steps of the operation, the 
 
ON THE OPEEATION OP LITHOTOMY. 329 
 
 lowering the handle of the staff. The staff thus held is to be 
 drawn into the arch of the pubis, and then is to be made 
 prominent in the perinseum. You are not, observe, to hold 
 the handle of the instrument inclined over the right groin of 
 the patient, as is generally directed. Let the staff be perpen- 
 dicular to the horizon : let it at the same time be drawn up as 
 closely as possible into the arch of the pubis, with its con- 
 vexity bulging out in the perinseum. 
 
 If you take care to keep the staff well up into the pubis 
 you will be secured against its slipping out of the bladder; 
 you will thereby save the rectum from being wounded, and 
 you will avoid all risk of injuring the pudic artery. In a 
 word, you will, by attending to this simple direction, render 
 the different steps of the operation easy and certain. Then 
 kneeling on your left knee hold the staff in this position ; and, 
 if you wish to render the right hand more steady, rest your 
 right elbow upon the corresponding knee. 
 
 The staff being thus held, you now feel for the arch of the 
 pubis with the forefinger of the right hand, and a little below 
 this spot you commence your external incision, close to the 
 left side of the raphe, and continue it obliquely, so as to pass 
 midway between the tuberosity of the ischium and the anus. 
 This first incision you will make, not with the point, but 
 by laying the bellying edge of your knife fairly to the 
 perinseum. The integuments will then fly asunder, their 
 natural elasticity being aided by the divarication of the 
 perinseum. In the same line with this you are to make your 
 second incision, commencing it half an inch below the upper 
 end of the first ; carry it deeply into the perinseum, by it you 
 will divide the transversalis perinaei, a few fibres of the 
 sphincter ani, a few fibres also of the transversalis perinsei 
 alter (if present) a portion of the levator ani, and a portion 
 of the ligamentous septum of the perinseum, taking care that 
 your second shall be nearly equal in length to your first 
 incision. Now enter your knife into the groove of the staff, 
 which you will readily accomplish if you recollect that your 
 incision is to open the membranous part of the urethra — that 
 this part of the canal passes through the ligamentous septum 
 of the perinaeum, at the distance of one iiich below the arch 
 
^30 ON THE OPEftAl'ION OF LITHOTOMY. 
 
 of the pubis and two inches above the tuberosity of the 
 ischium. Attention to these points will direct you to the 
 height in the perinseum, at which you are to enter into 
 the groove of the staff. The depth at which this ligament 
 lies from the surface may be ascertained by attending to 
 the fullness of the perineeum in each individual, and recol- 
 lecting that it is attached to the rami of the pubis behind the 
 crura of the penis. 
 
 It is the more necessary for you to bear these anatomical 
 facts in your recollection, because the deeper parts of the 
 perinseum do not recede when divided. On the contrary, 
 in corpulent subjects even the knife is concealed from your 
 view by the edges of the wound falling together as soon as it 
 has passed through them. 
 
 Therefore, holding the knife horizontally, you will push 
 it forwards and a little towards the right side of your patient, 
 taking care to enter it not at, but a little below, the upper 
 extremity of your external incision. As you perceive the 
 point of the knife grating on the staff, move it from side 
 to side, that you may be sure of its being in the groove, 
 as you might be deceived were you to rely merely on the 
 rubkng of the knife against the staff; when thus assured 
 that your knife is fairly lodged in the groove you are to 
 bare it for about a quarter of an inch: this is to be done 
 while the staff continues to be held perpendicular, by moving 
 the knife in the same perpendicular direction. If you do not 
 lay bare so much of the staff before you attempt the division 
 of the prostrate gland, you will have to encounter many and 
 most insuperable difficulties, of which we shall speak when we 
 come to describe the division of the prostate ; one, however, 
 may here be noticed, viz., the resistance given to the knife by 
 the levator ani and the triangular hgament, and by that 
 ligamentous structure which envelopes the membranous part 
 of the urethra. Having thus divided a portion of the 
 membranous part of the urethra, you now proceed to the 
 most difficult part of the operation, viz., the division of 
 the prostate gland and the neck of the bladder on its left 
 side. To effect this you must alter the position of your 
 instruments, because you know that the direction of the parts 
 
ON THE OPEEATION OF LITHOTOMY. 331 
 
 now to be divided is very different from the direction of those 
 through which you have already cut ; for you are now to 
 divide parts which he behind the arch and symphysis pubis. 
 Wherefore, while you hold your knife horizontally in the 
 lower part of the incision in the urethra, you should now 
 bring the handle of the staff down towards yourself by making 
 it move on the point of your knife, as on a pivot, and at 
 the same time keeping its concavity close up to the arch of the 
 pubis ; by this movement the back of the knife, instead of the 
 point, comes to be lodged in the groove of the staff, and the 
 beak of the latter is directed upwards. You will experience 
 but little difficulty in running the back of your knife along the 
 groove of the staff, if you but recollect the direction into 
 which this last movement has thrown the staff, viz., that it has 
 lodged it immediately behind the arch of the pubis, and, 
 therefore, in order to give a corresponding direction to your 
 knife, you must depress the handle of it, lowering your right 
 wrist by throwing back your hand, and then pushing the 
 knife on in the groove, taking especial care that you lower the 
 wrist as you push on the knife. 
 
 I should have observed that before you begin to push your 
 knife on along the groove you should incline its edge a little 
 towards the left ischium, that you may divide the prostate 
 gland on the left side. You will be sensible that your knife 
 has entered the bladder by all resistance being removed and by 
 the sudden flow of the urine. 
 
 I have said that it is a matter of the greatest importance to 
 the successful, and indeed to the safe performance of this 
 operation, that a considerable portion of the membranous part 
 of the urethra should be divided before the staff is depressed, 
 or that incision commenced by which the prostate and neck of 
 the bladder are to be divided ; for, if you have entered your 
 knife into the urethra high up in the perinseum, and while the 
 point of the knife is lodged there should depress the staff and 
 attempt the division of the prostate, you will have to make it 
 describe a portion of a circle at the time that it is dividing 
 very resisting parts. 
 
 Nothing can be more unsatisfactory to the operator than the 
 feel, when he attempts the division of the prostate, where 
 
332 ON THE OPEEATION OF LITHOTOMY. 
 
 he has entered the knife too high in the urethra ; he feels as if 
 the parts had not fully yielded, or indeed as if they had 
 not yielded at all ; and yet he is conscious that the degree of 
 force which he uses cannot be continued without the danger of 
 throwing the knife altogether out of the groove of the staff, 
 and plunging it far forwards into the cellular substance 
 between the bladder and rectum, or of sinking it into the 
 rectum if the point should be at all depressed ; so that the 
 knife used in this manner is productive of all the dangers, and 
 liable to many of those objections which apply to the gorget. 
 Should the knife, on the contrary, be used in the manner here 
 directed, you will not experience any resistance to the pro- 
 gress of it, except what you may naturally expect from 
 the texture of the parts to be cut ; and you have, in the 
 complete absence of all resistance, the most satisfactory proof 
 of the division being fully effected. 
 
 You may remark here that I have advised you to run the 
 back of the knife, slightly lateralised, along the groove of the 
 staff, and would wish you to have no other object in view 
 when performing this movement ; for if you accomplish this 
 the prostate and neck of the bladder must at the same time 
 be divided. 
 
 The breadth of your knife may in every instance be deter- 
 mined by this rule : use one of such breadth that when 
 lodged in the groove of the staff it shall be nearly equal 
 to the diameter of the canal of the urethra, and thickness of 
 the prostate gland. A knife of this breadth, and with its 
 cutting edge not above one inch long, will freely divide all 
 those deep-seated parts which are to be divided, and from its 
 dimensions and form cannot possibly divide the other parts 
 in the neighbourhood, if used in the manner here directed. 
 
 Let us suppose the incision to be made into the neck 
 of the bladder ; the knife is now to be withdrawn by drawing 
 its back a little way along the groove of the staff, and then by 
 lowering the knife as you come out such of the external 
 parts as have not been sufficiently divided can now be cut to 
 the necessary extent. Here your knowledge of the wide flat 
 pouch, formed by the rectum at this part, will prevent you from 
 carrying your knife too low down before you have withdrawn 
 
ON THE OPERATION OF LITHOTOMY. 333 
 
 it a little, lest you wound this intestine. Now examine 
 the state of the incision with the index finger of your right 
 hand, and if any bands of undivided cellular substance lie 
 across the wound break them down with your finger. You 
 now take the forceps with the handles lying on the same plane, 
 and, by introducing them inclined from below upwards and 
 forwards in the direction of the axis of the pelvis, you push 
 them into the bladder, guiding them by the staff which you 
 still hold, with its handle depressed. 
 
 This step of the operation requires a good deal of care, for 
 were you to enter the forceps horizontally you run the risk, or 
 rather you will scarcely avoid the danger, of pushing the 
 instrument into the cellular substance between the rectum 
 and bladder, however complete your division of the neck 
 of the bladder may have been ; for the edges of the wounded 
 levator ani contracting expose this interspace, which now feels 
 as a cavity, in consequence of the retraction of all that 
 cellular substance which lies between these parts. The 
 forceps being introduced you now withdraw the staff, and, 
 standing up, you search for the stone. When you have laid 
 hold on the stone proceed to extract it by withdrawing your 
 instrument in the direction of the axis of the pelvis, viz., 
 from above downward. If you attempt to withdraw the 
 forceps in a horizontal direction the stone, if large, must 
 injure the urethra by pressing it against the pubic ligament 
 and the arch of the pubis. Nor can room be gained in this 
 direction ; a slight pressure towards the right side of the 
 patient may gain some little room, but it is only in the 
 direction above mentioned that you can gain any material 
 room, and this too without inducing any contusion of the 
 soft parts. 
 
 When you introduce the finger to try for a second stone be 
 careful not to mistake, for the cavity of the bladder, the space 
 interposed between it and the rectum. 
 
 If the stone has been unfortunately broken into small 
 pieces by the forceps, you should endeavour to wash them 
 out by throwing tepid water into the bladder with a large 
 syringe, armed with a pipe three or four inches long. In 
 performing this you must also be careful to pass the pipe 
 
334 ON THE OPEEATION OP LITHOTOMY. 
 
 completely into the bladder, and not to mistake for its cavity 
 the space between it and the rectum, to which we have 
 so often alluded. Some leave these fragments to be dis- 
 charged with the urine, but this is objectionable, because 
 although they may have fallen down towards the fundus of the 
 bladder, yet they may be prevented from escaping by the 
 inflammation and swelling of the lips of the wound; and 
 while those fragments are allowed to remain the patient 
 suffers to a considerable degree that series of distress for the 
 removal of which he had submitted to the operation. 
 
 This, in point of the number of instruments employed, is 
 the most simple mode of performing the lateral operation for 
 lithotomy. It is the only mode that should be practised 
 on children under six or eight years of age, because in them 
 the urethra is too small to admit of the introduction of 
 the instruments, hereafter to be described, without danger of 
 lacerating this canal. At the same time we must admit that 
 a more accurate knowledge of the anatomy of the parts, more 
 dexterity in the use of the instruments, and more constant 
 practice in this particular operation than fall to the lot 
 of surgeons in general, will be required to enable the operator 
 to execute it with confidence in himself and security to his 
 patient. 
 
 By using two more instruments this operation can be per- 
 formed with much greater facility, and with such security that 
 few accidents have occurred during the operation, and still 
 fewer instances of a fatal event, since this mode of operating 
 has been generally adopted by the surgeons of this city. 
 
 The additional instruments required are a straight con- 
 ductor and a knife, which is called the lithotome. These 
 instruments had originally been invented by Mr. Daunt, 
 an eminent surgeon in this city; they were improved by 
 the late Mr. Dease, and owe their present perfect form to the 
 ingenuity of Mr. Peile. 
 
 The first steps of the operation are the same as those above 
 described. The position of the patient, the mode of holding 
 the staff, of making the external incision, and of laying bare 
 the groove of the staff, correspond in every particular, and 
 therefore it is unnecessary to describe them here. The rules 
 
ON THE OPEBATION OF LITHOTOMY. 335 
 
 to be observed in the part of the operation to be performed by 
 Mr. Peile's instruments are as follow : — The staff being laid 
 bare, and the surgeon being assured, by moving the Imife from 
 side to side, that its point is lodged in the groove, must now 
 bring down the handle of the staff towards himself, making 
 it move on the point of the knife, as on a pivot ; by this 
 motion the back of the knife is sunk into the groove. You 
 now divide the membranous part of the urethra and the 
 anterior point of the prostate gland ; this you effect by 
 lowering the wrist while you move the knife onwards, taking 
 especial care to make the back of the knife run in the groove, 
 which can only be done by lowering the wrist in proportion as 
 the knife is pushed forwards. The knife you now withdraw, 
 retaining the staff in the present position. Next take up the 
 conductor, catching a firm hold of it by applying your fore- 
 finger along its stem, while the remaining fingers embrace its 
 handle ; enter its beak into the groove of the staff, — you ascer- 
 tain that it is fairly lodged by moving it from side to side, — 
 and then, lowering the right wrist, run it along the staff, taking 
 care to lower the wrist as you push the director forwards, 
 until you have introduced it fairly into the bladder. The 
 urine now flows along the groove of the conductor, assuring 
 you of your success in this step. You now withdraw the 
 staff by moving up the handle towards the abdomen of the 
 patient, at the same time that you are drawing it out of 
 the urethra, the conductor during this time being held 
 immovable. Now, rising off your knee, stand between the 
 legs of the patient, and, passing the two first fingers of your 
 left hand into the ring, while your thumb is pushed against 
 the handle of the instrument, raise it up as high as possible 
 into the arch of the pubis. In this position you carefully 
 hold it, as by this alone can a wound of the rectum be 
 avoided. Now, holding the lithotome between the thumb and 
 two fingers of the right hand, lay its beak on the lower edge 
 of the groove, and, pushing it on until its point has got to the 
 external incision, give it the necessary degree of obliquity or 
 lateralisation, as it is termed, by turning the groove of the 
 conductor more or less towards the arch of the pubis. Having 
 determined on the degree of lateralisation which you judge 
 
336 ON THE OPEBATION OF LITHOTOMY. 
 
 necessary, now push on the knife, running it close and 
 parallel to the conductor until it is stopped at the point 
 of the conductor. Withdraw it cautiously by bringing it back 
 again along the groove. By this means the division of the 
 prostate is effected with the slightest possible force, for the 
 operator is scarcely sensible of any resistance from prostate, 
 and judges that it has been divided, not so much by his 
 having overcome a certain degree of resistance, as by the 
 knife having reached to the end of the groove. 
 
 The great advantages of this mode of operating are that 
 any man who can lay open the urethra on the grooved staff, 
 and has dexterity enough to introduce along it the straight 
 conductor into the bladder, will certainly guard against 
 dividing the rectum, will be enabled to give his knife the 
 required lateralisation, which is secured without any further 
 dexterity in making the incision, and therefore he will be able 
 to avoid in every instance the division of the internal pudic 
 artery. 
 
 Having withdrawn your lithotome, run your finger along the 
 conductor into the bladder to satisfy yourself of the extent of 
 the incision ; but should you find that the prostate is not 
 sufiiciently divided, introduce the same lithotome again, now 
 keeping the handle depressed below the stem of the con- 
 ductor. The division of the gland will be increased in 
 proportion as the handle of the knife is depressed, and there- 
 fore you can regulate the movement of the cutting part of the 
 Imife merely by observing the direction of its handle. Now 
 introduce the forceps guided by the conductor, but passed 
 from below upwards, or in a line corresponding with the axis 
 of the pelvis, and conduct the remainder of the operation as 
 already described. 
 
 The reader will perceive from tlie foregoing that Colles held the Btaff 
 himself. It may well be doubted whether surgeons of the present day, who 
 entrust to an assistant this important duty, have made any real improve- 
 ment. The dexterous manipulation of the staff constitutes assuredly about 
 the most important part of the operation. Up to the time when the 
 lithotomy scarpel divides the prostatic portion of the urethra and enters 
 the bladder, the nicety and success of the operation oliiefly turn upon the 
 rapidity, neatness, and precision with which the manoeuvres of the staff are 
 
TYING THE SUBCLAVIAN ARTEBY. 337 
 
 aooomplished. It is not possible for any assistant, however skilled, to 
 perform the necessary movements so well as does the left hand of him 
 whose right hand guides the knife which seeks the groove in the staff. 
 
 In cases of fat perinseum, so deep that the finger can with great 
 difi&culty reach the neck of the bladder, the straight staff or du'eotor of 
 Peile is a very valuable instrument. 
 
 ON THE OPEBATION OF TYING THE SUBCLAVIAN ARTEEY. 
 (Edin. Med. & Surg. Journal, 1815). 
 
 Soon after I had been raised to the office I now hold in the 
 College of Surgeons, I turned my attention to the study of 
 the subclavian artery. My first object was to discover the 
 most effectual means of compressing the artery, and to ascer- 
 tain the most eligible spot for this purpose ; my next, to 
 investigate the practicability of tying this artery either before 
 it reaches or after it has passed through the scaleni muscles. 
 The anatomy of the parts satisfied me of the feasibility of the 
 operation; and Mr. John Bell's luminous statement and 
 lively description of the anastomising arteries situated about 
 the joint encouraged me to hope for its final success. Still, 
 however, I did not feel myself justified in stating my opinion 
 to the pupils of the college, for as yet the operation had not 
 only been untried in practice, but the proposal wanted even 
 the sanction of analogy. At length Mr. Abernethy gave to 
 the world the first account of his operation of tying the 
 external iliac artery. From this moment I felt myself 
 authorised openly to express my sentiments ; and every year 
 since I have taken occasion, both in the anatomical and 
 surgical course, not only to state to the class my sentiments 
 generally on this subject, but to point out to them particularly 
 the manner in which I conceived the operation might be 
 performed. 
 
 A case of axillary aneurism having, in the year 1809, come 
 under my care in the hospital, I proposed this operation, on 
 
 z 
 
338 ON THE OPEEATION OF TYING 
 
 which I had so long meditated, to the other surgeons in 
 consultation. The proposal, however, was overruled, chiefly 
 on the grounds of the operation never having been performed ; 
 and I confess that I yielded to the voice of the majority with 
 the less reluctance, because I felt a secret apprehension of 
 some terrible revolution being produced in the frame by tying 
 an artery of such magnitude so close to the heart. This 
 patient, in a few months, fell a victim to the disease ; but 
 neither by argument, nor influence, nor stratagem, could I 
 obtain an opportunity of examining the body. Mr. Eamsden 
 now published his account of the operation which he per- 
 formed on this artery after its passage through the scaleni. 
 Although the result was finally unsuccessful, the experiment 
 served at least to prove to me one point incontestably, namely, 
 that the fear of immediate danger from a general revulsion 
 in the system was totally groundless. Emboldened by the 
 establishment of this fact I again proposed the operation in 
 the very next case that occurred, and it was unanimously 
 agreed to in consultation. In this case I undertook to tie the 
 artery before it had yet reached the scaleni. Several months 
 elapsed before another case presented itself; but the patient 
 in this instance positively refused to submit to the operation 
 unless I would assure him of complete success. The unshaken 
 fortitude and patient resignation with which he submitted to 
 the wide- spreading ravages of this painful disease through all 
 its successive stages proved that, in this determination, he was 
 not influenced by a desire to avoid the comparatively trifling 
 pain of an operation. Of this case I have related the appear- 
 ances on dissection, as I think they suggest some useful 
 practical inferences. 
 
 • The third case was, of all, the most favourable for operation, 
 and yet the result proved unfortunate. In this the artery was 
 tied after it had passed through the scaleni. 
 
 Case 1. — Michael Cowel, a labourer, aged 83 years, was 
 admitted into Dr. Steevens's hospital on 23rd September, 1811, 
 for an aneurism of the right subclavian artery. He gave the 
 following account of his disease : — 
 
 Thinks that he repeatedly hurt himself by endeavouring to 
 
THE SUBCLAVIAN ARTEEY. 339 
 
 push on with his shoulder a loaded car, the wheels of which 
 had sunk deep in passing over heavy ground. Soon after 
 these exertions (perhaps in the course of a week) he began to 
 complain at and near to the clavicle. At this time too he felt 
 a tumour the size of a cherry, which throbbed with a continual 
 pulsation. He points out a spot above the middle of the 
 clavicle, and rather towards its humeral extremity, as having 
 been the original seat of the disease. He did, in this early 
 stage of the disease, observe a tumour or pulsation in a spot 
 nearer to the sternum, but says that as the tumour increased 
 in size it extended itself in that direction. It was not until 
 the beginning of July he first felt a pain and numbness along 
 the right arm and forearm. 
 
 At present the tumour extends from the sternal origin of the 
 sterno-mastoid muscle along the clavicle, until it reaches a 
 little beyond the arch of that bone. It rises in height nearly 
 two inches above the clavicle, and is of a conical form, the 
 apex of the cone being situated at the outer edge of the 
 sterno-mastoid muscle. The finger can be passed with facility 
 between the clavicle and tumour, but at no part can it be 
 passed between the posterior surface of the tumour and the 
 subjacent parts. The aneurismal pulsation is less strong, and 
 the tumour more compressible between the heads of the 
 sterno-mastoid muscle than at any other part. Pulse 74, 
 and of nearly equal strength in both wrists. Of late he 
 complains of slight numbness in the fingers of his right 
 hand. He speaks of some uneasiness in the chest, which 
 he terms "a draw on his chest." This has been much 
 relieved since yesterday by blood-letting at the arm to the 
 ainount of fourteen ounces. His health in every other respect 
 is good. 
 
 On Thursday, October 10th, the operation was performed, 
 the patient being laid on his back upon a table, so placed that 
 the direct light fell on the right side of his neck. 
 
 Two incisions were made through the integuments ; the first 
 running along the middle of the sterno-mastoid muscle, from 
 the highest point of the aneurism to the top of the thorax ; the 
 second beginning at the middle height of the first, and ending 
 at the sternal articulation of the clavicle. The integuments 
 
840 ON THE OPEBATION OF TYING 
 
 being then separated from the subjacent parts, the lower 
 triangular flap of skin was laid down on the thorax, and the 
 upper portion turned upon the side of the throat. The 
 mastoid muscle being thus exposed to view, its different 
 portions were next divided. The sternal portion was first cut 
 through about an inch and a half above its origin. This was 
 done with a sharp-pointed bistoury passed on a director which 
 had been introduced on the outer edge of the muscle. The 
 clavicular portion was then divided to the breadth of about 
 half an inch, the director being passed on its inner edge. In 
 both these cases the introduction of the director was much 
 facilitated by slightly scraping along the edge of the muscle. 
 The lower divisions of the muscle were then dissected from 
 the subjacent parts and turned down over the clavicle. Now 
 the line of the carotid artery could be distinguished, and its 
 pulsations felt by the finger. The sterno-thyroid and hyoid 
 muscles lying exposed, were divided in the same manner, and 
 at the same height from the clavicle as the sterno-mastoid had 
 been. The division was carried only through so much of 
 their breadth as enabled us fully to expose the carotid artery. 
 We then proceeded to detach the lower divisions of these 
 muscles from the surrounding parts ; but here some delay was 
 occasioned by a large vein descending from the anterior part 
 of the throat into the internal jugular. The vein, however, 
 being secured by two ligatures applied at a small distance from 
 each other, and then divided in the interval between them, 
 the inferior portions of the sterno-thyroid and hyoid muscles 
 were raised from their beds and turned down on the thorax. Now 
 the sheath of the carotid artery was opened by pinching up a 
 small portion of it with the forceps and cutting the raised 
 part with the knife, carried horizontally. The director, 
 introduced at this opening, was passed down towards the 
 thorax, and on it the sheath of this vessel, near to its root, 
 was divided. 
 
 During this and all the subsequent steps of the operation 
 the internal jugular vein was removed beyond the reach of the 
 knife by an assistant, who, with a flat silver instrument, not 
 unlike a powder-knife bended at the point, drew it outwards 
 aaid held it aside. 
 
THK SDBC'LAVIAN ARTERY. 341 
 
 When the sheath of the carotid artery was divided the 
 eighth pair of nerves became visible ; it lay deep, and to the 
 outside, nearer to the carotid as they descended towards the 
 thorax. An instrument, similar to that above described, but 
 of larger dimensions and greater curvature, was now employed 
 to protect this nerve, together with the internal jugular vein. 
 The interval between the carotid and the eighth pair of 
 nerves in the vicinity of the thorax was now scratched a good 
 deal by cautious touches of the knife, for the purpose of 
 obtaining a view of the origin and course of the subclavian 
 artery. And now it was found that the aneurismal tumour 
 had extended so close to the trunk of the carotid as to leave it 
 uncertain whether any portion of the subclavian- artery was 
 free from the disease. Indeed, so strongly were the assistants 
 impressed with the apprehension that the aneurismal tumour 
 had extended to the aorta, or right common trunk, that 
 the majority appeared disposed to abandon the operation 
 altogether- Supported, however, by the concurrence of Mr. 
 Wilmot, I determined to persevere in the attempt, at least till 
 we could positively ascertain the actual state of the artery. I 
 therefore proceeded to lay open that portion of the sheath 
 which invests the very root of the carotid, in effecting which 
 a small artery was cut close to the coats of the carotid, and 
 yielded a smart haemorrhage. Some attempts were made to 
 secure it with a ligature, but these only served to impress us 
 with the idea that some irregular and nameless branch of the 
 carotid had been cut so close to its origin that it could not be 
 tied. Our uneasiness, however, on this head was soon at an 
 end, for the bleeding spontaneously ceased. The division of 
 the sheath being completed, we could now see that only a small 
 portion of the subclavian artery, lying between the aneurism 
 and the forking of the arteria inominata, remained in a sound 
 state. The length of this sound portion did not exceed a 
 quarter of an inch, and on this we resolved to apply the 
 ligature. For this pm-pose I endeavoured, with the point and 
 nail of my fore-finger, and occasionally with the flat handle of 
 a silver director, to separate the artery and adjoining portion 
 of the aneurismal tumour from the parts in their vicinity. 
 This was not accomplished without considerable difficulty and 
 
342 ON THE OPEEATION OF TYING 
 
 delay. But these disadvantages appeared to me of little 
 consequence in comparison with the danger that might attend 
 the use of the knife in this critical step of the operation. 
 When the artery seemed to be sufficiently detached I took an 
 aneurism needle of softened silver, blunt at the point and 
 longer than those in common use, armed with a ligatm-e 
 of six silk threads, and, guiding it with my left fore-finger, 
 passed it down on the inferior or thoracic side of the artery. 
 But I could not push it upwards, so as to pass its point with 
 safety beyond the cervical side of the vessel. 
 
 I then detached the artery still more completely from the 
 surrounding parts, and again made repeated trials to pass the 
 ligature, not only with the needle above described, but with 
 the common aneurism-needle, and also with a loop of softened 
 silver wire, but all without effect. 
 
 All these instruments had been introduced from below 
 upwards with the view of guarding against the danger of 
 wounding the pleura. 
 
 It was now proposed to try whether the artery might not be 
 surrounded by passing the needle in the contrary direction. 
 And with this advice I complied, rather indeed because I had 
 been so long and so repeatedly foiled in my former attempts 
 than because the danger of the proposed plan had escaped my 
 recollection. With the same instruments, therefore, I made 
 a few efforts to pass the ligature in the manner recommended, 
 in some of which I had reason to fear that the pleura was 
 wounded, both from the increased difficulty of respiration and 
 from the bubbling of the air among the blood. I soon found 
 it still more impracticable to pass the ligature in this than in 
 the former direction. Different plans for passing the Hgature 
 were now suggested by the assistants. Among these, one was 
 to tie one end of the ligature into a knot sufficiently large to 
 prevent it from slipping through the eye, and then, with a 
 sharp hook or pan- of spring-forceps, to lay hold of the knot 
 when carried in on the concave side of the needle. I made 
 the attempt, but the eye was so long that it allowed the knot 
 to remain behind the vessel when the needle was pushed for- 
 ward, in consequence of which this expedient failed. After 
 all these trials the ligature was at length passed with a common 
 
THE SUBCLAVIAN AETBRY. 343 
 
 silver aneurism-needle, introduced from the thorax upwards. 
 But it was necessary to use a good deal of force on the occasion, 
 so that the artery was raised up considerably out of its natural 
 situation. 
 
 I now put a single knot on the ligature, and ventured to 
 tighten it in the following manner : — I took a polypus-forceps, 
 the blades of which had been made fast, with an interval left 
 between them wide enough to receive the ai-tery. I then 
 passed one end of the ligature through each eye of the forceps, 
 and, holding in each hand a blade of the forceps and an end 
 of the ligature, I pushed the points of the forceps down on 
 each side of the artery. By this means the ends of the 
 ligature, which crossed each other on the surface of the artery, 
 were drawn in opposite dii'ections, and the knot was thus 
 gradually tightened. 
 
 The pulsation in the tumour and in the radial artery was 
 now considerably weakened, but not totally suppressed. Prior 
 to tightening the noose the breathing of the patient had 
 become more laboured, and he complained much of an 
 oppression at his heart. On tightening the ligature these 
 symptoms increased to such a pitch that every one present 
 apprehended his immediate death. He was raised up and 
 supported in a sitting posture, but without affording him any 
 relief; his countenance grew pale and indicative of instant 
 dissolution. Yet his pulse did not become intermitting, or in 
 any manner irregular, as was observed by a gentleman, who, 
 during these awful moments, kept his finger applied to the 
 right wrist. In this alarming state he continued for the 
 space of about a minute, during which some of the assistants 
 were so strongly impressed with the idea of his danger that 
 they quitted the room, lest he should expire before their eyes. 
 During these struggles the polypus-forceps were withdrawn, 
 and, as the ligature had been tied with only a single knot, it 
 is to be presumed that it yielded to tbe pulsations of the 
 artery. Yet the patient did not appear to be at all reheved. 
 Indeed, so great was his distress, and so strong my fears, that 
 I had actually passed the index finger of my left hand along 
 one side of the ligature, down to the noose, and was just 
 about to cut through it with a probe-pointed bistoury ; but, 
 
344 
 
 ON THE OPEEATION OF TYING 
 
 perceiving at this moment that his distress was a little 
 relieved, the idea occurred to me that the wound of the pleura 
 had been the principal cause of his sufferings. I now closed the 
 lips of the wound, and this procured him immediate and sensible 
 relief. However, the patient was so exhausted by this painful 
 and tedious operation, and had suffered so much on the 
 tightening of the ligature, that all present agreed to leave the 
 ligature in its place, and to wait the issue of a few hours or a 
 few days. It was conceived that by thus allowing time for 
 the wound in the pleura to be consolidated the operation 
 might hereafter be completed, as in that case, the right lung 
 being capable of performing its office, the heart would labour 
 less when this ligature was again tightened. Accordingly 
 the lips of the wound were brought into close contact by three 
 stitches of interrupted suture passed through the integuments. 
 The patient was laid in bed and supported in a sitting posture, 
 being incapable of lying horizontally. 
 
 Thursday evening, 8 o'clock. — Pulse 96, full, regular, and 
 equal in both arms. After the operation he had been unable 
 to swallow any fluid, except by sucking a bit of linen wetted 
 with his drink. Within the last two hours has been able 
 to swallow better, but still only a small sup at a time. Com- 
 plains only of his heart; says that it feels as if a knot 
 were tied on it, yet points to the scrobiculus cordis as the 
 seat of his distress. Countenance rather flushed ; skin 
 moist; temperature of both hands equal. Sixteen ounces 
 of blood being now drawn from his arm procured him some 
 relief. 
 
 Friday morning, 8 o'clock. — Did not sleep one moment 
 during the night, yet says he passed it very well ; his sister, 
 who sat vrith him, says that he had a great many catchings 
 at his heart. What she means by this term it is impossible 
 for me to ascertain, as I have not seen him affected in 
 the manner she attempts to describe. The blood drawn 
 last night is very buffy, and much cupped : pulse this morn- 
 ing 120. 
 
 At 12 o'clock. — Pulse 116; distress rather less. It was 
 determined that he should be bled again, but he was advised 
 not to have the blood drawn till his distress should increase. 
 
THE SUBCLAVIAN ARTEBY. 345 
 
 8 o'clock p.m. — He himself desired to be blooded, and 
 sixteen ounces were taken from him at 9 o'clock. He declared 
 himself much relieved by the bleeding ; pulse only 96. 
 
 Satm-day morning, 8 o'clock. — Has had some short slumbers 
 during the night; lies much more flat and horizontal; 
 swallows more freely, and takes large sups of his drink, 
 swallowing it gradually ; pulse 108, regular and equal in both 
 wrists. He thinks himself much better, but still complains 
 of his heart. No palpitation or fluttering of the heart can be 
 felt when the hand is applied to the thorax. 
 
 Saturday evening, 9 o'clock. — Pulse 96, as he lies without 
 speaking; when he speaks it increases to 110. He has eaten 
 a small quantity of boiled bread and milk, and a little cake 
 steeped in tea ; thinks himself much better. 
 
 Sunday morning. — Pulse 108 ; has enjoyed better sleep last 
 night ;• has lain on the left side for an hour, and now lies with 
 his head less raised. 
 
 Sunday evening. — Has eaten boiled bread and milk in 
 the day and some flummery in the evening; lies now with 
 his head very little raised, and has lain on both sides at 
 dififerent times this day. Pulse 130 and small ; complains 
 of some pain in the wound ; tongue is white ; countenance 
 rather flushed ; no stool since the operation. — Enema purgans 
 statim. 
 
 Monday, 12 o'clock. — He rested pretty well last night, and 
 feels refreshed this morning ; breathing free ; he lies hori- 
 zontally, and on his right side ; pulse 114. The enema has 
 procured a very copious evacuation ; thirst has been relieved 
 by taking lemon juice in his barley-water. 
 
 In the interval between our first seeing him and visiting 
 the rest of the hospital he was seized with a shivering which 
 lasted for ten minutes. During the shivering his skin did not 
 feel cold to the hand, nor had he himself any sensation of 
 chillness, but said that the shivering would go off directly. 
 He got a little warm wine and fifteen drops of tincture of 
 opium. His pulse and breathing seemed not at all affected 
 by this rigour. In half an hour after the rigour had ceased 
 we proceeded to dress him ; the lips of the wound appeared 
 nearly united ; a very small quantity only of thin discharge 
 
346 
 
 ON THE OPEEATION OF TYING 
 
 had flowed along the ligature. It was now deemed advisable 
 to cut out the two lowest sutures of the integuments, and 
 to separate the lips of the wound, for, in the present stage of 
 the wound, this could be easily effected, whereas, if it were 
 deferred for one or two days more, it would possibly require 
 the use of the knife. Accordingly the sutures were cut out, 
 and the lips of the wound separated by drawing the flat part 
 of an eyed probe along the line of the wound. The knot 
 of the ligature could now be felt at such a distance from the 
 artery that we thought that the point of the fore-finger could 
 just be insinuated a little between them. A consultation was 
 now held to decide on the propriety of immediately proceeding 
 to tie the ligature. Some proposed that it should be altogether 
 withdrawn ; others recommended that the attempt of tying it 
 should be made, but to postpone it for a day or two, till 
 the effects of the rigour should have shown themselves ; while 
 a third opinion urged the necessity of either instantly with- 
 drawing the ligatm-e, or tying it closely on the artery, — these 
 last assigning, as the grounds of their opinion, the danger 
 that the ligature, lying in contact with the artery, should 
 so far produce ulceration of its coats that they would 
 tear under the ligature if attempted to be tightened in one or 
 two days hence ; that the rigour had ceased, and the functions 
 of circulation and respiration were going on perfectly well at 
 this moment ; in short, that the present moment was as 
 favourable as any future period could be. The latter opinion 
 prevailed, and the third or uppermost suture being cut out, 
 and the wound thrown open, I proceeded to untie the remain- 
 ing single knot. My object in doing this was to include 
 in the noose along with the artery a bit of flexible silver wire, 
 for the purpose of enabling us more readily to cut out the 
 hgature if we found, on tightening it, that alarming symptoms 
 would be induced ; another reason was that we might tie 
 on it the surgeon's knot, which would not slip, whereas with 
 the single knot the ligature could scarcely be tied tightly 
 at the bottom of such a very deep cavity. Without much 
 difficulty the knot was untied, a probe and aneurism-needle 
 having been successively used for the purpose of widening the 
 noose. The wire, very much bent, was included in the 
 
THE SUBCLAVIAN ARTEEY. 347 
 
 new noose, on which was formed the surgeon's knot ; the en.ds 
 of the ligature were passed, each through the eye, on the end 
 of an iron wire ; these were thrust down, as I then fancied, to 
 the bottom of the wound, and attempts made to tighten the 
 ligature, but to very little purpose. Now, fearing that the 
 wire somehow prevented the ligature from being tightened, 
 one end of it was cut off close to the surface of the wound, and 
 the wire was then withdrawn by using a slight force. Now, 
 passing my finger down to ascertain the state of the ligature, 
 I discovered that we had not arrived at the bottom of the 
 wound ; the wires had descended only to the neighbourhood of 
 the anterior surface of the vessel. I now separated, with my 
 finger, the recent attachments of the artery to the surrounding 
 parts, and, passing each end of the ligature through the eye 
 of a polypus-forceps, the blades of which had been previously 
 taken asunder, I passed these down to the bottom of the 
 wound, and, giving the upper one to Mr. Wilmot to hold, 
 I held the lower one myself, and at the same time drew 
 it very tightly. This attempt reduced the strength of pulsa- 
 tion both in the tumour and at the wrists ; but we found that 
 this effect was owing, in a good measure, to the artery being 
 raised forward, and to the influence which pressing down the 
 blades of the forceps had on rendering it more tight. The 
 reason why I held the blade nearer to the thorax was, that I 
 feared if it had been directed downwards the plem-a must 
 almost inevitably have been again lacerated. I next made the 
 attempt, having only the upper end of the ligature passed 
 through one blade of the forceps, while the lower, which, from 
 being short and wet, could not be held firm by the fingers, was 
 rolled round the other blade, while the fore-fingers of my 
 right hand was employed in giving a favourable direction 
 to the ligature, so as to prevent it raising the artery up 
 out of its situation. After one or two attempts in this way the 
 closing of the artery was effected, as was manifested by 
 the pulsation of the radial artery completely ceasing. Some 
 slight obscure pulsation, however, was still to be felt in 
 the tumour, which led some present to apprehend that the 
 ligature was not drawn sufficiently tight ; but on a moment's 
 reflection it occurred- to us that this degree of pulsation 
 
348 ON THE OPBEATION OP TYING 
 
 was communicated to the tumour by the pulsation of the 
 sound part of the artery. A small quantity of florid blood 
 flowed from a deep part of the wound, but not in a stream, 
 just as the ligature was tied. A second knot was now 
 made, and the wound closed by two points of interrupted 
 suture. 
 
 During the tying of the ligature no alteration was observable 
 in his countenance, respiration, or the actions of his heart. 
 An assistant, who had held his hand on the left radial 
 artery during the tying, could not discover the slightest 
 alteration to have been induced by it ; the patient did not 
 exhibit the slightest symptom of pain ; in fact, he seemed 
 not to suffer in the slightest degree from this sudden revolution 
 effected in the arterial system ; he moved the arm as freely 
 as ever. 
 
 I saw him an hour after the operation, at which time 
 the temperature of both hands was equal, being in both 
 91 degrees. He continued free from any uneasiness. He had 
 drunk very largely of whey during the operation, which lasted 
 one hour ; his thirst at this time continues unabated ; he 
 wishes for lemonade. 
 
 8 o'clock p.m., Monday.— Pulse 120 ; temperature of both 
 arms, 91 degrees ; thirst continues ; has not had any sleep ; 
 tongue white and dry ; skin moist, and feels of the natural 
 warmth ; he did not use any food since the operation this day. 
 Tuesday morning, 8 o'clock.— Pulse 130 ; in half an hour 
 after, 120 ; passed the night without sleep, and has had very 
 great thirst; yet he thinks himself better. He wishes for 
 a few morsels of broiled meat, rather to indulge a medical 
 theory than to gratify his appetite, for his stomach and 
 bowels are extremely flatulent, which, he fancies, arises from 
 want of solid food. Tongue is white ; thirst is now less 
 urgent; temperature of both arms equal.— Habeat haust. 
 efferves, tertiis horis. 
 
 Tuesday evening, 9 o'clock.— He has just fallen asleep, and 
 is talking almost incessantly, is tossing his limbs about, and 
 would appear to suffer great distress ; yet his sister says that 
 this is not different from what occurs to him when in 
 health ; for that when he first falls asleep he talks over the 
 
THE SUBCLAVIAN ARTEEY. 349 
 
 occurrences of the past day, and tosses himself about in the 
 bed, but that after he has been asleep for some time 
 his repose becomes quiet and profound. Pulse, 120 ; temper- 
 ature of both arms apparently the same : has had some 
 sleep during the day, and thinks he might have had more had 
 he not wished to reserve it for the night ; thirst is very 
 inconsiderable since morning ; ate some flummery ; tongue 
 more clean- 
 Wednesday morning, 8 o'clock. — He has been just disturbed 
 from a short sleep, and appears rather confused ; has passed 
 a good night, but thinks himself weaker this morning. Pulse 
 120, smaller and weaker ; thirst not more urgent ; complains 
 of the fetor of the discharge from the wound, and wishes it to 
 be dressed. A considerable quantity of a yellow serous fluid 
 came from the lowest point of the wound ; part of it flowed 
 spontaneously, and some escaped when pressm'e was applied 
 to the more remote parts of the wound. The skin did not 
 adhere to the subjacent parts ; a small quantity of air seemed 
 to be interposed. No pulsation is felt in the tumour on the 
 humeral side of the longitudinal incision of the neck. He 
 appeared a good deal fatigued after the dressing. Tongue 
 white. — Habeat pil. purg. unam statim,^et post horas tres, 
 enema purgans, nisi prius alvus soluta sit. 
 
 Wednesday, 3 o'clock p.m. — Has had some refi'eshing sleep, 
 and for a much greater length of time than heretofore : has 
 eaten five or six morsels of beef-steak, and, lately, a little 
 flummery ; one copious stool after the injection. The nurse 
 reports that a small quantity of blood came off with the stool, 
 not more than was sufficient to streak it. He is now in a quiet 
 sleep, .lying on his left side. 
 
 Wednesday evening, 9 o'clock. — Has got still more sleep ; 
 temperature of the right hand, by the thermometer this day, 
 90 ; of the left hand, 92 ; but the right has been a good deal 
 exposed to the cold, being very seldom kept under the 
 bed-clothes ; pulse 120. A few minutes before this visit 
 a shivering had come on, which still continues; yet he 
 does not experience the sensation of coldness, nor does his 
 skin feel cold to the hand. His breathing now appears a little 
 hurried, as he lies on the right side ; yet, when desired to 
 
350 
 
 ON THE OPERATION OF TYING 
 
 make a full forced respiration, he does not experience any pain 
 from it, except what he refers to the heart, or scrobiculus 
 cordis, and this only in a trifling degree. 
 
 Thursday morning.— The rigour did not continue half an 
 hour ; he passed a good night ; had one sleep for three hours, 
 and during the rest of the night had a considerable share of 
 sleep. Pulse 120, rather small; tossing of the lower 
 extremities rather increased; thirst much less;, discharge 
 from the wound copious, but has passed off; none of it 
 has lodged. On pressing with the sponge an unusual 
 quantity of air escaped from under the skin ; no emphysema 
 noticed in the vicinity of the wound. An obscure pulsa- 
 tion ki the tumour was either felt or fancied by me ; certainly 
 none can be felt at the wrist ; size of the tumour a good deal 
 reduced. 
 
 Thursday evening. — Has slept well this day ; has eaten more 
 flummery than on any former day ; a slight emphysema 
 in the lower and anterior part of the neck. At five o'clock 
 this evening some blood had been observed on his shirt 
 and on the bandages ; yet in every respect he appears as well 
 as usual. At 7 o'clock p.m. the dressings were removed, and 
 the sutures cut out. On raising the flap of skin a small 
 quantity of coagulated blood was found in the wound, though 
 not in its deepest part ; emphysema increased ; obscure 
 pulsation continues to be felt in the tumour. Three small 
 pieces of sponge were laid in the wound ; a larger piece 
 was laid on the skin, and retained by adhesive plaster, as 
 pressure could not be applied by a bandage without confining 
 the thorax too much. Pulse 120; stomach moist ; tongue white; 
 temperature of limb and state of breathing as this morning. 
 
 Friday morning. — At 8 o'clock a.m. I received, from one of 
 my pupils, the following note : — " About one o'clock last 
 night this poor fellow got a change for the worse ; appeared as 
 if strangling, with continued tossing of his legs and arms ; 
 complained of his heart, and said there was some one pulling 
 a cord round his neck. He became quite delirious ; continued 
 in this state for nearly half an hour, after which he got com- 
 paratively easy ; and has been almost ever siace insensible, 
 and is at present, I think, very near his end." 
 
THE SUBCLAVIAN AETEEY. 351 
 
 I visited him at 9 o'clock this morning. He lay insensible, 
 rather pale, but not of that deadly paleness which so often 
 attends great haemorrhages ; his breathing very laboured ; in 
 short, with every appearance of immediate death. 
 
 About 10 o'clock this morning he died. 
 
 In a few hours after his death we hastily removed the heart 
 and large vessels, so low down as the clavicle, being prevented 
 by the attendance of his friends from examining the parts 
 in situ. No blood was effused into either cavity of the thorax. 
 The lungs of both sides were sound ; the upper extremity of the 
 right lung had a slight adhesion with the parts in the vicinity 
 of the ligature. The aorta was slit up from the heart to the 
 forking of the arteria inominata ; and thus we had an oppor- 
 tunity of observing the very diseased condition of the coats 
 of this artery, as manifested by the wrinkled state of its lining 
 membrane. A very remarkable pouch or recess, capable of 
 receiving the point of the little finger, appeared in the wall of 
 the aorta, on the right side of the artery, about one inch above 
 the heart. 
 
 In the apex of this dilatation the coats of the artery were 
 extremely thin, as if, the middle coat having been removed by 
 absorption, the lining and outer coats had adhered together. 
 The arteria inominata was dilated at the place of its forking. 
 Between this dilatation and the aneurism, for which the 
 operation had been performed, there was not above a quarter 
 of an inch of the subclavian artery free from disease, and on 
 this part the ligature had been applied. A pretty large open- 
 ing had been made by ulceration through the coats of the 
 artery, immediately above the ligature. 
 
 The next case of disease requiring the operation of 
 tying the subclavian artery occurred in William Levanee, 
 an invalided soldier, who was affected with aneurism of 
 the axillary artery a little below the clavicle. The disease 
 seemed to have arisen spontaneously. Tumour was the size of 
 a pullet's egg at the time of his applying for relief. 
 
 In fidl consultation the operation was decided on ; but this 
 man refused to submit to it unless we assured him of complete 
 success. He lingered for some months, and appeared to die, 
 
362 
 
 ON THE OPEEATION OP TYING 
 
 not from haemorrhage, but rather from extensive suppuration 
 and long-continued irritation. 
 
 Appearances on Dissecting the hody of William Levanee, eeUt 
 
 55 years. 
 26th April, 1813.— Very considerable swelling occupied the 
 right side of the body, extending from the clavicle down 
 to the eighth rib, and from the nipple of the breast across the 
 arm. The arm and fore-arm were very much distended by an 
 (Edematous swelling. Three large ulcers a little below and 
 before the axilla ; inferior costa of the scapula rough on its 
 internal surface ; the inferior angle of this bone exposed and 
 rough. On opening the thorax the viscera were found per- 
 fectly healthy, with the exception of slight adhesions of the 
 right lung to the pleura costalis, and some water in that side 
 of the chest. Heart rather small, but appeared perfectly 
 healthy. Large arteries near the heart not at all dilated, and 
 no other traces of disease in any of them than some very 
 small opaque spots visible on their internal coats. 
 
 The peetoralis major was of a pale brown colour, and much 
 thinner than natural ; the peetoralis minor converted into a 
 substance resembling a strong fascia. The parts above 
 the clavicle were still in a healthy state ; the different steps of 
 the operation for tying the subclavian artery before it had 
 reached the scaleni were performed on it. The trunk of this 
 aiiery was traced of natural size and healthy texture," for an 
 inch and a half below the origin of the vertebrals, and running 
 over the front of the aneurismal tumour. At this place 
 its coats became so thin that it was no longer possible 
 to distinguish them from the coats of the tumour. Im- 
 mediately before it became indistinct this part of the artery 
 seemed dilated to the breadth of a quarter of an inch. The 
 articulation of the humerus was opened and communicated 
 with the aneurismal tumour. The branches of the subclavian 
 artery did not appear at all enlarged. The basilic vein was 
 thickened in its coats, but not at all enlarged in its diameter. 
 
 On the 19th June, 1813, I was consulted by the Eev. Mr. S., 
 aged 48. He was a man of an uncommonly athletic frame ; 
 
THE SUBCLAVIAN AKTEEY. 353 
 
 had constantly enjoyed the most robust health, and had always 
 lived a regular and temperate life. The account he gave of 
 his complaint was as follows : — One night before Christmas 
 last, while lying in bed, his right arm was suddenly seized 
 with a numbness, and the right hand felt as if instantaneously 
 enlarged to twice its natural size. Soon after this the middle 
 of the fore-arm and the insertion of the deltoid muscle were 
 attacked with pains. He said that the physician whom 
 he had consulted in the country had remarked, with some 
 surprise, that he could not feel any pulse at the wrist of 
 the arm affected. The disease passed for rheumatism until 
 he came up to Dublin ; but, on his arrival in town, having 
 applied to Dr. Harty to be electrified, the doctor, during 
 the process, observed a portion of the chain, which happened 
 to lie on Mr. S.'s breast, to be moved up and down by 
 a violent pulsation of some subjacent part. Struck with 
 this occurrence, he proceeded to examine the seat and cause 
 of the .phenomenon, when he discovered an aneurismal 
 tumour situated below the clavicle, and covered by the pectoral 
 muscle. 
 
 On the day following I saw him, and found the aneurism 
 nearly of the size of a goose egg. The tumour pulsated 
 strongly, but seemed notvnthstanding to be both deeply seated 
 and thickly covered. The pulse of the right radial artery was 
 as full and strong as that of the left. By pressing with 
 my thumb upon the diseased artery, above the clavicle, along 
 the outside of the scalenus muscle, I suppressed the pulsation 
 both in the tumour and at the wrist. But a strong pressure 
 on the tumour itself, even when continued for some time, 
 excited no uneasy sensation whatever, either in the region of 
 the heart or in any other part of the thorax; nor did it 
 affect the powers of respiration in the shghtest degree. In 
 short, nothing preternatural could be discovered in the actions 
 either of the heart or of the arteries, under any possible 
 variation of circumstances. 
 
 On this very important case I requested a full consultation 
 without loss of time; and accordingly, next day Messrs. 
 Eichards, Peile, and Wilmot, Dr. Harty, and I met in con- 
 sultation. It was our unanimous opinion that, although tha 
 
 2a 
 
354 ON THE OPERATION OF TYING 
 
 present disease could not be clearly traced to an accidental 
 injury, yet, as not the slightest appearance of disease 
 could be discovered in any other part of the arterial system, 
 it was our duty to propose the operation of tying the subclavian 
 arterj'. 
 
 Mr. S., who was a man of uncommon fortitude of mind, 
 consented at once to submit to this formidable operation. He 
 wished, however, first to return to the country for some days, 
 in order to settle his affairs. To this delay we acceded, 
 advising him to avoid all bodily exertions, to live on very low 
 diet, and to debar himself of a full meal even of the coarsest 
 fare. We also prescribed some strong purging pills, to be 
 taken frequently, and directed that he should be blooded twice 
 at least before his return to Dublin. 
 
 On the 16th of July he returned, a good deal reduced in 
 flesh and colour. The aneurism had increased in size during 
 his absence, principally in the direction towards the clavicle. 
 Indeed, to judge by the eye only, the tumour seemed to have 
 extended to that bone ; but by the touch it could be ascertained 
 that the tumour and the clavicle were not yet in contact. He 
 now told us that some of his friends in the country had 
 reminded him of his horse having fallen and rolled over him 
 a few days before he felt the numbness of the right hand ; and 
 he can now distinctly recollect that he suffered considerable 
 pain about the shoulder at the time of the fall. 
 
 I commenced the operation by an incision beginning near 
 to the acromion, and terminating about midway up the side of 
 the neck. Another incision, commencing from the same 
 point, was carried along the clavicle, until it reached the 
 outer edge of the sterno-mastoid muscle ; the triangular 
 portion of integuments included between these incisions was 
 raised up from its apex, and laid back upon the throat. In 
 this first step of the operation some pains were taken to avoid 
 wounding one or two pretty large veins which ran very super- 
 ficially along the side of the neck. When the integuments 
 were thus removed I detached the external jugular vein, at the 
 highest point where it lay uncovered, and, with a blunt 
 aneurism-needle, passed a ligature round it. I next tied up, 
 in the same way, a branch of this vein which entered the 
 
THE SUBCLAVIAN ARTERY. 355 
 
 trunk a little above the clavicle, in a direction from the 
 acromion; and I then secured the lower extremity of the 
 denuded trunk of the jugular vein ; but to effect this last was 
 a task of more difficulty, for the vein here was not only covered 
 by three or four layers of tough cellular substance and fat, but 
 was besides, at times, suddenly puffed up to a very great size, 
 especially whenever from pain the patient made a great 
 exertion, accompanied with a deep and long-continued expira- 
 tion. But notwithstanding all these ligatures the trunk of the 
 vein was still freely supplied with blood from below, as 
 appeared by its occasionally swelling in deep expirations. 
 This obliged me to secure the trunk with a third ligature, 
 about an inch above the clavicle, and, having done so, I cut 
 the vein across between the two lowest ligatures, and laid the 
 inferior portion of it down upon the clavicle. Now removing 
 a little fat, I saw the omohyoid muscle covered with a fascia; 
 it was of an uncommonly large size, and lay very low, near to 
 the clavicle ; it consequently became necessary to sacrifice it, 
 in order to get at that part of the artery which lay near to the 
 outer side of the scalenus muscle. For this purpose a very 
 thin silver spatula was passed under the upper edge of 
 the omohyoid muscle ; with this it was raised a little from 
 its bed, and was cut across. On removing this muscle a thin 
 fascia appeared covering a deep bed of fat. Having cut 
 through the fascia, I now, with the flat end of a silver director, 
 cleared my way among the fat, until I could feel, though not 
 see, the artery. As the vessel was now lying at the bottom of 
 a deep contracted cavity, I judged it necessary to convert this 
 into a more open and less embarrassing form of wound. 
 This I did by cutting across the edge of the trapezius muscle 
 and the numerous layers of membrane which occupied the 
 space included between the deep cavity and the acromial end 
 of the external wound. In effecting this one small artery was 
 divided and secured by ligature. When the wound was thus 
 enlarged, the most anterior of the nerves going to the brachial 
 plexus appeared to view. I now proceeded to lay bare 
 the artery, holding my finger down upon it, and turning aside 
 the superincumbent fat with the flat end of a silver director. 
 But so great was the quantity of this substance to be removed, 
 
356 ON THE OPERATION OF TYING 
 
 that, although I cut away three or four large pieces of fat with 
 a scissors, and drew them out with a forceps, yet, to prevent 
 the remainder from falling down again into the cavity upon 
 the artery, I was obliged to have it held aside by three 
 long and broad spatulas of prince's-metal, bended at the end, 
 and applied one to each side of the wound. This materially 
 faciUtated the subsequent steps of the operation, by keeping 
 the artery uninterruptedly exposed to view. My next object 
 was to detach from the surrounding parts that portion of 
 the artery which lay close to the scalenus muscle. To effect 
 this I first made use of the flat end of the director, scraping 
 with it along the outer or acromial side of the artery. I then 
 ventured to separate it more completely by introducing a 
 blunt aneurism-needle in the room of the director. This 
 I moved upwards and downwards along the vessel until I was 
 enabled to pass it freely under the artery, and to receive 
 its point on the end of a narrow spatula, introduced between 
 the vessel and the scalenus. Peeling the point of the needle 
 on the spatula I was satisfied that it had cleared the artery. 
 I now therefore depressed the handle. On doing so I observed 
 that the point was covered by a dense white membranous 
 substance, closely resembling the coats of an artery. I with- 
 drew the needle, armed it with a double flat ligature (about 
 six threads thick), and, again introducing it on the acromial 
 side of the vessel, I quickly showed its point by the side of the 
 scalenus, covered with the membranous substance as before. 
 I hesitated for a moment, but every one present being satisfied 
 that this substance was not a part of the vessel, I readily 
 tore through it by scraping it with the flat end of the director. 
 Now, merely by depressing the handle of the needle, without 
 in the slightest degree raising the artery from its bed, I 
 was enabled to catch the ligature on the inner side of the 
 vessel. Having got a secure hold of it I withdrew the needle, 
 leaving the ligature, doubled, under the artery. I then 
 divided the ligature into two, and tied the lower with a 
 single knot. Mr. Peile, who had applied one hand to the 
 tumour and the other to the right radial artery, announced, 
 as I tightened the ligature, that all pulsation had ceased 
 in both. 
 
THE SUBCLAVIAN AKTEEY. 357 
 
 The assistants, being all anxious to satisfy themselves 
 of these facts, I let go the ligature. Although I let it out of 
 my hands but for the few moments I was necessarily occupied 
 in these inquiries, yet, even during this short period, the 
 pulsation perfectly returned; I therefore again drew the 
 ligature tight, the pulse in the limb ceased, and I quickly 
 made fast the ligature with a double knot. To enable us to 
 tie this knot we had no occasion for any instrument ; nothing 
 more was necessary than to catch the ends of the ligature 
 close to the vessel, and then to press on them with the points 
 of the fore-fingers, held on a level with the trunk of the 
 artery. No other precaution was necessary to save it from 
 being pulled up from its bed, in drawing the ends of the 
 ligature tight. The unanimous voice of all present directed 
 that the second or upper ligature should be tied, which was 
 done, close to the first, with a double knot. In this awful and 
 critical step of the operation I kept my eye firmly fixed upon 
 the patient. His coimtenance did not undergo the slightest 
 perceptible change. No alteration was observable in the 
 actions of his heart, or in his respiration ; nor did he experience 
 any pain or particular sensation in the limb on the tying of 
 the artery. 
 
 It should be observed that a large vein, which, in the dead 
 subject, I had often found running across the artery, in a 
 direction from the scapula towards the thorax, and which, I 
 had feared, might be productive of much inconvenience on the 
 present occasion, was here found to be flat and empty, and to 
 run so near to the thorax as not to interfere in the smallest 
 degree with the passing of the ligature. 
 
 When the operation was finished three stitches of inter- 
 rupted suture, aided by adhesive plaster, kept the lips of the 
 wound in contact ; on the flap was laid a piece of dry sponge, 
 to bring into apposition the upper and under walls . of the 
 cavity, which had been left after the operation. 
 
 Shortly after he had been laid in bed he complained of cold, 
 but had no rigour. In the course of an hour he felt himself 
 growing too hot. In three hours after the operation his pulse 
 was 96. In this short period he forced me to change his 
 position two or three times, from his back to his sides, to try 
 
358 ON THE OPERATION OF TYING 
 
 if he could by this means obtain any mitigation of what 
 he termed a pain in the small of his back. He did not, how- 
 ever, complain of any pain or fulness in the head, or of 
 any affection of the heart, or difficulty of breathing. His 
 distress, though' rather intense in degree, was of the same 
 kind as I have frequently witnessed after amputation, or other 
 great operations. 
 
 Mr. Wilmot, who remained with him from three o'clock this 
 day until nine o'clock at night, informed me, on my return, 
 that his pulse had got up so high that he had been almost 
 tempted to bleed him ; but a sweat breaking out, had reduced 
 the pulse to its present state (120). For the remainder of the 
 night I took charge of him, and during that time he was 
 affected with a slight tossing of his lower limbs. He continued 
 to complain of his back, and did not enjoy more than five or 
 ten minutes' sleep at a time. He had some thirst, and 
 in the course of the night his pulse rose to 134. He did not 
 complain of the wound, except when he turned on that side or 
 was awkwardly handled, and then he said it was sore. The 
 sweat having at one time ceased for two hours, I observed that 
 the right hand and arm became dry, as well as the left ; and 
 on the return of the sweat both arms were equally moist. 
 The heat of both arms, too, appeared to be the same since the 
 operation, and he has continued to enjoy the feelings and full 
 power of the right hand. 
 
 Wednesday morning. — At six o'clock this morning I took 
 twelve ounces of blood from his left arm ; it flowed slowly, for 
 he drew back his arm while I was making the incision. I 
 gave him a draught, with two drachms of Aq. Ammon. 
 Acetat. ; and for a short time after this I fondly flattered 
 myself that he became more easy and composed. These 
 transient hopes, however, soon gave way to more gloomy 
 apprehensions ; and when I reflected on the quickness of his 
 pulse, his restlessness and want of sleep, his forgetfulness and 
 occasional wanderings of mind, I became greatly alarmed. I 
 therefore summoned a consultation of all the gentlemen who 
 had assisted me, for an earlier hour than that agreed upon the 
 day before. We met at 11 o'clock a.m. His pulse was now 
 134, and the strokes ran so into one another that it was 
 
THE SUBCLAVIAN AETBEY. 359 
 
 difficult to count them. The state of his pulse, we judged, 
 would not be improved by a repetition of the blood-letting. It 
 was therefore agreed that he should be first purged, then take 
 tincture of digitalis," and, if his restlessness required it, take 
 an opiate at night. 
 
 Three o'clock p.m. — At this hour the physic had only 
 operated once, and then very sparingly. His pulse was now 
 driving at a rapid rate. He complained of an occasional 
 cough, which distressed him so much that he was forced 
 to entreat the attendant to keep one hand on his head and to 
 grasp his left hand with the other whenever he felt a fit of it 
 coming on. He complained also of a soreness in his throat 
 when he coughed or swallowed ; and he pointed to the middle 
 of his throat as the seat of this affection. Although I 
 suspected that his fears made him magnify his distress in this 
 particular (for he apprehended that the inflammation, spread- 
 ing from the wound to the throat, must quickly prove fatal), 
 yet, when I recollected that my former patient Cowell had 
 complained of the same sensation, I deemed it prudent to 
 meet it early, and therefore instantly commenced with the 
 digitalis, although his bowels had not been sufficiently freed 
 by the purging medicines. 
 
 At 4 o'clock p.m. he got the first dose of 10 drops. 
 
 At 8 o'clock the second dose of 15 drops. 
 
 At 10 o'clock, 25 drops. 
 
 At 2 o'clock a.m. Thursday, 30 drops ; and at 6 o'clock the 
 same repeated. 
 
 By this medicine his pulse was reduced, so that at 10 o'clock 
 p.m. it beat 120, but still with the same indistinctness as 
 before. 
 
 Thursday morning, 6 o'clock. — The longest sleep he has 
 had in the course of the night has not been above half an 
 hour ; the tossing of the lower limbs continues ; they are dry, 
 and, though covered with woollen stockings, are inclined to be 
 cold. Countenance is natural, but more reduced than when 
 in health. Mental faculties more perfect than yesterday. 
 Sweat continues on the head, trunk, and upper limbs. Has 
 had many stools through the course of the night. State 
 of tongue and thirst as yesterday. Pulse 120, and indistinct. 
 
360 ON THE OPERATION OF TYING 
 
 Moans at times to-day as he did the day before. Says that 
 he has an uneasiness at the small of his back, but that 
 it does not amount to pain. Thinks his throat better. 
 There is some swelling, with a slight appearance of inflam- 
 mation, across the top of the thorax. He now entertains 
 better hopes of his recovery. He begins, however, to com- 
 plain of some uneasiness in his chest, but says that it is 
 relieved by sighing. The bandage, which feels rather too 
 tight on the chest, is now cut across. Heat of right hand, 
 measured by the thermometer, 94 ; that of the left hand, 96. 
 
 Thursday evening, 8 o'clock. — This day, at 1 o'clock p.m., 
 he was suddenly seized with a rigour, which lasted for a 
 quarter of an hour. This was succeeded by a profuse sweat. 
 During the cold fit he talked much and incoherently. Soon 
 after the hot fit commenced he started up, jumped out of bed, 
 and became so violently outrageous that he required two 
 strong men to hold him. In this state he continued for more 
 than an hour. During this paroxysm he made the most 
 powerful exertions with the right as well as with the left hand. 
 After the paroxysm had subsided he enjoyed a sleep of half 
 an hour, during which his breathing was natural. The cough, 
 which had distressed him to such a degree yesterday, is so 
 much relieved to-day as to cause only a slight and momentary 
 uneasiness in his chest. 
 
 Thursday night, 10 o'clock. — He had been raving .a good 
 deal at 8 o'clock this evening, but at half-past nine he became 
 quite collected, and inquired very anxiously about his own 
 situation. Pulse more distinct, though not less frequent. 
 Sweats continue. Some wheezing in his chest. Distress of 
 that part less than it had been early in the evening. A large 
 blister is applied to his chest. 
 
 The inflammatory fulness and redness of the skin at the top 
 of the sternum and left side of the throat is considerably in- 
 creased; the slightest pressure on this swelling gives him 
 very sharp pain. Mr. Wilmot and I, conceiving it possible 
 that his distress might be aggravated by some collection 
 of matter confined or pent up within the wound, removed the 
 dressings. Only a small quantity of reddish water was 
 discharged. I then cut out one of the sutures, and passed a 
 
THE SUBCLAVIAN ARTERY. 361 
 
 probe into the deepest part of the wound, conducting it along 
 the ligature of the artery. We then made a pressure on the 
 inflamed integuments, at the top of the sternum and left side 
 of the thorax, but without obtaining the smallest additional 
 discharge. At this time the aneurismal swelling was in 
 appearance quite removed, and both sides of the thorax were 
 to the sight and touch perfectly alike. 
 
 Friday morning. — He passed the night without any sleep ; 
 raved a good deal, but was not violent. Purging more 
 frequent. Has taken two doses of a mixture, each dose 
 containing §ss. Oxymel Scillse. Cough has not distressed him. 
 He has expectorated some mucus. During the night he 
 complained a good deal of the right fore- arm and hand, — at 
 one time of numbness, and at another of pain. The hand is 
 held with the fingers folded in, and rather stiffened. It now 
 became too obvious that the storm, which had been collecting 
 since the operation, had taken a fatal direction. The present 
 state of the limb so strongly proved the near approach 
 of mortification, that, however reluctantly, I was forced to 
 relinquish every ray of hope, and to prepare my mind for the 
 speedy termination of a case which I had watched with more 
 fluctuations of hopes and fears than ever had agitated me on 
 any former occasion. 
 
 Two o'clock p.m. — The fore-arm was distended at the in- 
 sertion of the pronator teres, and also where the extensors of 
 the thumb pass over the end of the radius ; the hand and 
 fore-arm cold ; the fingers rigidly flexed. The usual appli- 
 cations were made to the limb, but without affording any 
 relief. The mortification went on increasing ; his delirium 
 continued for the greater part of the night; and at four 
 o'clock on Saturday morning he died. 
 
 Appearances on exa/mining the body 26 hours after death. 
 
 Suppuration was established under the integuments on the 
 fore-part of the throat, anteriorly to the sterno-mastoid 
 muscles. On the thorax being laid open we discovered an 
 appearance of suppuration commencing on some masses of 
 fat lying in the anterior mediastinum. The upper lobe of the 
 right lung was attached to the ribs by close and old adhesions. 
 
362 ON THE OPERATION OF TYING 
 
 Between three and four ounces of water found in the peri- 
 cardium. The jugular veins, both, the external and internal, 
 were of a deeper colour than usual. Heart felt rather soft ; 
 right auricle full ; right ventricle less full than usual. No 
 disease in any of the valves on either side of the heart. The 
 internal surface of the right auricle, especially on the septum 
 of the auricle, more red than usual. The redness, though of 
 a brighter tinge than that of the jugular veins, was not such 
 as to indicate the existence of inflammation of this cavity. 
 The venous blood was more fluid than usual. Coagula were 
 found in the right and left ventricles, but not uncommon either 
 in their size or other properties. 
 
 On endeavouring to separate the aneurismal sac from the 
 walls of the thorax, it was found to have connected itself so 
 intimately with the second rib as to have its cavity laid open 
 by an attempt to disunite them. The form of that portion of 
 the bone upon which the aneurism rested was changed from a 
 flat surface to a cupped form. The extent of the altered part 
 of the second rib was about half an inch. 
 
 The aorta, with the great arteries springing from its arch, 
 and the humeral artery, being removed from the body, were 
 examined next day. 
 
 The aneurismal tumour had extended more in length 
 than in breadth, and had ascended so high as to have 
 reached near to the spot on which the ligature had been 
 applied. The aneurismal tumour was nearly as large as a 
 pidlet's egg. 
 
 The artery immediately above the ligature was seen thrown 
 into folds and furrows, which would seem to be the inevitable 
 effect of tying an artery of so great a size. On removing the 
 ligature, and slitting up the artery, its internal coat was found 
 ruptured by the ligature only at one part, to the extent 
 of about one-fourth of its circumference. Through the 
 remainder of the circle the internal surface of the artery 
 presented a white line, obviously produced by the tightening 
 of the ligature. Two very small portions of coagulable 
 lymph were found immediately above the ligature. The 
 trunk of the artery below the ligature was rather small. The 
 branches of the subclavian artery were not at all enlarged. 
 
THE SUBCLAVIAN ARTERY. 363 
 
 I have been (perhaps tediously) minute in detaiUng the 
 particulars of the foregoing cases, because we have, as yet, 
 but one account published of the operation of tying the 
 subclavian artery after it has passed through the scaleni 
 muscles, and no instance, I believe, has hitherto been recorded 
 in which this artery was tied before it had arrived at these 
 muscles. Under such circumstances I would not presume to 
 exercise my own judgment in omitting those particulars which 
 to me did not seem important. 
 
 As I wished that every one who reads these accounts should 
 be unbiassed in drawing his own inferences from the facts, I 
 have studiously avoided interweaving any reflections of mine 
 own. Such as have occurred to me in my attendance on these 
 cases I shall now briefly state. 
 
 To lay bare the right subclavian artery before it reaches the 
 scaleni will not be found difficult by any surgeon possessed of 
 a steady hand and a competent knowledge of anatomy ; but I 
 fear that, with the utmost dexterity, much difficulty wUl be 
 experienced in passing and tying the ligatm-e, even in the 
 most favourable cases. The instrument delineated in Mr. 
 Eamsden's book appears to me well calculated for the purpose, 
 and yet it is not free from objection. I should fear that the 
 coats of the artery might be cut by the sharp edges of the 
 flexible steel plate as it is passing round the vessel. Some 
 means similar to those I have mentioned must be adopted to 
 prevent the artery from being raised out of its bed while the 
 surgeon is tying the knot. 
 
 This operation, difficult on the right, must be deemed abso- 
 lutely impracticable on the left subclavian artery. For the 
 great depth from the surface at which this vessel is placed, — 
 the direct com'se which it runs in ascending to the top of the 
 pleura, — the sudden descent which it makes from this to sink 
 under the protection of the clavicle, and the danger of including 
 in the same ligature the eighth pair of nerves, the internal 
 jugular vein, or the carotid artery, which all run close 
 to and nearly parallel with this artery ; these all constitute 
 such a combination of difficulties as must deter the most 
 enterprising surgeon from undertaking this operation on the 
 left side. 
 
364 ON THE OPEEATION OF TYING 
 
 Even on the right side this operation will be very seldom 
 required ; for it can only be called for in injuries or diseases 
 of that small portion of this artery which lies between the 
 scalenus and the clavicle. It is scarcely necessary to observe 
 here how frequently such a case will be complicated with 
 diseases of the great trunks of the arteries nearer to the 
 heart, or how difficult it must be to discover the existence of 
 those internal affections. When examining any pulsating 
 tumour near the top of the thorax, the surgeon should bear in 
 recollection the remark made by Mr. Astley Cooper, as quoted 
 by Mr. A. Burns, in his ' Surgical Anatomy of the Head and 
 Neck,' " that aneurism of the aorta may assume the appear- 
 ance of being seated in one of the arteries of the neck." The 
 quantity of blood lost by the haemorrhage, which yet we 
 presume was the immediate cause of death in this case, was 
 very inconsiderable, being infinitely less than I had ever before 
 known to prove fatal. 
 
 The operation of tying the subclavian artery on the acromial 
 side of the scaleni muscles is one which will be much more 
 frequently required, and which can be performed with equal 
 facility on the artery of either side. The most striking and 
 most unfavourable circumstance of this operation is the great 
 length of time required to perform it, although the ultimate 
 and essential steps of it had been executed with so much 
 facility. 
 
 This delay is by no means unavoidable. Indeed, any man 
 who will take the trouble of reflecting on the anatomy of the 
 parts concerned, or who will himself perform this operation 
 on the dead subject, must be convinced that it may be executed 
 in as short a time as the operation for femoral aneurism. The 
 causes of delay in this instance were, first, the almost unpre- 
 cedented nature of the operation ; the caution with which we 
 tread upon untried ground rendering every incision more slow, 
 and every step more deliberate. Next, the great anxiety to 
 secure every vessel, even the smallest branch of an artery, or 
 a vein, lest our view should be obscured, or our progress 
 obstructed by any quantity of blood flowing into the wound, 
 was a principal source of this delay. By referring to the 
 account of the operation the reader can readily estimate what 
 
THE SUBCLAVIAN ABTBRY. 365 
 
 loss of time was occasioned by this object. I do not mean to 
 say that we should pass through the various stages of the 
 operation absolutely regardless of the flow of blood ; but I am 
 confident that we have no occasion to tie up any but the 
 larger veins, and the suprascapular artery, if it should chance 
 to be wounded. The curved spatulas, while they hold aside 
 the lips of the wound, will, at the same time, serve to stop the 
 bleeding. I cannot forbear to recommend, in the strongest 
 manner, the use of these instruments, not merely in this, but 
 in every other operation where the depth of the wound is 
 considerable, compared with its length, and where it is of 
 importance for the surgeon to distinguish the jparts which lie 
 at the bottom of such a cavity. 
 
 The necessity for removing any portions of fat can occur 
 only in very corpulent subjects. 
 
 In passing the needle round the artery, it will be found 
 absolutely necessary to have the scalenus muscle held back by 
 one of these spatulas, otherwise it will be impossible to pass 
 the ligature without including along with the artery some 
 portion of the muscular fibres. 
 
 The facility with which the ligature was passed round the 
 artery was in the highest degree gratifying to every one 
 present. This inestimable advantage will be secured by an 
 attention to the following points : — First, to extend the wound 
 out towards the acromion, by which the form of it is changed 
 from a deep cavity to a superficial wound ; next, to introduce 
 the needle on the outer or acromial side of the artery ; and, 
 lastly, to select the most favourable part of the artery. This, 
 on inspection, will be found to be where it has just passed 
 through the scaleni. How necessary this selection is will 
 appear by the perusal of the account of Mr. Eamsden's 
 operation ; for he, by attempting to secure this vessel near to 
 the first rib, or rather, as he says, at the lower edge of the first 
 rib, found it almost impossible to turn the needle round the 
 artery in the very narrow space between this bone and the 
 clavicle. 
 
 Cases in which this operation may be necessary will not be 
 very infrequent. In wounds of the axillary artery, either 
 while it runs in front of the thorax, or whUe it lies along the 
 
366 TYING THE SUBCLAVIAN AKTEEY. 
 
 humerus, this operation will be preferable to following the 
 course of the wound by cutting through the pectoral muscles 
 in the one case, or entangling ourselves in the brachial plexus, 
 when the artery is wounded in the axilla. The pain and 
 difficulties of the operation above described are trifling when 
 compared to those which must occur in following the course of 
 these wounds. 
 
 When an aneurism of the axillary artery shall require this 
 operation, we may indulge a confident hope that the rest 
 of the arterial system is free from disease, as it appears 
 to have been in two of the foregoing cases, that of Levanee 
 and of the Eev. Mr. S. ; one, where the disease arose spon- 
 taneously, — the other, where it could be traced to accidental 
 injury. Although this operation has not yet proved ultimately 
 successful, yet I think we should not desj)air. The history 
 of surgery furnishes parallel instances of operations, now 
 generally adopted, which, in the few first trials, failed of 
 success. 
 
367 
 
 PEACTICAL OBSERVATIONS UPON CERTAIN DISEASES 
 OP THE ANUS AND RECTUM. 
 (Dublin Hospital Reports vol. 5.) 
 
 Diseases of the anus and rectum have of late years, much 
 engaged the attention of the profession, as appears by the 
 numerous publications on these subjects. StiR, however, 
 I think practitioners will allow that the diagnosis and treat- 
 ment of these complaints admit of further improvement. 
 With a wish to contribute to this desirable object, I beg leave 
 to submit to the profession the following remarks on a few of 
 these diseases : — 
 
 OEGANIC STRICTURE OF THE RECTUM. 
 
 This disease spares neither sex nor rank ; it most frequently 
 attacks those who are about the meridian of life ; sometimes, 
 however, it afflicts children as early as the seventh or eighth 
 year of their age. I have not met with any instance where it 
 attacked a person at or beyond sixty years of age. 
 
 In some few cases the patient appears to be aware of 
 the moment of the first attack of this disease, for he tells 
 us that without any previous illness the bowels at a certain 
 period suddenly became costive; that for the purpose of 
 relieving them he took large and repeated doses of physic for 
 three, four, or five consecutive days; that at length his 
 bowels suddenly gave way and a very severe purging took 
 place, which, having continued for a day or two, was then 
 succeeded by those symptoms which attend the disease when 
 fully formed. 
 
 Many patients, however, cannot give any account of the 
 first approach of this disease ; they merely state that they 
 have been for many weeks, months, or years subject to it ; 
 that the symptoms from the commencement were pretty much 
 the same as those they now labour under, but perhaps not 
 quite so severe and urgent. 
 
868 CERTAIN DISEASES OF THE 
 
 When organic stricture is fully formed (by questioning him), 
 we learn from the patient that in the course of each day 
 he has many and sudden calls to stool ; that at each of these 
 he is obliged to strain very much, and that the straining, 
 which is not followed by any severe pain, produces a discharge 
 of not more than a tablespoonful of mucus, which is some- 
 times streaked with blood, and very rarely mixed with a small 
 quantity of fasces ; that these evacuations are generally 
 attended with a copious discharge of wind, and that as soon 
 as the evacuation has taken place he feels free from pain or 
 uneasiness ; the remission, • however, is of short duration, as 
 he is soon again compelled to undergo the same unavailing 
 distress. The number of these discharges are seldom less 
 than from seven to twelve during each day and night ; they 
 do not take place at regular intervals, but generally a con- 
 siderable number occur in quick succession, and then are 
 followed by a pretty long interval of ease. The greater 
 number of these evacuations are devoid of fseces ; a feculent 
 stool is passed perhaps once in two or three days ; the faeces 
 are then found passed in short pieces and of very reduced 
 dimensions, not larger than a full-sized catheter, and in 
 quantity not equal to what is passed in an ordinary evacuation 
 by a person in health, yet after each feculent stool the patient 
 feels much reheved. 
 
 There is not the slightest prolapsus ani with any of these 
 evacuations. 
 
 The bladder is in some cases slightly affected ; the patient 
 then complains of a little difficulty or delay in passing 
 his urine. 
 
 In some cases a fistulous opening forms in the nates or the 
 perinaeum, which will admit a probe to pass into the rectum ; 
 it yields a moderate quantity of healthy pus. The fistula 
 undergoes little or no change from the time of its first appear- 
 ance, even until the death of the patient. In some cases, 
 especially in females, I have known the number of these 
 fistulous openings to amount to twelve or twenty. The 
 majority of cases of stricture of the rectum, however, are 
 unattended by fistulae. 
 Although this state of daily suffering proceeds with the 
 
ANUS AND RECTUM. 369 
 
 most unvarying regularity, not only for weeks and months, 
 but even for many years, yet the constitution of the patient 
 does not seem to sympathise in the slightest degree for a long 
 time ; not only do his colour and appearance proclaim 
 the enjoyment of good general health, but even the most 
 strict examination cannot discover in any of the functions 
 the slightest deviation from health, except those above men- 
 tioned. 
 
 After a lapse of time, however, which is very different in 
 different cases, a peculiar paleness of countenance and wasting 
 of flesh announce an inroad on the constitution ; those 
 symptoms are soon followed by night-sweats, and now the 
 patient complains of uneasiness about the sigmoid flexure of 
 the colon, which soon extends along the left colon. 
 
 In this stage of the disease it too frequently happens 
 in females that a communication is formed between the rectum 
 and vagina, which causes the greater part of the entire of the 
 faeces to pass through the latter. In men, but more rarely, a 
 similar communication is established between the rectum and 
 bladder. 
 
 As the disease draws to a close the patient begins to suffer 
 much more serious distress from the state of the rectum, for, 
 in addition to the frequent unavailing efforts to discharge the 
 bowels, he is troubled on the slightest exertion — such as 
 coughing, sneezing, or voiding urine — with an involuntary 
 discharge of a thin brownish fluid of a muco-purulent nature. 
 After some time this peculiar discharge comes away in the 
 morning, the moment the patient rises from his bed. In the 
 last stage of the disease this discharge comes away unceasingly 
 without the consciousness of the patient, and the faeces will 
 not pass unless in a perfectly liquid state. 
 
 This aggravation of local distress is accompanied by 
 a corresponding decline in the general health ; his appetite 
 fails, thirst becomes very urgent, emaciation proceeds rapidly, 
 hectic fever becomes fully formed, though more marked 
 by profuse night-sweats than by mid-day or evening exacerba- 
 tions ; and now the patient, extenuated tp the last degree, 
 seems to be carried off as much by the exhausted state of his 
 constitution as by the torments of the local disease. 
 
 2b 
 
370 CERTAIN DISEASES OF THE 
 
 Sometimes, in the advanced state of this disease, the 
 patient is seized with symptoms of peritoneal inflammation, 
 which puts a speedy termination to his sufferings, and he 
 is suddenly carried off. In such cases, on examination after 
 death, we discover that the process of ulceration had opened 
 the intestine immediately above the stricture, and that through 
 this opening a portion of faeces had passed into the cavity 
 of the abdomen. 
 
 In some very few patients the hectic fever seemed to 
 have been arrested by the warmth of summer weather, but 
 only to run the remainder of its course with unusual precipi- 
 tancy on the approach of winter. 
 
 Among a considerable number of patients afflicted with this 
 disease I have had an opportunity, in two instances only, of 
 meeting with it in its incipient state. In both of these the 
 patient complained of different symptoms of irritation of the 
 rectum, frequent stools, discharges mixed with mucus, and 
 certain feelings of uneasiness. On examination, by the finger, 
 a thickening and slight projection of the gut was felt at 
 a small spot on one side; this morbid alteration spread 
 gradually round the entire of the canal, and extended along it 
 only to a small distance ; but, until the morbid derangement 
 of structure had almost entirely performed the circle of the 
 intestine, the patient did not exhibit those symptoms which I 
 consider as the common and inseparable attendants on 
 stricture of the rectum. However constant in their attend- 
 ance or unvarying in their course may be the symptoms of 
 this disease, yet will the surgeon desire to be confirmed in his 
 opinion by manual examination. Proceeding to make this 
 examination we often observe, at the orifice of the anus, the 
 following appearance, which is indeed almost always present 
 when the disease is seated near to the external sphincter, 
 namely, at each side of the anus a small projection, which on 
 its external surface appears as a mere elongation and thicken- 
 ing of the skin, but internally presents a moist surface, not 
 exactly like the lining membrane of the gut, nor yet can 
 we say that it is ulcerated; these two projections lie close 
 together below and divaricate above, presenting a resemblance 
 to the mouth of an ewer. Whenever this external appearance 
 
ANUS AND EBCTUM. 371 
 
 exists I feel almost certain of finding a stricture of the rectum 
 before the finger is pushed as far as the second joint into the 
 gut. In some cases, however, this external mark has not 
 been present. 
 
 When the stricture is situated pretty high up, the portion 
 of the gut interposed between it and the anus is found to be 
 in a perfectly healthy state ; but when the finger arrives at the 
 stricture it is arrested by the narrowness of the canal, which 
 will barely admit the point of it; if now a slight degree 
 of force, combined with a boring motion, be employed, the 
 finger may be pushed through the thickened and indurated 
 part, and will then (as well as its benumbed condition permits 
 it to feel) find that the gut just above the stricture is in a very 
 healthy state. The extent of the stricture, however, is very 
 variable ; sometimes it is little more than a mere ring, but at 
 other times it extends along the canal as high as the finger 
 can reach. 
 
 I have not yet met with any instance in which the intestine 
 was strictured, only by means of bands thrown across its 
 canal. Such cases, I presume, must be very rare. 
 
 In a few instances the stricture has been seated so high 
 in the gut that it could be but barely touched with the 
 point of the finger, until the patient was desired to "force 
 down," and then a satisfactory examination of it could be 
 made. 
 
 Cases of this disease examined after death present all the 
 coats of the intestine very much thickened, except the peri- 
 toneal tunic, which, when closely inspected, is found to retain 
 its healthy structure and appearance ; the muscular, cellular, 
 and mucous coats are much thickened ; the latter is moreover 
 hardened and raised into irregular ridges or folds, but without 
 any ulceration.* 
 
 As this disease admits of examination by the touch, and 
 produces symptoms so unchangeable in their course, and 
 BO uniformly alike in every case, it cannot, with ordinary 
 
 * In the fourth fasciculus of Dr. Bailie's Morb. Anat., and plate 4, we 
 have an excellent specimen of the disease of organic stricture of the 
 rectum ; and in the same plate, fig. 2, we have a good specimen of cancer 
 of this intestine. 
 
372 CERTAIN DISEASES OF THE 
 
 attention, be confounded with any other ; nor can it, when 
 present, be overlooked by the practitioner. In consequence, 
 however, of its presenting some symptoms in common with 
 some other diseases, both of the rectum and the adjoining 
 organs, I shall notice a few of the distinguishing characters 
 between stricture of the rectum and these other affections. 
 
 1st. Cancer of the rectum has much in common with 
 stricture, namely, the same narowing of the canal and hard- 
 ness of its walls, the frequent straining stools and discharge 
 of bloody purulent mucus ; in the cancerous affection, how- 
 ever, the patient has a leaden sallow cast of countenance, and 
 suffers severely from lancinating pains darting through the 
 hips and pelvis into the groins and down the thighs and legs. 
 Although cancer of the rectum, in its early stage, presents to 
 the finger a feel very similar to stricture, yet, by repeating the 
 examination after an interval of a few weeks, we discover that 
 the cancerous ulceration has, in the interval, destroyed some 
 portion of the hardened wall of the intestine, and has thus 
 produced a condition of the parts very different from that found 
 in cases of stricture of the same duration. 
 
 2nd. There is a rare form of scirrhus of the uterus and 
 vagina, in which the latter passage is almost obliterated by a 
 cancerous thickening of its walls ; this gives rise to a train of 
 symptoms not unlike those attending stricture of the rectum ; 
 examination by the finger, however, is alone required to 
 remove all doubts. 
 
 3rd. The same test will apply to enlarged prostrate gland, 
 if at any time the symptoms should simulate those of stricture 
 of the rectum. 
 
 4th. Stricture of the rectum, in its early state, may be 
 mistaken for an ulcer in this intestine ; if, however, the ulcer 
 be low down, it will become visible by expanding the anus, or 
 by introducing a blunt polished gorget into the bowel, with its 
 concavity towards the diseased side of the rectum ; the finger, 
 too, if steadily pressed against it, will be received into the 
 cavity of the ulcer, although in a hasty examination this part 
 feels as if it were a ridge; a severe pain, too, attends the 
 evacuation of the bowels in cases of ulcer of the rectum, while 
 stricture is free from such. 
 
ANUS AND RECTUM. 373 
 
 5th. A tumour in the pelvis may compress the rectum so 
 as to narrow and materially obstruct the canal; in such 
 cases, however, we shall- find that the projection comes from 
 one side only, and the coats of the intestine at this part 
 retain their healthy structure and their natural softness. 
 
 And lastly. It may not be amiss to mention that we some- 
 times find in patients who are free from all symptoms of 
 morbid condition of the rectum, that the finger in ano cannot 
 discover any canal in the gut, the entire of its calibre above 
 the sphincter being filled up with soft folds of the lining mem- 
 brane; repeated observations, however, teach us that such 
 a state is not morbid, as it in no way intercepts or disturbs 
 the healthy functions of the intestine. 
 
 The treatment by bougie, usually recommended in this 
 disease, appears to be well calculated to alleviate the sufferings 
 of the patient. I feel confident, however, that a perfect cure 
 of the organic stricture of the rectum has not been affected by 
 any plan of treatment hitherto employed. I have paid great 
 attention to the use of bougies, and yet I must candidly 
 declare that hitherto I have not been so fortunate as to have 
 effected a permanent cure in a single instance^ nor have 
 I had the good fortune to meet with any patient whom I kneiv 
 to have been afflicted with this disease, who had been cured 
 by another surgeon. No man can be more ready to proclaim 
 and boast of our control over diseases, and therefore I trust 
 that this declaration will be received by my brethren as it is 
 intended, viz., that it will cause them to consider the history 
 and nature of this intractable disease, and to engage them- 
 selves earnestly in discovering some other plan of treatment 
 which will gain the object of our anxious wishes. 
 
 I have not been contented with applying the bougie simply ; 
 I have often made it at the same time the means of conveying 
 various applications to the seat of disease. For this purpose 
 I have employed bougies with a deep groove running spirally 
 their whole length, so that the ointment employed should not 
 be rubbed off the instrument by the tightness of the anus and 
 its sphincters. 
 
 I have nothing cheering to offer on the treatment of this 
 disease ; I have given the fullest and fairest trials to various 
 
374 CERTAIN DISEASES OF THE 
 
 internal medicines. Mercury I have employed in a great 
 number of its preparations, and, although I have never yet 
 met with a case of this disease which could be fairly traced to 
 a venereal origin, yet I have pushed the mercury as far, and 
 have kept up the ptyalism as long, as I have done for the most 
 obstinate forms of venereal disease, but without any permanent 
 benefit in a single instance. 
 
 Arsenic also I have administered, as far as was consistent 
 with the safety of the patient, but without benefit ; I must say 
 the same of cicuta ; neither has iron shown any power over 
 this disease. 
 
 Large quantities of mucilage appear to give most relief. 
 Blue pill, combined with a quantity of Dover's powder, has 
 also occasionally afforded much temporary alleviation. 
 
 This is the only disease to which I think the title of stricture 
 of the rectum should be applied ; I would not give this name 
 to the obstruction of the gut at the junction of the colon and 
 rectum, nor can I admit the existence of what is termed the 
 spasmodic stricture of the rectum. I am well aware that the 
 greater number of modern authors not only speak confidently 
 of spasmodic stricture of the rectum, but that even some 
 describe various forms of this affection. Thus Mr. White 
 speaks of, but certainly does not describe : — 1st. Permanent 
 spasmodic stricture; 2nd. Simple stricture; 3rd. Spasmodic 
 constriction of the sphincter ani ; and he declares the bougie 
 to be the principal remedy for each of these. Even those 
 authors who notice only one kind of spasmodic stricture of 
 the rectum agree with him in extolling the bougie as the 
 principal remedy. 
 
 I must, however, frankly declare that in the course of 
 a pretty extensive practice for the last twenty years I have not 
 been able to discover a single case of a disease corresponding 
 to the description of the spasmodic stricture of authors. I 
 therefore feel a considerable share of scepticism on this point. 
 Indeed, I not only doubt the existence of any such disease, but 
 I can recollect many cases in which this suspected condition 
 of the rectum has yielded to the ordinary means for improving 
 the state of the stomach and bowels, especially when com- 
 bined with positive assurance to the patient that no such 
 
ANUS AND RECTUM. 375 
 
 disease had existed ; by this assurance alone we can sometimes 
 remove all his anxiety and apprehension on this subject. 
 
 With respect to the obstruction and thickening of the colon, 
 either at its junction with the rectum or higher up, I think 
 that it is an affection very different in its symptoms and in its 
 nature from that disease which I have just attempted to de- 
 scribe ; for in cases of the former we find that in the advanced 
 stages of the disease the patient cannot procure any evacuation 
 without the aid of purgatives, nor is he (as in stricture of the 
 rectum), harassed by frequent ineffectual strainings at stool ; 
 guided by his own sufferings, too, he can point to the spot 
 where the disease is seated. On examination after death we 
 find a very considerable thickening of the coats of the 
 intestine in the circular direction, but of short extent longi- 
 tudinally. The canal at the seat of the stricture is nearly 
 obliterated, while the intestine immediately above is dilated 
 into a wide pouch. 
 
 The symptoms which are stated by authors to indicate these 
 diseases of spasmodic stricture, or of organic stricture seated 
 beyond the reach of the finger, will, upon investigation, be 
 found very fallacious ; even supposing all those enumerated 
 should be found combined in the same individual : thus we 
 are told that in such cases we arrive at a knowledge of the 
 existence of these diseases by examination with a soft bougie, 
 by the very diminished diameter of the fseees, and by the 
 admixture of blood or mucus with the stools. 
 
 The soft bougie, however, may, and very generally will, 
 receive an impression from the projecting ridge of the sacrum; 
 for it is by no means an easy matter to pass a rectum-bougie 
 so that it shall not be arrested at this point, and consequently 
 receive an impression from the projecting bone. 
 
 The diminished diameter of the fseees, too, may be produced 
 by any irritation in the rectum, which will cause it to act 
 frequently, and with increased contraction; this is often 
 experienced even in perfect health. 
 
 The admixture of mucus or blood with the faeces is also 
 frequently met with in other and very different affections 
 of the bowels. 
 
 To prove the futility of these symptoms as a discriminating 
 
376 CERTAIN DISEASES OF THE 
 
 test, and the danger of being misled by them, I shall briefly 
 state the outlines of one case only. 
 
 Mr. — — , set. ann. 36, who had lived rather fully and freely, 
 applied to me six or seven years ago under the following 
 circumstances: — He said that he had been, for the last 
 two years, affected with stricture of the rectum ; that in the 
 preceding year he had an attack of dysentery, and that since 
 that time he found the stricture worse ; the diameter of the 
 faBces diminished, calls to stool more frequent, and seldom 
 passing without an admixture of blood and purulent mucus ; 
 he was losing flesh rapidly, his appetite and rest were very 
 indifferent, and his mind was miserable. Having examined 
 the rectum by the finger I expressed to him my hopes that he 
 was not affected with such an intractable malady, by which I 
 very nearly forfeited his confidence ; for he told me that he 
 had applied to a very eminent physician in the north of 
 England, and then to another in London, both of whom 
 assured him of the existence of this disease ; and lastly, he 
 had been under the care of the late Mr. White, of Bath, who 
 furnished him with the bougies he was then using, and, 
 immediately introducing one, he showed me the mark which 
 the stricture impressed on it. My most urgent remonstrance 
 could at this time only obtain from him a promise that 
 he would not use the bougie as frequently, or for as long 
 a period as usual. By small doses of blue pill, combined with 
 compound powder of Ipecacuanha and an enema of Olei. Oliv. 
 cum Subacet. Litharg. liquor., the irritation of the bowels was 
 mitigated in the course of eight or ten days. Availing myself 
 of this favourable change I again urged him to lay aside 
 the bougie, and, with some difficulty, obtained a truce for ten 
 days ; within this period it fortunately happened that he 
 passed one consistent motion, in which the faeces were of 
 a large diameter ; after this I had but little trouble in pre- 
 vailing on my patient to lay aside altogether the use of 
 the bougie. By persevering in the internal use of mild bitters 
 and bark, and injecting every night an enema, consisting 
 of 01. Oliv. and Unguent. Supernitrat. Hydrargyr., into the 
 rectum, his disease was finally cured, and since that time his 
 bowels, though sometimes deranged by ordinary complaints, 
 
ANtrS AND RECTUM. 377 
 
 have never suffered from a return of the former affliction, and 
 he has enjoyed very good health. 
 
 When we consider the irritable state of this patient's bowels, 
 the wasting of his flesh, and the wretchedness of his mind, 
 we may, I think, reasonably believe that a further perseverance 
 in the use of the bougie would have rendered his disease 
 eventually fatal; yet here were present all those symptoms 
 which are said to indicate stricture high up in the rectum : the 
 event has proved that no such disease did exist. And here let 
 it be remembered that serious mischief has occasionally been 
 committed by rude attempts to dilate a supj)osed stricture at 
 the top of the rectum or termination of the colon, for I have 
 known two cases where peritoneal inflammation and death 
 speedily ensued ; and I have heard, on the best authority, of 
 two similar instances. 
 
 Spasmodic stricture of the sphincter ani must, I believe, be 
 a very rare disease. Dr. Baillie has given one case of it 
 in 6th vol. Trans. College of Physicians, and has, with his 
 usual perspicuity, pointed out its characteristic symptoms. 
 The only case which I had ever met with had been treated as 
 stricture of the rectum ; it was in a young man of rank, who 
 applied to me for relief from a stricture of the rectum. He 
 told me that an eminent surgeon in a provincial town, another 
 in Dublin, and another in London, had all assured him that 
 such was his disease. He informed me that during the 
 last two years he had suffered from it for two or three months 
 at a time, and then he enjoyed immunity from it for four 
 or five months. By minute inquiry into the symptoms, 
 and by examination of the rectum, I satisfied myself that 
 this disease was only a spasmodic condition of the sphincter. 
 But, in order to convince my patient that his fears of stricture 
 were unfounded, I passed a wooden globe, three and a half 
 inches in circumference, mounted on a stalk of whalebone, 
 ten inches up the rectum without having met with any 
 • obstruction. 
 
 VASCULAE XUMOUKS OF THE EECTXJM. 
 
 This disease is readily known by attention to the following 
 symptoms : — Whenever the bowels are evacuated the patieni; 
 
378 CERTAIN DISEASES OF THE 
 
 feels a protrusion through the anus ; the protruded part 
 is observed to consist of a greater or smaller number of 
 tumom-s of different sizes, soft and spongy to the feel, of 
 a pm-plish colour, with a number of minute, yet very distinct, 
 vessels on the surface of each. It will be absolutely necessary 
 for the surgeon, in suspected cases, to examine the parts 
 when protruded; for if, relying upon the accuracy of his 
 touch, he merely examines by the finger introduced into 
 the rectum, these tumours will, in all probability, elude his 
 scrutiny. 
 
 In the early stage of the disease the protruded parts retire 
 spontaneously, but in the advanced stages they require to be 
 replaced by the hand. The evacuation of the bowels is 
 followed by pain, which in that advanced stage of the disease 
 does not cease for two or three hours. In some instances the 
 patient informs us that the pain, which is pretty severe at the 
 time of the evacuation, becomes almost insupportable in 
 the course of half an hour or an hour after, and generally 
 continues so for five or six hours. -These last are cases 
 of vascular tumours, complicated with fissure of the rectum, 
 the very severe pain being caused by the latter disease. 
 
 There are some cases of vascular tumours in which the 
 patient suffers, not so much from pain as from loss of blood 
 at each evacuation; this I have known to reduce some of 
 these unhappy sufferers to a state of exsanguine exhaustion. 
 In this exhausted state of the patient we find the sphincter 
 ani so very wide that it can easily admit all the fingers 
 conjoined; yet this, in a few days after the operation, will 
 resume its natural state of contraction. If we watch this 
 disease for some months together we shall find that when the 
 vascular tumours are combined with fissure there are periods 
 of exacerbation during which the patient, after an evacuation, 
 writhes in severe agony, and cannot allow the parts to be 
 returned. At this time the tumours feel hard and seem to be 
 inflamed. 
 
 I had an opportunity of examining the structure of these 
 tumours in a patient who died of another disease. On slitting 
 up the rectum I saw three blood-vessels, each as large 
 as a crow-quill, running for some way down the intestine, and 
 
ANUS AND RECTDM. 379 
 
 then dividing into a number of branches ; these vessels 
 ramified very profusely, and each seemed, by interweaving of 
 its branches, to form one of these tumours. The trunks and 
 branches were covered only by the lining membrane of the 
 intestine. This examination shows us how inapplicable to 
 this disease are the terms " varicose tumours," " hsemorrhoidal 
 excrescences." 
 
 The opinions of the profession are divided as to the best 
 mode of removing these tumours, some preferring the ligature, 
 others excision. I am decidedly in favour of the latter, for 
 this reason, that Tetanus, the consequence which is to be 
 dreaded in the former mode of proceeding, cannot by any 
 means be foreseen or guarded against ; whereas haemorrhage, 
 which alone is to be feared in the operation by excision, may 
 be prevented, and can most certainly be suppressed. 
 
 The following mode of operating I have found to be uniformly 
 and permanently successful ; and it is considerably less severe 
 than that generally recommended : — 
 
 The tumours having been made to protrude by means of a 
 purgative injection, I direct my assistant to pass a hook 
 or common tenaculum through one or two of the largest, 
 while I seize another lengthwise with a polypus-forceps ; then, 
 drawing the tumour a little towards the axis of the gut with a 
 large pair of scissors passed behind the forceps, I cut off all 
 that portion which is engaged between its blades. I then 
 proceed in the same manner to remove those tumom-s which 
 the assistant holds transfixed by the hook. By fastening and 
 drawing out the tumour with the forceps we much facilitate 
 its removal by the scissors. Proceediag in this way I guard 
 against these tumours being drawn up within the sphincter as 
 soon as the first had been removed. I do not think that any 
 case will require the removal of more than three of these 
 tumours, and not unfrequently the cure will be ensured by 
 cutting off only two of them. "When the operation is finished 
 the protruded parts generally retire within the sphincter. 
 Should any part remain out, it must be completely pushed in 
 with the finger. 
 
 In order to guard against the danger of haemorrhage, I take 
 care not to prolong my incision higher on the bowel than 
 
380 CERTAIN DISEASES OF THE 
 
 what I conceive will, when replaced, lie within the circle 
 of the sphincter ; for if we cut the gut higher up this part, 
 when returned, may bleed freely from not having any surface 
 closely opposed to it. Besides, we know that by cutting 
 higher up we are in danger of cutting the trunk of the 
 vessel, instead of confining our incision to the tumour, which 
 is composed solely by the convolutions of its very minute 
 branches. 
 
 I have said that if hsemorrhage should follow this operation 
 it can most certainly be arrested. This I have done 
 satisfactorily in a case where the patient had suffered for 
 nearly twelve hours by bleeding into the gut, from which 
 it was at intervals shot forth involuntarily, with forcing and 
 straining. Many and unavailing were the methods employed 
 by three or four surgeons and myself, until at length I 
 bethought me of Petit's method of stopping an haemorrhage 
 from the rectum. In this ease I made use of sponge instead 
 of the lint recommended by that author. 
 
 I should be afraid to adopt Mr. Hey's method of cutting 
 away all the protruding tumours, together with the skin at the 
 verge of the anus, lest the patient should afterwards experience 
 that distress which a too contracted state of this outlet must 
 occasion ; for in one case where, for the purpose of extirpating 
 warts, a ring of skin at the verge of the anus had been cut 
 away along with these excrescences, the condition of the 
 patient was rendered truly miserable. 
 
 It will be satisfactory to timid patients to learn that this 
 disease of vascular tumours may be rendered very mUd, if not 
 ultimately cured, without the necessity of resorting to an 
 operation. By causing the patient to inject four or five 
 ounces of an injection, consisting of two grains of sulphate of 
 zinc to each ounce of water, every night going to bed, and 
 making him retain it during the night, I have known the 
 disease so much alleviated that patients have flattered them- 
 selves they had obtained a perfect cure. I have known some 
 of them, though not living in the most regular manner, yet 
 enabled to enjoy all the sports of the field without incon- 
 venience. I fancy that this plan of treatment has succeeded, 
 best when begun immediately after one of the painful fits 
 
ANUS AND RECTUM. 381 
 
 the disease. I have known many of these patients much 
 benefitted by smearing, after each evacuation, the protruded 
 parts with a liniment of 01. Oliv. §ii. and Plumbi Subacetat. 
 liquor., 5i. 
 
 ULCER OF THE RECTUM. 
 
 We sometimes find within the rectum, at a short distance 
 above the anus, an ulcer unconnected with any other disease. 
 In such cases the patient complains that he observes his linen 
 stained with a purulent discharge, which often flows when he 
 is not at stool ; on examination this will prove different from 
 healthy pus, frequently containing an admixture of thin 
 bloody fluid; at times the quantity of discharge is much 
 lessened, and then the sufferings of the patient are aggravated, 
 but on the flowing off of a larger quantity he experiences great 
 relief ; he suffers sharp pain on going to stool, and this con- 
 tinues for an hour or two. On examination the finger soon 
 discovers the seat of the disease, which at first feels raised and 
 rather tough, but, by pressing the finger firmly on this spot, 
 the point sinks into a smaU hollow cup of an ulcer, the edges 
 of which are found in some degree hardened. We may obtain 
 a satisfactory view of the ulcer by passing upon the finger a 
 blunt polished gorget, the cavity of which is to look towards 
 the seat of the disease ; then, by everting the anus as much 
 as we can, we shall obtain a full view of the ulcer by the light 
 reflected from the gorget. 
 
 The unhealthy nature of the discharge, the degree of pain 
 and hardness of the edges of this ulcer, might make us 
 apprehend some carcinomatous affection ; but in any doubtful 
 case, by temporising and watching the course of the disease 
 for a few weeks, we shall have all doubts removed ; for if it be 
 cancerous the ulcer will, in this period, have changed in form 
 and extended in size ; besides, on strict examination, whilst 
 the point of the flnger lies in the cup of the ulcer, it will be 
 found that the hardness is confined to the edges, whilst 
 the bottom of the ulcer is soft. 
 
 The remedy for this disease is to introduce into the rectum 
 a convex-edged scalpel, and make an incision through the 
 entire length of the ulcer, continuing it through the sphincter, 
 and dividing the verge of the anus ; as soon as this wound 
 
382 DISEASES OP THE ANUS AND RECTUM. 
 
 has got into a state of suppuration we should dress it and the 
 ulcer with some stimulating ointment, introduced on a dossil 
 of lint. The cure goes on without interruption, although it 
 is rather tedious and slow of healing. I need hardly add 
 that the final cicatrisation will be promoted by the occasional 
 application of nitrate of silver. 
 
383 
 
 FATAL CONSEQUENCES RESULTING FROM SLIGHT 
 WOUNDS RECEIVED IN DISSECTION. 
 
 (Dublin HospitalReports, vols. A & i.) 
 
 Case 1.— On Monday, December 1st, 1818, Mr. William 
 Hutchinson, one of my pupils, of rather a delicate constitution, 
 received a slight scratch of the knife on the. outer side of the 
 first phalanx of the right thumb on opening the body of a man 
 who had died of cynanche laryngea in Dr. Steeven's Hospital. 
 The cellular membrane on the external surface of the larynx 
 and pharynx contained that amber-coloured fluid, resembling 
 melted jelly, which is so often met with in such as have been 
 carried off by this disease. The wound was not more than 
 one-sixth of an inch in length, and so superficial that he took 
 scarcely any notice of it at that time. 
 
 In the evening of this day he was drowsy, and retired 
 to bed earlier than usual ; the next morning he complained of 
 headache, sick stomach, and of a most acute pain in the 
 right shoulder and axilla. In the course of the day these 
 symptoms became so severe that he was desired to take 
 an emetic, which, after a short interval, was followed by 
 a purgative medicine. 
 
 On the third day the pain had increased in an extraordinary 
 degree ; it was confined to the shoulder joint ; there was 
 no discoloration of the integuments, but there was some 
 swelling about the joint and above the clavicle ; he suffered 
 no uneasiness in the elbow joint ; no inflamed lymphatic 
 vessels could be traced along the arm, nor could any enlarge- 
 ment of the glands be discovered either in the axilla or above 
 the clavicle, but he suffered exquisite pain in both these 
 places from the slight pressure necessary in making the 
 examination. The scratch on his thumb was at this time 
 quite free from inflammation, the cuticle was raised into a 
 small flattened vesicle, and was about half-filled with a very 
 white milky fluid. 
 
 In this state he continued for three or four days, suffering 
 
384 SLIGHT WOUNDS 
 
 the most agonising paia, and labouring under a violent fever, 
 accompanied with the greatest dejection of spirits. 
 
 Fomentations were applied, but without relief. Leeches in 
 the axilla and cold washes were also tried, but with no better 
 success. Large doses of opium failed to procure the slightest 
 mitigation of pain, and the fever was not in the smallest 
 degree controlled by the usual remedies. 
 
 He now at length had some relief from the severe pain in 
 the shoulder, but this was not accompanied by a corresponding 
 remission of the- fever. In the course however of a day 
 or two he for the first time complained of a pain along the 
 right side of the thorax. A diffused erysipelatous redness 
 was seen extending from the axilla nearly half way down 
 to the ileum ; and, although a fulness appeared on the ribs, 
 yet nothing like a phlegmon could be discovered. In a day 
 or two more this redness had extended down that side as low 
 as the great trochanter, and could be traced across the 
 abdominal muscles to the groin ; the skin had a doughy feel, 
 and easily received the impression of the finger. In some 
 places the surface presented to the eye the appearance of 
 distinct vesicles, yet these parts, when examined by the 
 finger, felt perfectly solid ; in fact, they resembled accurately 
 those elevations which are observed in the site of leech-bites 
 long healed, when the skin to which the leeches had been 
 applied becomes swollen by inflammation. The fever con- 
 tinued unabated, and his strength seemed nearly exhausted, 
 and was supported only by large quantities of wine. In this 
 extremity, on the 15th of December, an incision was made 
 over the fourth and fifth ribs, in the hope of finding some 
 lymph or matter diffused through the cellular substance, but 
 none was discovered. Neither the local inflammation nor the 
 febrile symptoms seemed at all influenced by this incision. 
 In a few days more the inflammation ceased to extend, the 
 cuticle began to desquamate, and the pain to diminish ; the 
 skin which had been affected still retained its morbid feel. 
 At the termination of three weeks after the accident he was 
 suffering no pain in his side, the shoulder had long since 
 ceased to trouble him, the cicatrix in the thumb could scarcely 
 be observed, and his general health was gradually recovering ; 
 
Received in dissection. 385 
 
 yet at this time he began to experience pain in the arm, along 
 the inner edge of the biceps muscle : this was but slight for a 
 day or two ; it soon, however, became very violent. There was 
 a considerable degree of induration along the biceps, which 
 extended even to the pectoralis and latissimus dorsi ; the arm 
 became red, swollen, and cedematous ; the swelling extended 
 below the elbow ; the pain, which at all times was exceedingly 
 great, was rendered almost insupportable by any movement 
 of the arm. Fomentations and poultices were applied, and a 
 fluctuation being obscurely felt along the inner edge of the 
 biceps, an opening was made on the 1st of January, which 
 gave exit to a small quantity of matter. In a few days after 
 the abscess in the arm was opened a fresh attack of inflam- 
 mation took place in his side, which ended in the formation 
 of another abscess, situate over the sixth rib, and not very far 
 from the spine. After this period he rapidly improved, 
 so that in the latter end of January he was able to go to the 
 country. 
 
 On the 14th of February, when he had been three weeks in 
 the country, the abscesses were healed, the hardness along the 
 biceps was greatly diminished ; but even then he could not 
 make any use of the arm ; the integuments along the side had 
 regained, in a considerable degree, their natural feel. His 
 general health was wonderfully improved. He did not regain 
 the full use of the arm for some weeks after this ; the 
 induration of the integuments of the side was also very slow 
 in dispersing. 
 
 From the commencement of the disease his spirits were 
 sunk ; he frequently raved ; his pulse throughout was never 
 less than 120, and sometimes it was 130. His stomach was 
 at the commencement very irritable, and got better ; but it 
 again became alarmingly irritable about the beginning of 
 January. This might have been partly caused by the large 
 quantity of opium he used, for he could not procure any relief, 
 except by a large dose, amounting to a drachm or four scruples 
 of the tincture daily. 
 
 Case 2.— On Saturday, February 13th, 1819, Mr. Dease, 
 late Professor of Anatomy and Surgery to the Eoyal College 
 
 2o 
 
386 SLIGHT WOUNDS 
 
 of Surgeons in Ireland, lectured on the cervical nerves and 
 brachial plexus. The subject (which was dissected for him), 
 a female about forty years of age, had died in one of the 
 hospitals of a chronic pulmonary affection ; the body had not 
 been buried, and was nearly fresh, for she had not been dead 
 above forty-eight hours. 
 
 On the morning of Friday, when she had been just brought 
 into the College from the Hospital, I saw the thorax opened by 
 Mr. Shekelton, who called my attention to a brown thick fluid 
 contained in the pericardium. The lecture was delivered at 
 one o'clock on Saturday by Mr. Dease, and on Sunday 
 morning early he awoke with a violent shivering and sickness 
 of stomach ; the former was very severe, and the latter con- 
 tinued for upwards of two hom-s. He threw up his dinner, 
 consisting of fish, of which he had eaten very freely, and 
 afterwards he vomited a large quantity of bile. Even at this 
 time he complained of acute pain in his left shoulder. His 
 friend. Dr. Sheridan, saw him early this morning. 
 
 He sent for me at half-past eleven o'clock, and earnestly 
 besought me to bleed him for this pain of the shoulder, which 
 he described as very severe, and as aggravated by the slightest 
 attempt to move the arm. I found him at this time labouring, 
 as I supposed, under high symptoms of the prevailing fever, 
 and, conceiving that his complaints of the arm were in some 
 measure the effects of impatience, I declined bleeding him 
 unless by the desire of his physician. At 3 o'clock p.m. 
 I again saw him, and although I still was of opinion that he 
 was affected with common fever, attended with derangement 
 of the stomach and liver, greater than ordinary, yet I 
 could no longer resist his importunate solicitation to be 
 blooded, and I took away nearly twenty ounces of blood from 
 his arm by a large orifice ; the blood flowed freely. He 
 thought himself relieved of the pain in the shoulder while the 
 first cup was filling, but this was probably ideal, as he did not 
 express relief towards the conclusion of the operation, and as 
 I found his pain not at all mitigated at 9 o'clock p.m., when 
 the fever was as high as it had been at any time of the day. 
 The blood was neither buffed nor cupped, and the proportion 
 of serum was considerable. I now observed a slight fulness 
 
RECEIVED IN DISSECTION. 387 
 
 above the clavicle, along the left side of the neck, in the 
 space between the sterno-mastoid and trapezius muscles, and, 
 being in doubt whether this apparent fulness might not be 
 owing to the position of the head, which was held rather 
 towards this side, I wished to satisfy myself by the touch, but 
 on applying my finger, even with the slightest pressure, 
 he complained of exquisite pain. 
 
 Monday morning, February 15th. — I was called upon at 
 8 o'clock this morning to see him, and found that he had 
 spent a very restless night, owing to the pain of his shoulder ; 
 and when I went into the room he had the entire of the joint 
 covered with leeches, to the amount perhaps of one hundred. 
 We advised a draught with Elect. Scam, fomentations, and 
 opiate-liniment. At 5 o'clock p.m. we met again. Dr. Sheridan, 
 Dr. Brooke, Mr. Eichards, and myself. We learned that the 
 draught was rejected almost as soon as it had reached the 
 stomach, and, although the pills had brought away some 
 liquid stools, yet the fulness of the abdomen remained un- 
 reduced. No relief has been derived from the fomentations and 
 liniment. Eepeat the pills, and assist their operation by 
 enemata. 
 
 Tuesday morning, 16th. — Bowels have been more satis- 
 factorily freed; symptoms, however, remain as yesterday. 
 We felt at a loss to account for the pain of the shoulder, 
 which however was less severe. We advised him to persevere 
 in the use of purgatives, giving him the Inf. Sennae et Tamarind, 
 with Tinct. Jalapse. 
 
 9 o'clock p.m. — On visiting him this evening he accidentally 
 mentioned an uneasiness which he felt in his left side. On 
 examination I discovered a colourless swelling on the side 
 of the thorax, a little behind and below the posterior border of 
 the axilla ; upon which the recollection of Hutchinson's case 
 at once occurred to my mind. On my suggesting to him my 
 suspicions of the cause of his sufferings Mr. D. denied 
 his having received any cut, of which he was so positive 
 as almost to refuse to let me examine his hand. I discovered 
 on the dorsum, rather towards the ulnar side of the second 
 joint of the thumb, the mark of a slight scratch, not one 
 fourth of an inch long ; this formed the diameter of a vesicle. 
 
388 SLIGHT WOUNDS 
 
 which was almost half filled with a fluid of a milky whiteness 
 and consistence, and about this .size ([^J) 
 
 I should have observed that the pain of his shoulder was 
 better on Monday night and Tuesday morning, so that he was 
 not (as on Sunday or Monday morning) fixed to one spot, but 
 he could now lie with his body slightly turned towards the 
 right side, and could raise himself in the bed by pulling, with 
 the left hand, a cloth tied to the foot-post. The skin above 
 the clavicle at this time bore pressure very well ; the skin at 
 the swollen part of the side was not discoloured, but was 
 possessed of the most painful sensibility to the touch. It 
 should be observed that every evening, about six o'clock, 
 he had an exacerbation of restlessness and depression of 
 spirits. 
 
 Wednesday, February 17th. — This morning we resolved to 
 give a bolus of calomel, with a liquid purgative, and at night 
 a draught with twenty-five drops of laudanum. 
 
 Thursday, February 18th. — The discharges from the bowels 
 in the course of yesterday were very free and natural. He 
 slept for four hours after taking the draught, and awoke 
 cheerful and refreshed. He was directed to take a bolus of 
 carbonate of ammonia, together with some diaphoretic medi- 
 cine ; also to foment the side, and rub it gently with a liniment 
 of camphorated oil and aqua ammonise. Draught to be 
 repeated at night with forty drops of laudanum. 
 
 Friday, February 19th. — Had a very bad night; some 
 delirium this morning, but is now, at half-past eleven o'clock, 
 more composed. Face with a yellow tinge ; countenance 
 sharp, yet not indicative of much pain or inward distress ; 
 pulse smaller. He desired me to look at the right arm, 
 which had been blooded. I found the incision inflamed 
 in the ordinary way; but I remarked on the forearm, 
 about two inches below the incision, a small vesicle con- 
 taining a fluid like that produced by the original wound on 
 the thumb. 
 
 N.B. — This vesicle did not increase in size, or alter in any 
 way, until the time of Mr. Dease's death. 
 
 Saturday, February 20th, 1819. — At our visit this morning 
 (11 o'clock) we observed his manner quick, and bordering on 
 
KECBIVED IN DISSECTION. 389 
 
 delirium. Pulse 126 and smaller. The entire side, from 
 a very little below the axilla down to the hip, was swelled. 
 
 This day we observed the swollen part studded pretty thickly 
 with small elevations, to the eye like vesicles, yet hard to the 
 touch. They bore a resemblance to the elevations which arise 
 in the cicatrices of a part which had been scarified, when it is 
 affected with swelling. 
 
 An erysipelatous blush, which had been first observed on 
 Thursday, and had rather increased on Friday, was now more 
 strong, but occupied only a small portion in the middle of 
 the swelled side. Tongue covered with a white coating ; 
 countenance less yellow than yesterday, but still contracted 
 and small ; abdomen full. 
 
 Saturday evening, 9 o'clock. — Delirium set in soon after 
 our visit, and has continued high; perspiration warm and 
 rather general; however, the left side of the trunk of the 
 body, where the clothes lightly cover him, is quite dry though 
 warm ; pulse weaker ; the swelling has passed more from the 
 abdomen towards the back ; erysipelatous redness more 
 extended and more strong, occupying a considerable portion 
 of the side ; bowels free. Although the perspiration is warm, 
 while he remains covered, yet if his hand remain uncovered 
 for a few minutes it feels cold and clammy. 
 
 Sunday morning, February 21st, 9 o'clock a.m. — At ten 
 o'clock last night he took Tinct, Opii gutt. xl., but the delirium 
 continued for three hours after it ; he insisted on being moved 
 to an adjoining bed, and there he lay for nearly three hours 
 without any clothes. On being again laid in his own bed he 
 was stupid, and his left leg was stiff; countenance still sharp, 
 but not yellow ; lips of a good red ; he has clammy sweats on 
 the head and upper parts of the body; frequent deep in- 
 spirations, like sighing ; pulse 126 and weak. Wine negus, 
 with nutmeg. 
 
 12 o'clock.— General state as at 9. Inflammation of the 
 side extends up to the axUla; and on the posterior edge 
 of the axilla appears as if there was an abscess, but is without 
 fluctuation; colour of the inflamed part darker; he has 
 passed no urine since nine o'clock last night, although he 
 had an enema this morning. We advised a poultice to the 
 
390 SLIGHT WOUNDS 
 
 side, a bolus of scammony, calomel, and jalap, and cordial 
 draughts every two hours. We now observed a swelling on 
 the anterior part of the right arm, occupying about a hand's- 
 breadth of the belly of the flexor muscles, beginning about an 
 inch and a half below the orifice made in bleeding him. The 
 vesicle on this arm remains as when first observed : a poultice 
 to this swelling. 
 
 5 o'clock p.m. — We agreed to puncture this tumour, although 
 he appeared approaching fast to dissolution. A quantity 
 of serous fluid, nearly a teaspoonful; flowed from the opening, 
 but did not in the slightest degree reduce the swelling. 
 
 Sunday evening, 9 o'clock. — Pulse in right wrist not to 
 be felt ; heat of limbs not reduced ; breathing quick and 
 laboured. He passed urine at five o'clock this evening, and at 
 ten o'clock he died. 
 
 Monday morning. — I was called early this morning to 
 examine his body, as one of his pupils, who remained in the 
 room, fancied that he heard him breathing. I now observed 
 
 that two or three vesicles of this size ( ^ had formed 
 
 (O 
 
 on his back ; the swelling had extended down the thigh ; the 
 left arm was swelled, and rather hardened from the elbow 
 nearly up to the shoulder ; this swelling was chiefly along its 
 anterior surface, but it could also be felt all around ; yet there 
 was no redness or vesication on the limb. 
 
 Along the left side of the trunk the raised hard spots still 
 continued as in life. 
 
 It is not irrelevant to mention here the outlines of Mr. 
 Egan's case. Mr. Egan had, on Saturday, 13th February, 
 after Mr. Dease's lecture, employed himself in dissecting a 
 part of the same subject. On Sunday evening he had a 
 rigour, followed by febrile paroxysm. On Monday he felt him- 
 self not well, yet he went into company, and danced in the 
 evening. On Tuesday he complained of hoarseness ; inflam- 
 mation attacked the metacarpal joint of the thumb, accom- 
 panied with pain and erysipelatous redness around it, the 
 pains passing up along the back of the forearm. This was 
 attended with a smart degree of fever. On Friday he com- 
 plained of tenderness under the border of the pectoral muscle, 
 
RECEIVED IN DISSECTION. 391 
 
 and a gland could be felt enlarged under the edge of this 
 muscle. He had no perspiration in this febrile state, and his 
 chest appeared to be seriously affected. This affection com- 
 menced on Tuesday. 
 
 On Sunday, February 28th, I saw him. Fever very high ; 
 pulmonary affection and distress very severe. An abscess, 
 which had been collecting for some days in the axilla, now 
 appeared to me fit to be opened, although there was no 
 .redness of the skin, no pointing, no surroimding hardness ; 
 the matter discharged IV^as purulent, of an unusually thick 
 consistence, and the cavity proved to be very extensive, passing 
 across from the pectoral to the latissimus dorsi muscle. 
 
 N.B. — This night he had retention of urine, probably owing 
 to an opiate draught ; he had no recurrence of this distress. 
 He gradually recovered. 
 
 Eeflbctions. 
 
 I have been thus minute in relating the circumstances of 
 these two cases, because I consider them as presenting us with 
 the character of a disease both formidable and new. 
 
 The severe pain felt on the point of the shoulder; the 
 peculiar colourless swelling or fulness above the clavicle within 
 a few hours after the infiiction of the wound; the wound 
 itself at this time free from inflammation or pain; no red 
 streaks, no pain, nor even tenderness on pressure through 
 the whole course of the limb. In short, no trace at the 
 time of any morbid connection between the wound and the 
 seat of the pain, were the most remarkable features of this 
 disease. 
 
 Another remarkable feature was the very peculiar appearance 
 of the pustules (unlike to any I had ever witnessed), and the 
 striking resemblance of the pustules to each other. Add 
 to this the appearance of a similar pustule on the forearm 
 of Mr. Dease, observed on Friday the 19th. The character of 
 this pustule could not have been influenced by the wound 
 of the lancet, for that wound had only the ordinary appear- 
 ances observed in cases where a*slight inflammation supervenes 
 on blood-letting ; besides, this pustule was seated lower down 
 on the limb, and the skin intervening between it and the 
 
392 SLIGHT WOUNDS 
 
 wound remained perfectly natural, free from discoloration, 
 swelling, or pain. The elevations of the cuticle, to the eye 
 resembling vesications, while actually solid ; and the swelling 
 on the forearm, which was opened on Sunday, only a few 
 hours before Mr. Dease's death, present characters which tend 
 still further to remove the resemblance of this to any other 
 disease usually consequent on wounds. 
 
 The description of the swelling, passing from the axilla 
 along the side down to the hip, and, being accompanied with 
 redness, may induce some to consider these two cases merely 
 as instances of erysipelatous inflammation. But to such 
 I would beg leave to observe that the redness was of a bright 
 healthy colour, did not appear until the fourth day, and at no 
 period did the redness occupy more than one-sixth of the 
 swollen part. So very unlike were the characters of this 
 disease to those of erysipelas that the late Mr. Eichards could 
 not be persuaded to believe that there existed any connection 
 between the wound and the disease, until I brought with me 
 Mr. Kinchela (a very intelligent pupil, who had kindly attended 
 Mr. Hutchinson), and who, on seeing the peculiar swelling 
 along the side of the thorax, instantly pronounced this to be 
 the same disease as Hutchinson's. It should be observed that 
 erysipelatous redness, though more considerable in Mr. 
 Hutchinson's case, never occupied more than one-half of the 
 swollen surface. The inflammation seizing on the arm in 
 three weeks after the receipt of the wound in Mr. Hutchinson's 
 case, and in eight days in the case of Professor Dease, presents 
 another striking point of resemblance. 
 
 In whatever way the question of the nosological arrange- 
 ment of this disease is disposed of, this much is obvious, that 
 neither habits of dissection the most lengthened, nor a state 
 of the subject the most free from putrefaction, can secure the 
 anatomist from the danger of this formidable disease. For 
 upwards of twenty years was Mr. Dease, during the winter 
 months, in the habit of dissecting human bodies. If my 
 . recollection serve me, I have found most of the instances of 
 inflammation and fever following wounds received in dissection 
 among those pupils who have arrived at the third season of 
 their anatomical pursuits. 
 
EECEIVED IN DISSECTION. 393 
 
 It is an opinion tmiversally held by the public, and pretty 
 generally received by professional persons, that the danger 
 from wounds in dissection is in proportion to the putrefaction 
 of the subject, or to the contagious nature of the disease 
 which had caused death. On the contrary, according to my 
 observation, unpleasant consequences have been so rare, 
 where the subject was far advanced in putrefaction, as to 
 induce me to think that putrefaction rather gives protection to 
 the anatomist ; nor could I trace any connection between the 
 disorder in question and the contagious nature of the disease 
 which had destroyed the subject of dissection, and surely 
 during the winters of 1818 — 19, when fever raged so exten- 
 sively in Dublin, we should have had some striking instances 
 of such a connection had it existed. Perhaps the majority of 
 the affections in question have occurred in cases of examination 
 of bodies to ascertain the cause of death, and where the body 
 had not even been interred. 
 
 According to the paper contained in Hist, de I'Academie 
 Eoyal des Sciences de Paris, Annee 1776, p. 53, the infection 
 from animal matter, under peculiar circumstances, is more 
 dangerous when communicated from other animals than from 
 human bodies, for in the former it did not require the presence 
 of a wound to produce effects the most strange and violent. 
 And this may serve to impress those who pursue comparative 
 anatomy with due caution. 
 
 I have never witnessed any of those dangerous constitutional 
 affections which are mentioned by some authors as attending 
 the dissection of bodies in a state of putrefaction. I have no 
 doubt often seen persons suffer a momentary sickness or faint- 
 ness from the foetid vapours which issued as soon as the 
 cavities of the thorax or abdomen were opened ; but never did 
 I observe fever supervening. Some of our dissecting pupils 
 every season suffer from fever, but these are cases of the 
 ordinary type, and are to be traced to ordinary causes of 
 fever ; for instance, irregularities in their mode of living, 
 excessive fatigue, sitting in wet clothes, great anxiety of mind, 
 or contagion. Affections of the lungs more frequently than 
 any constitutional disease can be traced to the occupation of 
 the anatomical student, but these arise from the cold and 
 
394 SLIGHT WOUNDS 
 
 damp of the dissecting rooms, and not merely from hanging 
 over the dead and putrefying body. 
 
 In eases of the severe consequences following wounds 
 received in dissecting, does an infection enter by the wound 
 and cause all the mischief? Or are the symptoms to be 
 accounted for by some peculiarity in the constitution of the 
 individual? The peculiarity of the symptoms and the 
 similarity between the cases of Professor Dease and Mr. 
 Hutchinson is so strong as to lead to the opinion of both 
 having arisen from infection ; besides, I think the number of 
 severe cases arising from slight wounds to anatomists is much 
 greater than what we find in those classes whose occupations 
 expose them to similar slight wounds and punctures of the 
 fingers while handling dead animal matter ; yet, on the other 
 hand, it must be admitted that in Mr. Egan's case the 
 symptoms were very different from those under which Pro- 
 fessor Dease suffered, although both received their wounds in 
 a few h ours from each other, and while dissecting the same 
 subject. 
 
 The opportunities of treating the cases of Professor Dease 
 and Mr. Hutchinson have not enabled me to discover any plan 
 or remedy of service in this formidable disease. It is therefore 
 the more incumbent on anatomists to attend to the means of 
 prevention. 
 
 The advantages of the immediate application to such wounds 
 of caustics in a solid or liquid form is too obvious to require 
 any comment ; they are the only means upon which we can 
 rely with absolute certaiaty. 
 
 But those who are acquainted with the zeal of anatomists 
 must doubt whether any practice which interferes with the 
 prosecution of their pursuits will be generally adopted ; the 
 pain and the delay which must be occasioned by applying 
 caustic to every little scratch will prevent this plan from being 
 as generally followed as it should be, or as the safety of 
 individuals requires. 
 
 I would therefore recommend that each dissecting-table be 
 furnished with a cup of oleum terebinthinse, into which the 
 anatomist should plunge his finger the moment it is wounded. 
 The smart which this produces is so inconsiderable that it 
 
RECEIVED IN DISSECTION. 395 
 
 will not cause any serious delay, while the irritation may 
 counteract the power of infection, or alter the mode of inflam- 
 mation in the wound. 
 
 On Tuesday, May 18th, 1824, Mr. Shekelton was engaged 
 in examining the body of a man who had died of peritoneal 
 inflammation, consequent on the operation of lithotomy. The 
 examination took place in a very few hours after death, the body 
 still retaining its heat. I observed that soon after the 
 abdomen was opened, Mr. Shekelton pricked himself with the 
 point of the knife, which called forth the usual involuntary 
 expression of pain, but was not further attended to. He 
 proceeded to take out the contents of the pelvis, so that his 
 hands were necessarily immersed in that cavity for a con- 
 siderable time. 
 
 On the following evening (19th) he felt himself unwell ; on 
 Thursday (20th) he gave an anatomical demonstration as 
 usual, and immediately after it he went home very ill, but 
 owing to the natural reserve of his disposition he did not 
 apply to any of his medical friends. On Friday evening (21st) 
 Mr. Cusack accidentally saw him, and found some of the 
 glands swelled in the left axilla, from which he was 
 apprehensive that the disease was produced by the wound 
 received on Tuesday. When Mr. Cusack again visited him, on 
 Saturday (22nd), the condition of these glands was so much 
 improved as to induce him to look upon the case as one of 
 simple fever brought on by cold and fatigue, to which Mr. S. 
 had lately been much exposed. 
 
 On Sunday morning (23rd) I first saw Mr. S. He told me, in 
 a most emphatic manner, that he had passed a most wretched 
 night ; yet the febrile symptoms were not very severe. Pulse 
 only 84, though his skin was hot, and there was an 
 indescribable anxiety and distress very perceptible : he said 
 that he felt as if his stomach was too full. The glands in the 
 left axilla were slightly enlarged, and tender to the touch; 
 but there was neither swelling nor redness along the arm. 
 He complained of pain along the course of the ulnar nerve, 
 and down the left side of the thorax. There was no appearance 
 of inflammation in the ring finger, which had been wounded ; 
 
396 SLIGHT WOUNDS 
 
 indeed we could scarcely discover any trace of the wound. 
 Were it not that I recollected to have seen him wound the 
 finger, and that his present anxiety and distress very far 
 exceeded in severity the other febrile symptoms, I should have 
 supposed him affected with common fever only. 
 
 By his own desire leeches were applied to the axillary 
 glands, but he suffered so much from the bites of each of 
 these, that, after the fourth had fixed, he refused to let any 
 more be applied. He took an emetic, which operated well, 
 but did not produce any marked impression on the symptoms. 
 
 Monday (24th). — He complained of uneasiness in the 
 stomach and bowels, and felt as if he would be much relieved 
 by having a free stool. His tongue was covered, but not very 
 thickly, with a white mucous coating ; skin of the face assuming 
 a yellow colour ; features rather sharp ; no uneasiness in the 
 course of the lymphatics of the arm ; swelling and pain of the 
 axillary glands had ceased ; so that some of his medical friends 
 still indulged the hope that the case would prove to be but a 
 severe instance of common fever. 
 
 Tuesday (25th). — Constitutional distress increased, and the 
 real nature of the disease was too obvious to all his medical 
 attendants. We agreed that he should have a full opiate at 
 night. 
 
 Tuesday evening. — This afternoon a red spot, the size of a 
 shilling, appeared on the right patella. For two hours this 
 evening he suffered such severe torture in the knee that he 
 declared he would much rather endure the pain of having 
 every limb amputated in succession than again undergo the 
 pain he had suffered in that knee ; this pain he referred to the 
 cavity of the joint. 
 
 Wednesday (26th). — At ten o'clock last night he got sixty 
 drops of laudanum, and in the course of two hours twenty 
 more : these produced very profuse and general perspiration, 
 but no alleviation of symptoms followed. He dozed a good 
 deal, and his attendants reported that he had passed a good 
 night ; he himself declared that it was a most uncomfortable 
 night. 
 
 During the night his brother, Dr. Eobert Shekelton, 
 observed a large red and swollen patch over the right tibialis 
 
EEOBIVED IN DISSECTION. 397 
 
 anticus muscle. This, and the spot on the patella, now had a 
 solid feel, and were not very tender to the touch. 
 
 Early this morning (at two o'clock) the right arm, from the 
 shoulder down to the elbow, was observed to be swelled, but 
 without discoloration ; the right thigh also was swelled, but 
 not discoloured. A red patch appeared on the dorsum of the 
 left foot, and he complained of a pain in the left scapula and 
 shoulder. Tongue covered with a thick coating of white 
 mucous ; countenance of a deeply yellow tinge. 
 
 Thursday (27th). — He now complained of pain in the left 
 arm, with considerable swelling of it and of the forearm. 
 Yellowness of skin was now universal, and more deep than 
 before ; adnatse of the eyes very yellow ; countenance more 
 sharp and contracted ; tongue as yesterday. 
 
 At six o'clock, this evening, his weakness became extreme, 
 his features very sharp and contracted, yet his pulse was 
 regular, and not very quick. 
 
 Friday (28th). — Twice in the course of last night he was 
 supposed to be dying; yet he soon after called for solid 
 nourishment, ate a teacupful of panada, and took the yolk of 
 an egg beat up with brandy : this he did from some notion 
 that he now only required solid food in his stomach to 
 complete his recovery. He was obviously not free from 
 delirium. 
 
 During the night he passed a large quantity of urine of a 
 peculiarly dark brown colour. 
 
 At five o'clock this morning he sent for me, and requested 
 that I would make incisions into the left arm and forearm, 
 which were much swollen, but free from redness ; indeed, the 
 only place where any redness could be seen was on the left 
 scapula. I could not refuse to comply with his wishes, 
 although I knew how unavailing this measure must be ; for 
 the hand was livid, and cold as a gangrened hand : he had the 
 power of moving the thumb only; all his extremities were 
 cold ; this was the coldest ; the right arm and forearm were 
 less swelled, and soft ; the spot on the middle of the right leg, 
 which always had a solid feel, was now more extended, and 
 less raised. 
 
 I made an incision into the red patch on the back of the 
 
398 SLIGHT WOUNDS 
 
 left shoulder, on the inner side of the arm, on the forearm, 
 and along the outer edge of the biceps at the bend of the arm. 
 All these incisions were carried through the fascia of the limb. 
 Nothing, except a small quantity of blood, issued from any of 
 these incisions ; in none of them did the skin or cellular 
 substance exhibit any diseased appearance, except in that at 
 the bend of the arm, where the cellular membrane had a deep 
 yellow colour. His brother, in the course of the night, had 
 punctured the bursa on the olecranon of the left arm, which 
 was very tense, red, and painful ; from this a large quantity of 
 red watery fluid still continued to flow. During the night he 
 complained that half a glass of claret felt as strong and hot 
 in his stomach as if it had been ardent spirits. 
 He died at nine o'clock this morning. 
 
 In this case we recognise the same train of symptoms as in 
 the eases of Mr. Hutchinson and Mr. Dease. The present 
 case tends to strengthen the opinion I advanced, "that slight 
 wounds received in dissecting fresh bodies sometimes give rise 
 to a peculiar disease, perfectly distinct from every other disease 
 consequent on similar wounds." In addition to the other 
 symptoms there described as being characteristic of this 
 disease, we may mention this striking one, viz., that previously 
 to the disease terminating either in death or in recovery, swell- 
 ing and inflammation seize upon the portion of the limb inter- 
 posed between the original wound and the first seat of pain. 
 We see that this took place in Mr. Hutchinson's case at so late 
 a period as three weeks ; the fever, although it had remitted, 
 not having ceased until this inflammation had occurred. 
 In the fatal cases of Mr. Dease and Mr. Shekelton it 
 appeared, in the former on the ninth, in the latter on the 
 tenth day. 
 
 I must entreat the attention of the reader to this fact, that 
 the redness which is seen on the swollen parts is very unlike 
 to that of erysipelas, for the colour is that of a peach-blossom, 
 is of very small extent compared with the extent of the 
 swelling, is seen for a few days, perhaps for a few hours only, 
 on the same spot, and next is observed in some very distant 
 part, possibly in the opposite limb ; besides, this peculiar 
 
RECEIVED IN DISSECTION. 899 
 
 redness vanishing quickly from a part does not leave any 
 vesication or desquamation after it, as is seen in cases of 
 erysipelas. 
 
 If any proof be wanting to establish an essential difference 
 between this disease and phlegmonoid erysipelas, it will be 
 found in the state of the swollen parts when cut into. For, 
 although four incisions were made into different parts of the 
 left arm of Mr. Shekelton, yet no discharge, except a small 
 quantity of blood, issued, nor was any change of structure 
 visible except that slight one which has been noticed at the 
 bend of the arm. 
 
 This sudden shifting of the swelling and redness from one 
 to another, and very distant part, is not to be confounded with 
 what we sometimes observe in chronic diseases, viz., an 
 abscess suddenly appearing in a part remote from the original 
 seat of the disease. For in such cases the abscess quickly 
 forms, and with this peculiarity, that we feel the fluctuation of 
 pus although we have scarcely any marks of preceding or 
 accompanying inflammation : the skin is not reddened until 
 the ulcerative process is about to give exit to the fluid. In 
 such cases, although we may have a succession of abscesses, 
 yet we have not any instance of a sudden swelling accom- 
 panied by a light blush of redness, and of its equally sudden 
 disappearance, leaving after it only a slight degree of swelling, 
 without any other symptom or trace of inflammation. 
 
 In short, this peculiar disease, the effect of slight wounds 
 received in dissection, presents much less of inflammation of 
 the wound or its vicinity than occurs in the various other 
 diseases to which slight injuries more frequently give rise. 
 Here it seems to produce mischief by exciting a fever, which, 
 in its turn, induces a swelling and redness of very peculiar 
 characters, although at length (if the patient chance to 
 suiTive), it will end in inflammation and suppuration of the 
 wounded limb. 
 
 Whatever difference of opinion may be entertained as to the 
 nature of this affection, it will be allowed on all hands that, 
 although some few have escaped, yet the plans of treatment 
 hitherto pursued have all proved quite unequal to contend 
 with so formidable a disease. 
 
400 SLIGHT WOUNDS 
 
 The plan which I would suggest as most likely to succeed 
 (for as yet it is untried), is to administer calomel with the 
 view of speedily exciting ptyaUsm. Many experienced prac- 
 titioners I know are in the hahit of combining this medicine 
 with opium, when their object is to excite ptyalism very 
 quickly. But I should prefer giving it in an uncombined form, 
 and in doses of three grains every three or four hours. When 
 administered in this manner it seldom fails to produce saliva- 
 tion in thirty-six or forty-eight hours, provided that the two 
 or three first doses affect the bowels. In cases where the 
 bowels are not moved by the first doses of this medicine 
 it wiU be necessary, in order to ensure its effects, either to 
 combine the calomel with some purgative, or occasionally 
 to. interpose a purgative. When thus administered it will 
 very seldom disappoint our expectations. Mercury administered 
 in other forms of fever has so often succeeded in effecting a 
 cure that I think we may, with some confidence, anticipate its 
 good effects when administered in the fever consequent on 
 wounds received in the dissection of very fresh human bodies. 
 
 Postscript. — Since the preceding pages. were written a very 
 valuable essay on the subject of Diffuse Inflammation has 
 appeared in the first volume of the Transactions of the 
 Medico-Chirurgical Society of Edinburgh, from the pen of 
 Dr. Duncan, jun. The extensive collection of cases contained 
 in that essay demonstrates the dangers which too frequently 
 arise from slight wounds ; but I cannot agree with the author 
 in considering all these cases as examples of diffuse inflam- 
 mation. Some few of them obviously are instances of the 
 same disease as that of Mr. Shekelton. It is remarkable 
 how exactly the morbid appearances in the thorax of the 
 female subject, whose dissection gave rise to cases 8 and 9, 
 corresponded with those of the subject which Mr. Dease was 
 dissecting when he received his fatal wound. 
 
 As so few histories of the dissection of these fatal cases have 
 been published, I shall make no apology for drawing the atten- 
 tion of the reader to this sentence in the report of morbid appear- 
 ances in the 9th case : — •' The cellular substance of the arm 
 was everywhere healthy, and there was not the slightest vestige 
 
RECEIVED IN DISSECTION. 401 
 
 of disease in the forearm, nor could any connection be 
 traced between the abrasion on the finger and the morbid 
 parts." 
 
 I shall only add that every reliance may be placed on 
 the accuracy of this account, for the dissection was made 
 by Mr. Lizars. 
 
 Mr. Travers, of London, in his " Inquiry concerning Con- 
 stitutional Irritation," a work rich in valuable materials, and 
 replete with ingenious reasoning, considers the effect of slight 
 wounds received in dissection as a distinct disease ; and he 
 seems inclined to ascribe the mischief to the introduction of a 
 poison, which he thinks is generated by the first stage of 
 decomposition of the human body. 
 
 I shall not pretend to decide whether the disease be owing 
 to this cause, or rather (to use Mr. Travers's words), "to the 
 condition of the remaining animalisation, which has hitherto 
 resisted the operation of external agents"; but I must say 
 that I cannot admit the general conclusion that " this disease, 
 bearing a specific character, may be derived from absorption 
 of the fluids of both fresh and stale bodies." No doubt it has 
 arisen when the body under dissection has been cold, and 
 nearly twenty-four hours dead, as certainly as where the 
 subject was so recently dead as still to retain some of its 
 warmth. I do not think, however, that we have on record a 
 single well-marked case of this disease having arisen from the 
 dissection of a body in which any of the obvious signs of 
 putrefaction were present. 
 
 In No. 88 of the Edinburgh Medical and Surgical Journal 
 is a paper by Dr. James Dease, Surgeon to the Forces, 
 the second case of which is clearly an instance of this disease, 
 and one in which calomel had been given pretty largely ; but 
 it does not appear that it was given with the view of inducing 
 salivation. Ptyalism was not excited, and the case terminated 
 fatally. 
 
402 
 
 OBSERVATIONS ON SOME MORBID AFFECTIONS OF 
 THE NAIL OP THE GREAT TOE. 
 
 (The Dublin Medical Journal, 1843.) 
 
 The morbid affections of this part, which are attended 
 by ulceration, do not appear to me to have received that 
 attention from writers on practical surgery to which they are 
 entitled, both on account of their troublesome and painful 
 character as also on account of the very severe operations 
 which have been suggested for their removal. Authors allude 
 to these affections as if they were only different stages of the 
 same disease, viz., onychia, and for their cure have recom- 
 mended the evulsion of the entire nail and the excision of all 
 the ulcerated parts, together with the matrix of the nail. I 
 hope, however, to show in the following observations not only 
 that these diseases differ from one another in many essential 
 points, but that also in all of them those very severe operations 
 to which I have alluded may be dispensed with, and that the 
 cure of these troublesome affections can be effected by means 
 of a bloodless operation, and by external applications of a 
 mild nature. 
 
 1 shall first allude to that form of fungous ulceration which 
 is described by writers under the title of " the nail growing 
 into the flesh." In this disease we observe, at the angle of 
 junction between the anterior and external edges of the nail, 
 an ulcerated fungus, into which this angle, as also a portion 
 of the outer edge of the nail, are more or less sunken. The 
 colour of the fungus is rather florid, its surface is smooth, the 
 discharge is purulent, in small quantity and tolerably healthy, 
 unless the parts have been irritated by too much exercise 
 of the limb or by some external application or local injury ; 
 there is little or no surrounding inflammation, no enlargement 
 of the toe, and the pain is in general very trifling, unless 
 during exercise, when the weight of the body on the limb causes 
 the nail to press into the soft substance of the fungus, which 
 thus often induces considerable uneasiness and lameness. 
 
AFFECTIONS OF THE NAIL OP THE GBEAT TOE. 403 
 
 This disease does not appear to me to have any tendency to 
 spread to, or to involve the adjoining parts, as I have seen cases 
 in which it has remained stationary for some months, and in 
 one for two years, at the end of which period the symptoms 
 were in no way more severe than at the commencement, 
 although most writers assert that it generally passes into 
 malignant onychia. The origin of this troublesome affection 
 is usually attributed to the effects of a tight boot or shoe, or 
 to some accident in cutting or breaking off the end of the nail ; 
 in many instances, however, no cause can be recollected or 
 assigned for its occurrence. 
 
 The unaided powers of the constitution do not appear 
 capable of curing this disease ; hence various methods of 
 treatment have been employed by different surgeons, such, for 
 example, as (according to Dessault) introducing a small plate 
 of tin under the edge of the depressed nail, and insinuating 
 it between the latter and the fungus, with the twofold intention 
 of compressing the fungus and of elevating and everting the 
 edge of the nail, so as to make the latter completely overlap 
 the former. This plan of treatment has not stood the test of 
 experience, and Dessault himself admits that it is very tedious, 
 and often very painful for several days, that the fungus does 
 not entirely disappear before two months, and that even after 
 this the metal plate must be occasionally worn to guard against 
 a relapse. 
 
 Caustics of different sorts have been employed by others, 
 and Mr. Wardrop, in his paper in the 5th vol. of the ' Medico- 
 Chirurgical Transactions,' particularly recommends the 
 Argentum Nitratum ; I have employed this remedy myself, and 
 have seen it also used by others, but, I regret to say, not with 
 that degree of success which Mr. Wardrop's recommendation 
 would lead us to expect. I have, however, found some benefit 
 from this application ; under it the fungus has become reduced 
 in size, also less irritable, but these improvements have con- 
 tinued only for a few days, after which the parts returned to 
 their former condition. 
 
 Sir Astley Cooper, in his lectures, and Dupuytren, in his 
 Le9ons Orales, recommend an operation for the cure of this 
 disease, the directions for performing which are essentially the 
 
404 MORBID AFFECTIONS OF THE 
 
 same by each of these distinguished surgeons, viz., pass one 
 blade of a scissors beneath the nail, from its anterior edge up 
 to the root, then cut through the entire length of the nail, next 
 seize the outer segment with a strong forceps, and by means 
 of these tear it off the toe. 
 
 This operation inflicts a great degree of suffering, because 
 in this disease the nail is not, as in onychia, separated from 
 the vascular and highly sensitive matrix, except only through 
 a small extent of space, not more in any direction than a 
 quarter of an inch at its external angle, and, therefore, the 
 scissors pushed ujDwards between the nail and the adherent 
 matrix, and the forcible evulsion of the former by the forceps, 
 must cause exquisite pain, which, though of short duration, 
 can be regarded as nothing short of actual torture. A similar 
 operation is also recommended by Mr. Liston in his recently 
 published work on Surgery. Notwithstanding these authorities 
 in favour of this plan of treatment, I am by no means 
 an advocate for this peculiarly painful and distressing opera- 
 tion, but on the contrary I believe we may be relieved from 
 the necessity of performing it, and that we can in all instances 
 effect a permanent cure by a very simple operation, and one 
 comparatively free from suffering, namely, by confining the 
 excision of the nail to so much only as is already detached 
 from the matrix ; all of this portion, as well as that imbedded 
 in the fungus, must be removed. 
 
 To effect this I proceed as follows : — While an assistant, 
 with a spatula, presses down the fungus, I seize with a forceps 
 (with strong flat blades, like those of the torsion forceps) the 
 edge of that portion of the nail which is to be removed. I 
 then pass a probe with a thin flat extremity beneath the nail, 
 close to the fungus, as high as it can go, taking care to direct 
 it towards the outer edge of the nail ; this enables me to judge 
 how far the nail is detached. I then take a strong crooked 
 scissors of a large size, with one sharp-pointed blade ; this I 
 introduce beneath the nail as far as the probe has directed 
 me ; with one stroke of the scissors I then cut off all this 
 detached portion of the nail, while, by means of the forceps, 
 I draw it away with moderate force. Should this attempt 
 fail to remove it, I then re-examine the part with the probe, 
 
NAIL OF THE GEEAT TOE. 405 
 
 and again introduce the scissors as high as they can be 
 pushed ; a second cut will then complete the separation, and 
 admit of the easy removal of this part of the nail ; this 
 second attempt is sometimes attended with a sharp momentary 
 pain, as the point of the scissors often enters a short distance 
 into the sensitive matrix. The portion of detached nail 
 presents no change of texture whatsoever ; but a few drops of 
 blood follow this operation. The only dressing required is a 
 small bit of dry lint, which is to be pressed firmly with the 
 probe between the fungus and the edge of the nail. In a few 
 hours the toe is free from pain, and the patient can walk 
 without any lameness or uneasiness in three or four days after 
 the operation. The dressing continues perfectly dry, and 
 need not be changed until the fourth day ; at this time the 
 fungus will be found much reduced in size, perfectly dry, and 
 of a firmer consistence. A small bit of lint is to be reapplied 
 as before ; it should not, however, be pressed down so firmly 
 as at the first dressing. In the course of ten or fifteen days 
 the fungus will have entirely disappeared, and the parts be 
 restored to a healthy state. I have never found it necessary 
 to apply the olive-shaped cautery to destroy the fungus, 
 as described by Dupuytren. In the course of this treatment I 
 also advise the patient (in compliance with the rules laid down 
 by authors) to scrape the upper and outer surface of the nail 
 with a sharp penknife, or with a bit of glass, an instruction, 
 however, which the patient neglects as soon as he feels himself 
 relieved from pain. 
 
 It affords me much gratification to be enabled to state that 
 in no instance have I met with a case of relapse after thfs 
 operation has been efficiently performed. But the result of the 
 operation itself is not in all eases so successful as I have 
 hitherto represented, for in some instances, four or five days 
 after the operation, the patient will complain of some uneasiness 
 in the toe, when we shall find, on examination, that the 
 dressing is moistened with a little discharge, and that a 
 small portion of a whitish substance, like soft and swollen 
 leather, is rising up through the fungus. This substance, 
 may be, is regarded as a sort of accessory ungual filament, 
 arising close to the original nail from the anterior and outer 
 
406 MORBID AFFECTIONS OF THB 
 
 border of its matrix, and which is now altered in texture and 
 direction : this filament is so soft that it breaks and tears, if 
 caught by the common dissecting forceps ; in order, therefore, 
 to remove it (which it is necessary to do), we must seize 
 it mth the torsion forceps, and excise it with one cut of 
 the scissors, passed well and fully beneath it ; the lint 
 dressing is to be reapplied in the manner before mentioned, 
 and the case will proceed without further interruption to a 
 perfect cure. 
 
 Before I dismiss this subject of " the nail growing into the 
 flesh " I may add that I have seen many cases of this disease 
 remaining unchanged for months, and even for a year and 
 upwards ; and I have never yet met with an instance in which 
 the ulceration has extended so as to induce that more severe 
 disease of " onychia maligna," although some writers of high 
 reputation have described this latter as an increase or extension 
 of the former. 
 
 There is another morbid affection which occasionally 
 engages the anterior and inner angle of the great toe-nail, 
 and which causes considerable lameness and uneasiness, 
 particularly on pressure ; this affection is often mistaken for 
 an attack of gout, particularly in those persons where such an 
 attack may be expected, or even desired. In this disease there 
 is no swelling or redness, but pain, on pressure, at the anterior 
 and internal angle of the nail. On a close examination 
 of this spot we find that this angle rests on a hard white 
 mass of laminated, horny cuticle, which we can easily remove 
 in bran-like scales, when we shall see a small cup-like cavity 
 without ulceration or disease. The ungual angle appears 
 thick and bulbous opposite this point, and the pain is caused 
 by its pressing against this mass. This affection is easily 
 cured by scraping away all this substance and exciting the 
 bulbous angle of the nail, and then interposing a little 
 lint. Attention is required for some little time to remove 
 any unhealthy growth of the cuticle or nail, and to secure 
 the patient from any further uneasiness. Finally, I may 
 remark, I have never seen this disease engage the outer 
 angle, neither have I seen that last described engage the 
 inner angle of the toe-nail. 
 
NAIL OF THE GREAT TOE. 407 
 
 ONYCHIA MALIGNA OP THE GREAT TOE. 
 
 This painful disease is often the result of some local injury, 
 such as a heavy weight falling upon or rolHng over this part ; 
 it occasionally occurs without any assignable cause. In some 
 instances the nail is found very much altered from the healthy 
 state, being of a dirty brown or black colour, and adhering to 
 its matrix in detached spots only, while it is separated from it 
 both at the root and to a considerable extent of its under 
 surface. In other cases it has been altogether thrown off, and 
 a foul ulcer occupies its site : this ulcer presents jagged edges 
 and unhealthy surface, with an ichorous discharge, and 
 extends along the toe above or beyond the matrix of the 
 nail ; both phalanges are swollen, so that the circumference 
 of the toe is increased by at least a quarter of an inch, the 
 last phalanx presenting a very peculiar bulbous shape. When 
 the original nail has been cast off, we usually see projecting 
 from the sides and tarsal border of the ulcer a narrow plate 
 of a white substance, not unlike white leather soaked in 
 water ; this sometimes forms one continuous shelf all round 
 the ulcerated border, projecting in a peculiar prominent 
 manner, that is, rather at an angle to, instead of being on a 
 plane parallel to, the dorsal gurface of the phalanx. In some 
 cases this white substance (which is the result of an abortive 
 attempt to produce a true nail) appears only in detached 
 spots or flakes, the intermediate parts of the ulcerated margin 
 being devoid of any such growths ; they are most frequently 
 seen at the posterior and anterior angles of the nail, but 
 occasionally in other parts of the circumference. The sur- 
 rounding integument is discoloured, being often of a livid or 
 purplish tint ; it is also indurated, and exudes a copious 
 perspiration of a peculiar heavy odour. This ulceration 
 sometimes induces caries of the bone, and even extends to the 
 phalangeal articulation. 
 
 All modern authors concur in the opinion that onychia 
 depends upon the morbid condition of the secreting matrix of 
 the nail, and that it can be cured only by removing, by 
 excision, this diseased organised structure ; and no writer 
 that I can recollect encourages the idea of a permanent im- 
 provement being possibly effected by any other local treatment. 
 
408 MOKBID AFFECTIONS OF THE 
 
 I admit that the operation of the complete removal of 
 the entire of this deceased matrix does effect the cure in 
 a very short space of time, provided the bone or joint is not- 
 diseased (in which case amputation is inevitable), and that 
 subsequently rest and simple dressing will alone accomplish 
 the healing process, the place of the nail being supplied by a 
 dense hard skin. But still this operation is not without 
 objection ; it is always attended with severe pain, and which 
 sometimes continues for many hours ; it also too frequently 
 happens that the disease returns in some one spot or other, 
 owing to the matrix not having been wholly eradicated, which 
 indeed it is often extremely difficult to do ; for the shape of the 
 toe is so bulbous and so deformed, the textures so changed and 
 so condensed by chronic inflammation, and the edges of the 
 ulcer are so raised over the part to be removed, that even an 
 anatomist cannot easily recognise the relations of the several 
 tissues involved in the disease, or ascertain the exact extent 
 of the substance to be excised ; during the operation also the 
 flow of blood is so profuse as to prevent the operator dis- 
 tinguishing one texture from another ; accordingly, it occa- 
 sionally happens that the patient, having enjoyed an immunity 
 from pain for some days after the operation, becomes alarmed 
 by feeling a slight return of his former uneasiness on any 
 exercise of the limb, or on any pressure on some particular 
 spot, generally on one of the angles of the original ulcer ; and 
 the surgeon, on a careful examination of this spot, finds there 
 is still a little ulceration and a fresh production of that 
 ungual growth already described as abnormal both in texture 
 and in direction, and which indicates the persistence of some 
 of the diseased matrix. This will again act as a foreign body, 
 exciting constant irritation, and will soon lead to a renewal of 
 all his former sufferings, and for the removal of which the 
 excision of this morbid tissue must be repeated. Any surgeon 
 who has experienced this disappointment can, I am confident, 
 bear testimony to the horror with which the patient has con- 
 templated, and the reluctance with which he has submitted to, 
 a repetition of this peculiarly painful operation. I have known 
 it necessary to repeat this even a third time ; and therefore, 
 whenever these secondary operations become necessary, I 
 
NAIL OF THE GEE AT TOE. 409 
 
 should remind the surgeon that to insure success he must cut 
 much more deeply and extensively than he might at first 
 suppose to be necessary. 
 
 Notwithstanding these objections to this operation of 
 excising the diseased matrix, I yet admit that when it is 
 properly performed it will be followed by a speedy and a 
 perfect cure ; however, I am of the opinion, founded on some 
 experience, that this disease may be cured, without resorting 
 to such a painful measure, by external applications alone, 
 which are unattended with pain, and which, in a few days, 
 will induce a considerable amendment, and even a perfect cure 
 in the course of three or four weeks. The plan of treatment 
 which I have pursued for some years, and as yet with 
 invariable success, is as follows : — I confine the patient to bed, 
 and direct a poultice to the toe for two or three days ; I then 
 cleanse the ulcer carefully by directing on it, from some 
 height, a smaU stream of tepid water from a sponge ; I next 
 cut away as much of the loose nail as I can without paining 
 or irritating the sensitive surface around, and then I fumigate 
 the part by means of a mercurial candle, containing 5i. of the 
 Hydr. Sulphuretum Eubrum (olim cinnabar), to two ounces of 
 wax.* This fumigation is to be applied night and morning, 
 and after each the toe should be gently enveloped in lint or 
 linen, lightly spread with Ung. Spermaceti. In four or five 
 days the patient will express himself as considerably relieved ; 
 the discharge from the ulcer will be found of a healthy 
 purulent character, and the appearance of the whole part 
 much more favourable. The fumigation is still to be persevered 
 in, and all projecting portions of nail to be closely cut ; I 
 consider this latter direction as very essential, as thereby the 
 mercurial fumes can have more free access to the surface of 
 the ulcer. In proportion as the ulcer improves, it is in- 
 teresting to observe so does the condition of the growing nail ; 
 it acquires not only its natural firm and horny consistence, 
 but also assumes its proper horizontal direction. For some 
 time after the general surface of the ulcer has been healed 
 there still remain small spots of ulceration, generally at the 
 angles, around some white germs of new nail. Against these 
 * See CoUes's Practical Observations on tbe Venereal Disease, p. 76. 
 
410 APB'ECTIONS OF THE NAIL OF THE GEEAT TOE. 
 
 points the full force of the mercurial vapour should be directed ; 
 this can be effected by adding a small conical ivory tube to the 
 funnel. I attribute much of the success of this treatment to 
 the use of the mercurial candle in preference to fumigation in 
 the ordinary mode. I must observe that during this course of 
 treatment the patient must absolutely abstain from walking, 
 or eren standing on the affected limb ; exercise but for a 
 single day will counterbalance all the amendment produced 
 by a week's rest and fumigation. In the cases which I have 
 thus treated I have had no recourse to any constitutional 
 treatment, or to any peculiar regimen. No doubt cases must 
 occur in which there will be derangement of the general 
 health, and which will require suitable constitutional remedies 
 before we can expect to cure the local disease by mere 
 local applications. I make no doubt that this ulceration 
 may sometimes arise from, or be so intimately connected 
 with, some constitutional derangement as to be incurable 
 without the aid of constitutional treatment. Mr. Wardrop, 
 in his paper above alluded to, has recommended a cautious 
 and judicious use of mercury, and has recorded some instances 
 of its success. 
 
 The uniform success which has attended this plan of treat- 
 ing onychia by mercurial fumigation — during the last few 
 years I have adopted it — leads me to hope that the surgical 
 operation I have already alluded to may in future be dis- 
 pensed with ; but even should more extended experience 
 prove that I have been too sanguine as to this expectation, 
 yet I feel persuaded that this practice cannot be injurious, 
 and that it will never fail to improve the condition of the 
 ulcer and of the surrounding parts, reducing the enlarge- 
 ment and removing the deformity of the toe ; so that, even 
 should the operation be ultimately necessary, the surgeon 
 will be better enabled to ascertain the exact situation and 
 extent of the disease, and thus by a single operation to 
 remove the whole of the matrix so effectually as to secure his 
 patient from any relapse ; therefore the time which has been 
 occupied in the fumigating process cannot be considered as 
 lost or misapplied. 
 
411 
 
 ON THE FEACTUEE OP THE CAEPAL EXTEEMITY OF 
 THE EADIUS. 
 
 (Edinburgh Medical aud Surgical Journal, Vol. 10, 1814.) 
 
 The injury to which I wish to direct the attention of 
 surgeons has not, as far as I know, been described by any 
 author ; indeed the forna of the carpal extremity of the radius 
 would rather incline us to question its being liable to fracture. 
 The absence of crepitus, and of the other common symptoms 
 of fracture, together with the swelling which instantly 
 arises in this, as in other injuries of the wrist, render the 
 dif&culty of ascertaining the real nature of the case very 
 considerable. 
 
 This fracture takes place at about an inch and a half above 
 the carpal extremity of the radius, and exhibits the following 
 appearances : — 
 
 The posterior surface of the limb presents a considerable 
 deformity ; for a depression is seen in the fore-arm, about an 
 inch and a half above the end of this bone, while a consider- 
 able swelling occupies the wrist and metacarpus. Indeed, the 
 carpus and base of metacarpus appear to be thrown backward 
 so much as on first view to excite a suspicion that the carpus 
 has been dislocated forward. 
 
 On viewing the anterior surface of the limb we observe a 
 considerable fullness, as if caused by the flexor tendons being 
 thrown forwards. This fulness extends upwards to about 
 one-third of the length of the fore-arm, and terminates 
 below at the upper edge of the annular ligament of the 
 wrist. The extremity of the ulna is seen projecting towards 
 the palm and inner edge of the limb ; the degree, however, 
 in which this projection takes place is different in different 
 instances. 
 
 If the surgeon proceed to investigate the nature of this 
 injury he will find that the end of the ulna admits of being 
 readily moved backwards and forwards. 
 
 On the posterior surface he will discover, by the touch, that 
 
412 CARPAL EXTREMITY OF 
 
 the swelling on the wrist and metacarpus is not caused 
 entirely by an effusion among the softer parts ; he will 
 perceive that the ends of the metacarpal and second row 
 of carpal bones form no small part of it. This, strengthening 
 the suspicion which the first view of the case had excited, 
 leads him to examine, in a more particular manner, the 
 anterior part of the joint ; but the want of that solid 
 resistance which a dislocation of the carpus forward must 
 occasion forces him to abandon this notion, and leaves him in 
 a state of perplexing uncertainty as to the real nature of the 
 injury. He will, therefore, endeavour to gain some informa- 
 tion by examining the bones of the fore-arm. The facility 
 with which (as was before noticed) the ulna can be moved 
 backward and forward does not furnish him with any useful 
 hint. When he moves his fingers along the anterior surface 
 of the radius he finds it more full and prominent than is 
 natm'al ; a similar examination of the posterior surface of 
 this bone induces him to think that a depression is felt about 
 an inch and a half above its carpal extremity. He now 
 expects to find satisfactory proofs of a fracture of the radius 
 at this spot. For this purpose he attempts to move the 
 broken pieces of the bone in opposite directions ; but, although 
 the patient is by this examination subjected to considerable 
 pain, yet neither crepitus nor a yielding of the bone at 
 the seat of fracture, nor any other positive evidence of 
 the existence of such an injury, is thereby obtained. The 
 patient complains of severe pain as often as an attempt is 
 made to give to the limb the motions of pronation and supina- 
 tion. 
 
 If the sm'geon lock his hand in that of the patient and 
 make extension, even with a moderate force, he restores 
 the limb to its natural form, but the distortion of the limb 
 instantly returns on the extension being removed. Should 
 the facility with which a moderate extension restores the limb 
 to its form induce the practitioner to treat this as a case 
 of sprain, he will find, after a lapse of time sufficient for the 
 removal of similar swellings, the deformity undiminished. 
 Or, should he mistake the case for a dislocation of the wrist, 
 and attempt to retain the parts in situ by tight bandages and 
 
THE RADIUS. 413 
 
 splints, the pain caused by the pressure on the back of the 
 wrist will force him to unbind them in a few hours; and 
 if they be applied more loosely, he will find, at the expiration 
 of a few weeks, that the deformity still exists in its fullest 
 extent, and that it is now no longer to be removed by making 
 extension of the limb. By such mistakes the patient is 
 doomed to endure for many months considerable lameness 
 and stiffness of the limb, accompanied by severe pains on 
 attempting to bend the hand and fingers. One consolation 
 only remains, that the limb will at some remote period again 
 enjoy perfect freedom in all its motions, and be completely 
 exempt from pain; the deformity, however, will remain 
 undiminished through life. 
 
 The unfavourable result of some of the first cases of this 
 description which came under my care forced me to investigate 
 with peculiar anxiety the nature of the injury. But while the 
 absence of crepitus and of the other usual symptoms of 
 fracture rendered the diagnosis extremely difficult, a recol- 
 lection" of the superior strength and thickness of this part of 
 the radius, joined to the mobility of its articulation with the 
 carpus and ulna, rather inclined me to question the possibility 
 of a fracture taking place at this part of the bone. At last, 
 after many unsuccessful trials, I hit upon the following simple 
 method of examination, by which I was enabled to ascertain 
 that the symptoms above enumerated actually arose from a 
 fracture seated about an inch and a half above the carpal 
 extremity of the radius. 
 
 Let the surgeon apply the fingers of one hand to the seat of 
 the suspected fracture, and, locking the other hand in that of 
 the patient, make a moderate extension until he observes the 
 limb restored to its natural form. As soon as this is effected 
 let him move the patient's hand backward and forward, and 
 he will, at every such attempt, be sensible of a yielding of the 
 fractured ends of the bone, and this to such a degree as must 
 remove all doubt from his mind. 
 
 The nature of this injury once ascertained, it will be a very 
 easy matter to explain the different phenomena attendant on 
 it, and to point out a method of treatment which will prove 
 completely successful. The hard swelling which appears on 
 
414 CAEPAL EXTREMITY OP 
 
 the back of the hand is caused by the- carpal surface of the 
 radius being directed slightly backwards instead of looking 
 directly downwards. The carpus and metacarpus, retaining 
 their connections with this bone, must follow it in its derange- 
 ments, and cause the convexity above alluded to. This 
 change of direction in the articulating surface of the radius 
 is caused by the tendons of the extensor muscles of the 
 thumb, which pass along the posterior surface of the radius 
 in sheaths firmly connected with the inferior extremity of 
 this bone. The broken extremity of the radius being thus 
 drawn backwards causes the ulna to appear prominent toward 
 the palmar surface, while it is possibly thrown more towards 
 the inner or ulnar side of the limb by the upper end of 
 the fragment of the radius pressing against it in that direc- 
 tion. The separation of these two bones from each other is 
 facilitated by a previous rupture of their capsular ligament, 
 an event which may readily be occasioned by the violence 
 of the injury. An efifusion into the sheaths of the flexor 
 tendons wUl account for that swelling which occupies the 
 limb anteriorly. 
 
 It is obvious that in the treatment of this fracture our 
 attention should be principally directed to guard against the 
 carpal end of the radius being drawn backwards. For this 
 purpose, while assistants hold the limb in a middle state 
 between pronation and supination, let a thick and firm 
 compress be applied transversely on the anterior surface 
 of the limb, at the seat of fracture, taking care that it shiall 
 not press on the ulna; let this be bound on firmly with 
 a roller, and then let a tin splint, formed to the shape of the 
 arm, be applied to both its anterior and posterior surfaces. 
 In cases where the end of the ulna has appeared much 
 displaced, I have laid a very narrow wooden splint along the 
 naked side of this bone. This latter splint, I now think, 
 should be used in every instance, as, by pressing the extremity 
 of the ulna against the side of the radius, it will tend to 
 oppose the displacement of the fractured end of this bone. It 
 is scarcely necessary to observe that the two principal splints 
 should be much more narrow at the wrist than those in general 
 use, and should also extend to the roots of the fingers, 
 
THE KADIUS. 415 
 
 spreading out so as to give a firm support to the hand. The 
 eases treated on this plan have all recovered without the 
 smallest defect or deformity of the limh, in the ordinary time 
 for the cure of fractures. 
 
 I cannot conclude these observations without remarking 
 that were my opinion to be drawn from those cases only which 
 have occurred to me, I should consider this as by far the 
 most common injury to which the wrist or carpal extremities 
 of the radius and ulna are exposed. During the last three 
 years I have not met with a single instance of Dessault's 
 dislocation of the inferior end of the radius, while I have 
 had opportunities of seeing a vast number of the fracture 
 of the lower end of this bone. 
 
 The foregoing short but accurate description of the fracture, now so 
 very generally spoken of as " Oolles's Fracture," is, without doubt, of all 
 his writings that by which Mr. Colles's name is most universally known. 
 If we except the observations of Petit and Pouteau, there are no earlier 
 accounts of the injury, and the characteristic deformity accompanying it, 
 worth being referred to. 
 
 Since the appearance of Mr. Colles's memoir few subjects in surgery 
 have been more carefully studied : innumerable essays and lectures have 
 been published about it, and its literature has attained large proportions. 
 Much additional light has been thrown on the exact pathology of the 
 injury in question, and many excellent suggestions have been offered as 
 to its treatment. Yet I venture to think that few more accurate accounts 
 have been given of the symptoms and appearances by which the surgeon 
 may recognise this fracture in the vicinity of the wrist-joint than that 
 contained in Mr. Colles's paper. As Professor E. W. Smith says, the 
 most important diagnostic signs are given by CoUes ; and when we 
 recollect that at the time the account was published the author had had 
 no opportunity of investigating post mortem the nature of the accident, 
 it must be admitted that he conjectured its anatomical characters with 
 tolerable accuracy. Sir Astley Cooper says, " I have seen this accident 
 frequently, and at first did not understand the nature of the injury ; 
 indeed, dissection alone taught me its real character ; " and yet, although 
 furnished with the information derived from post mortem examination, 
 he observes, " that there is an evident projection of the radius and ulna 
 on the dorsal surface, and of the carpus on the pahnar surface of the 
 forearm."* Surely, adds Professor Smith, -f- dissection could not have 
 
 * Treatise on Dislocations and Fractures. Edited by Mr. Bransby 
 Cooper, p. 494. 
 
 f A Treatise on Fractures in the vicinity of Joints. Dubhn, 1847. 
 
416 CARPAL EXTREMITY OF 
 
 taught him this, for the carpus is displaced backwards with the lower 
 fragment of the radius, and the inferior extremity of the ulna projects 
 in front and internally. 
 
 The fracture is usually the result of a fall upon the palm of the hand, 
 and is liable to happen whenever a person, in the act of falling forwards, 
 throws out before him liis arms and hands in a state of extension, which 
 he does, as it were, instinctively, to save the head and face from injury. 
 Under these circumstances (if luxation of the bones of the forearm at the 
 elbow-joint does not occur), from the influence, upon the one part, of the 
 weight of the body and impulse of the fall, and, upon the other, of the 
 resistance given to the hand by the' ground, the radius, which receives 
 almost the whole force of the shock, breaks at its weakest part, that is, 
 its lower extremity, for it is here that the cellular structure is most 
 abundant, and the compact tissue thinnest ; the carpus escapes uninjured, 
 owing to the number of its articulations, which, as it were, divide and 
 decompose the shock, and it is further protected by the palmar fascia, and 
 by the numerous tendons which traverse the front of the carpus. 
 
 Severe pain is immediately felt at the seat of the fracture ; the patient 
 is sensible of having sustained some severe injury, and is in general 
 conscious of something having given way in the limb ; he finds that the 
 hand is powerless, that he cannot, without material aggravation of suffering, 
 allow it to hang unsupported ; and therefore the limb is usually presented 
 to us for examination resting by its ulnar margin on the palm of the other 
 hand, and usually in a middle state between pronation and supination. 
 If we desire the patient to supinate the hand, he attempts to do so, and 
 generally succeeds in the effort ; but if we watch closely the manoeuvre by 
 which he aooomphshes the movement we find that the motion takes place 
 not in any part of the forearm, but in the shoulder-joint ; the patient 
 rolls the head of the humerus outwards, and frequently is obUged to 
 incline the entire shoulder towards the side of the injured limb before he 
 can accomplish such an amount of rotation as wiU be sufacient to 
 supinate the hand. He finds it extremely difficult and painful to main- 
 tain the forearm and hand in the horizontal posture by the unaided 
 efforts of the muscles ; the fingers are usually flexed, and the neighbour- 
 hood of the wrist presents a Bing^^larly distorted appearance ; the lower 
 fragment of the radius and the carpus incline to the side of supination, 
 while the shaft of the radius tends to the side of pronation ; one fragment, 
 the superior, is shghtly drawn forwards, while the lower undergoes a 
 considerable displacement backwards, and causes a remarkable promi- 
 nence upon the dorsal surface of the forearm ; immediately above this 
 projection is seen a well-marked sulcus, the direction of which is generally 
 somewhat oblique from above, downwards and inwards, towards the 
 lower end of the ulna. 
 
 This obliquity is seen even in cases in which the line of fracture 
 is accurately transverse, and is owing to the double displacement which 
 the lower fragment undergoes. 
 
THE RADIUS. 417 
 
 The dorsal prominence extends across the entire breadth of the fore- 
 arm, but, as might be expected, is most striking towards its radial border, 
 and gradually sinks as it approaches the ulnar margin of the forearm. 
 Upon the palmar surface of the limb there is likewise seen a tumour, 
 which is less prominent than that upon the dorsal aspect, but more 
 extensive, reaching up a considerable distance along the forearm ; it ceases 
 below at the annular ligament of the carpus, where a deep and narrow 
 transverse sulcus is seen, and which remains evident, even though a 
 considerable amount of swelhng has set in : these two prominences are 
 not placed upon the same level, and, generally speaking, the dorsal 
 is more evident and striking than the palmar, for in the latter direction 
 the swelling is usually greater, and the foi-m of the tumour not so 
 circumscribed. This want of correspondence between the anterior and 
 posterior projections is one cause of the appearance of obUquity which so 
 many of these cases present. 
 
 The lower extremity of the forearm assumes a rounded form ; its 
 antero-posterior diameter is increased, but though there may be some, 
 there is by no means a corresponding diminution in its transverse 
 measurement ; the alteration in the latter direction is much more marked 
 when the fracture engages the body of the bone about two or three inches 
 above its lower extremity ; it depends upon the displacement, towards the 
 ulna, of "the upper end of the lower fragment, the fracture being in general 
 above the pronator quadratus muscle, the influence of which is then, of 
 com'se, exerted upon the inferior fragment alone. The inter-osseous 
 interval, however, in the situation of Colles's fracture is so narrow that 
 the deformity arising from this cause is very sHght, and the diminution 
 in the transverse diameter of the forearm scarcely perceptible. 
 
 The convexity of the ulnar edge of the forearm is slightly increased, 
 but when the eye is cast along the radial margin of the limb the latter is 
 observed to present a double concavity, one (supposing the arm to 
 hang by the side) directed forwards, and projects at the ulnar border of 
 the carpus. 
 
 The most usual seat of the fracture is from three-quarters of an inch 
 to one inch above the radio-carpal articulation : sometimes it is only a 
 quarter of an inch above the joint, but I have never seen it higher than 
 one inch ; it always appears to be higher than it really is ; but should the 
 lesion of the bone take place at two inches or two inches and a half above 
 the radio-carpal articulation, the injury no longer presents the peculiar 
 and remarkable characters which distinguish Colles's fracture of the 
 radius. 
 
 Professor B. W. Smith,* in his admirable treatise, next turns to the 
 pathology of the injury. I am not acquainted with any abler or more 
 accurate criticism of the view of those who have maintained that fractures 
 
 * A Treatise on Fractures in the vicinity of Joints, &c. By Bobert 
 Wilham Smith. Dublin, 1847. 
 
 2e 
 
418 CARPAL EXTEEMITY OF 
 
 of tlie lower end of the radius, witliin an inch of its carpal surface, are 
 at least in general, if not always, examples of impacted fractures. This 
 view has been advocated with much ingenuity by Voillemier ; Nelaton 
 has, in fact, adopted the theory in his ' Siemens de Pathologie Chirur- 
 gicale, t. i., p. 742, and the late Mr. CaUender produced in support of it 
 actual recent pathological specimens. That " fractv/res pwr penetration " 
 are, however, those most usual when a breach of continuity occurs within 
 an inch of the carpal end of the radius can hardly any longer be main- 
 tained in face of the evidence accumulated by Professor Bennett, to which 
 I shall presently refer. 
 
 " In a fall upon the palm of the hand," writes Monsieur Voillemier,* 
 " where the radius rests chiefly upon the dorsal surface of the upper range 
 of carpal bones, the whole force of the shock is transmitted to the radius, 
 tending to approximate its extremities ; it breaks, therefore, at its 
 weakest part, which is a short distance above the wrist-joint, where the 
 compact structure of the shaft is thinnest, and the cancellated tissue 
 most abundant ; the compact tissue of the upper portion is, by the con- 
 tinuance of the force after the fracture has taken place, driven into the 
 cancellated tissue of the lower fragment. This may occur in several 
 ways : if the end of the bone is large ; if the shock has been transmitted 
 in the direction of its axis ; and if the bone has yielded throughout its 
 whole circumference at the same moment ; then the whole extremity of 
 the upper fragment penetrates into the lower, and thus the two fragments 
 are locked together. But if the force of the shock has been very con- 
 siderable, then the upper fragment continues to descend, and the lower, 
 compressed between it and the carpus, is split into several pieces ; the 
 styloid process is broken off, and the lower end of the bone crushed. 
 Dupuytren has alluded to cases of this description, and has termed them 
 ' Fractures par ecrasement.' This mode of penetration is, however, as 
 might be supposed, very rare. 
 
 " But there ii another mode of penetration, and the more common ; 
 it also happens from a faU upon the hand, the force of the shock coming 
 obliquely on the radius, so that the posterior surface of the bone has to 
 support the greater part of it ; the lower fragment is at the same time 
 carried backwards, and thus the posterior wall of the compact tissue of 
 the upper fragment begins to penetrate into the spongy structure of the 
 bone, while the anterior wall glides upon the palmar aspect of the cai^pal 
 fragment. 
 
 " In all the specimens of fracture of the lower end of the radius, 
 examined long after the occurrence of the accident which broke the bone, 
 a line of compact tissue is found, covered over with cancellated structure, 
 directed vertically, and descending to within a greater or less distance of 
 the articular surface of the radius, as the case may be. Free below, it is 
 manifestly continuous above with the body of the bone, the compact wall 
 of which becomes all at o nce thicker where it is joined by this Ime. 
 * Archives generales de Medicine. May, 1842. 
 
THE RADIUS. 419 
 
 This line is never double ; it is continuous with the posterior wall of the 
 bone when the fracture is attended with displacement of the lower frag- 
 ment backwards, and with the anterior when the inferior fragment is 
 thrown forwards. 
 
 " The explanation of this fact, not hitherto noticed, becomes sufficiently- 
 simple if we admit the doctrine of fracture by penetration. Let us take, 
 for example, a case of fracture with displacement of the lower fragment 
 backwards — the more common species : in consequence of the peculiar 
 nature of the displacement (renversement) the penetration can only 
 happen posteriorly, for in front " ce veritable inoii/aement de bascule " will 
 tend rather to separate the two anterior edges of the fracture, or will 
 leave them merely in contact. Thus the line of compact tissue can only 
 exist posteriorly, for it is only the compact tissue of the posterior surface 
 of the upper fragment that penetrates the cancellated tissue of the carpal 
 end of the bone. 
 
 " In the case of reciprocal penetration the posterior border of the 
 upper penetrates the lower fragment, and the anterior wall of the carpal 
 end of the bone ascends into the superior fragment. In this case there 
 should be two hnes of compact tissue, when the bone is divided from 
 before backwards ; one only, however, is found. The explanation of this 
 fact offers itself when we reflect upon the extreme thinness and deUcacy 
 of the layer of compact tissue which invests the front of the lower frag- 
 ment, in consequence of which it is broken and destroyed at the moment 
 of penetration into the upper fragment, but posteriorly it is the thick 
 resisting compact structure of the shaft that penetrates the carpal frag- 
 ment. We cannot judge of the extent to which this penetration has 
 taken place by the length of the hne of compact tissue, for this always 
 appears longer than it really is, for the periosteum, in passing from one 
 fragment to the other, fills up in part the depression produced at the level 
 of the fracture ; there is also a remarkable thickness of the compact 
 structure of the lower end of the bone, in old fractures, of which it is 
 difficult to give an explanation." 
 
 Monsieur VoiUemier further supposes that the circumstance of the 
 fracture being impacted explains the difficulty of detecting crepitus in 
 cases of fracture of the lower end of the radius. 
 
 This theory of M. Voillemier is admitted by ProfesBor Smith to be 
 ingenious ; M.ay more, he admits that the appearances are quite correctly 
 described. In every instance of CoUes's fracture which he had an 
 opportunity of examining, he found, upon making a section of the bone 
 from before backwards, a line of compact tissue continuous with the 
 posterior wall of the shaft, and extendmg into the reticular structure of 
 the lower fragment. 
 
 But, he adds, do the appearances above described warrant us in con- 
 cluding that these inquiries are examples of fracture with penetration ? 
 This question, after a careful and exhaustive investigation, Professor 
 Smith answers in the negative. According to him the compact structure 
 
420 CARPAL EXTEEMITY OP 
 
 of the shaft of the radius appears, in old cases where union has long 
 since taken place, to have penetrated the lower fragment in consequence 
 of its having become encased in osseous matter deposited for the union of 
 the fracture. 
 
 The impaction theory is liable to the following objections : — 1. The 
 distance between the line of compact tissue and the posterior wall of the 
 lower fragment is but the measure of the amount of displacement back- 
 wards of that fragment. 2. This interspace is considerable even in those 
 cases in which the fragments are found to be on the same plane in front. 
 3. Were the theory correct the amount of shortening of the posterior 
 surface of the bone should be much greater than it ever is. 4. There is 
 no correspondence between the length of the line of compact tissue and 
 the amount of shortening of the back of the radius. 5. The possibiUty 
 of either fragment being driven into the other is difficult to be conceived 
 as long as the ulna remains entire and the ligaments uninjured. 6. Were 
 it possible to separate the united fragments, and draw down the inferior 
 so as to extricate it from the apparent impaction, we would not thereby 
 succeed in restoring the normal form of the lower end of the radius. 
 
 In addition to these arguments Professor Smith adds that the appear- 
 ances disclosed by the examination of recent specimens are opposed to the 
 impaction theory. This, however, we now know is not altogether true. 
 The examples of recent fracture dissected by the late Mr. Oallender and 
 others prove beyond doubt that penetration may take place, and that, too, 
 without any fracture of the ulna. 
 
 Professor Bennett, by a careful examination of a large number of 
 specimens, seems to have placed himself in a good position to decide 
 between the relative merits of those who have advocated the impaction 
 or the non-impaction theory, and of whom VoUlemier and E. W. 
 Smith are the respective champions. His memoir* appears to me so 
 valuable a contribution to the pathology of this subject that I do 
 not hesitate to quote from it at some length the part referring to this 
 topic : — 
 
 " Since their views have been published, we find authorities ranging 
 themselves on opposite sides, according as they adopt the non-impaction 
 theory of Smith or the opposing doctrine of Voillemier, that aU these 
 injuries are fractures by penetration. Of late the number of recent 
 dissections have forced most writers to admit the occurrence of each form. 
 We have ample proof that the simple transverse fracture without im- 
 paction, the impacted, and the fracture pa/r ecraaement with a shattered 
 lower fragment, are all possibilities. Intimately connected with the 
 theory of impaction is the explanation of the variability of the symptom 
 
 * Eemarks on Colles's fracture, &c. By Ed. H. Bennett, M.D., M.Ch., 
 Professor of Surgery in the University of Dublin, &c. Bead in the 
 Section of Surgery at the Annual Meeting of the British Medical Associa- 
 tion in Cork, August, 1879. 
 
THE RADIUS. 421 
 
 SO much relied on in the diagnosis : crepitus. Yet anyone who will take 
 the trouble to investigate the statements contained in the accounts of 
 recent cases which have been submitted to dissection may find that this 
 symptom has been absent in each form of the injury. We cannot, there- 
 fore, rely on its absence as a proof of the existence of impaction in any 
 given case, nor are we for the same reason to abstain from attempting 
 reduction of the deformity for fear of undoing the impaction, or again 
 rely on it as a safeguard against displacement, and so adopt a lax treatment. 
 I will notice here that, valuable as recent dissections are in guiding our 
 examination of united specimens, too high an importance has been 
 attached to them by some. Certainly I cannot agree with Mr. Callender 
 that the dissection of three cases where the fracture was caused by 
 exceptionally great violence are sufficient ' to remove all doiibt on this 
 subject.' I cannot agree with him even when he makes the following 
 remark : — ' There can be no question but that impaction is the cause of the 
 displacement.' This surely is to mistake the effect for the cause. The 
 following passage from Voillemier shows that, however fully impressed 
 he was in favour of the theory of impaction, he avoided the error 
 of committing himself to its absolute adoption : — ' Mais il faut etre 
 prevenu que dans certains cas de penetration pen marquee, de fractures 
 par arrachement, il pent n'y avoir aucun ohangement dans les axes du 
 membre, pas de raccourcissement, pas de mobilite des fragments, pas de 
 crepitation et seulement de la douleur du gonflement autour du poignet, 
 enfln tous les symptomes d'une entorse, et ces cas ne sont pas tres- 
 rares.' 
 
 " Here the author admits a group of injuries sufficiently common, in 
 which impaction is absent or inappreciable ; in which, too, crepitus and 
 deformity are absent. If such cases be overlooked, as they too commonly 
 are, the most extreme deformity establishes itself in a short time, as I 
 have more than once observed. These facts are certainly inconsistent 
 with the theory that deformity, the result of displacement, is solely due 
 to impaction, and that muscular action takes no part in its production. 
 
 " In opposing VoiUemier's views Smith falls into the opposite error, in 
 almost absolutely denying the occurrence of impaction. He says : — ' I 
 am inchned to believe that the doctrine of fracture with penetration 
 is untenable.' He says, indeed, in another passage, ' Until, therefore, the 
 result of the examination of recent specimens can be adduced in support 
 of the theory, I shall be inclined to beheve that impaction is only 
 apparent.' I have the good fortune to be able to exhibit here the speci- 
 men, the recent dissection of which seems to have so strongly influenced 
 his opinion, a specimen familiar to the readers of his book, which the 
 CoUege of Surgeons have kindly exhibited here. This specimen, with 
 many others since recorded, obtained by post-mortem examination and 
 by experiment, estabhsh the existence of the simple fracture, no matter 
 how many cases of the impacted variety may be found. The circumstance 
 which seems to have confirmed him in his opinion is expressed in the 
 
422 CARPAL EXTREMITY OF 
 
 following passage in that part of Ms paper in whicli he discusses the 
 opinion of Voillemier on the value of the constancy of the third line of 
 compact tissue seen imbedded in the canoeUi of the lower fragment of 
 united specimens : — ' If it indicated the forcible impaction of the upper 
 into the lower fragment, we should expect to find the latter split into two 
 or more pieces, but this form of fracture of the lower end of the radius is 
 comparatively rare.' 
 
 " I can prove from the coUeotion before me, a collection made without 
 any reference to this opinion, and certainly representative of the general 
 features of the injury, that the opinion that comminuted fractures of the 
 , ower fragment are comparatively rare, is incorrect. 
 
 " I think, too, that I can show proof that VoUlemier's opinion as to the 
 relative frequency of the forms of impaction is not correct. He describes 
 four possible varieties of impaction : — 1. The penetration of both walls of 
 the upper fragment into the tissue of the lower without its being burst 
 asunder. 2. The same mode of penetration, with crushing of the lower 
 fragment, — Dupuytren's fracture 'par ecrasement. 3. The bending or 
 hinging, so to speak, of the anterior walls, with impaction of the upper 
 into the lower fragment posteriorly. 4. The reciprocal penetration of the 
 fragments, the upper into the lower behind, and the lower into the upper 
 in front. Of these possible forms of impaction he believes the third 
 to be the most common, founding his opinion apparently on the observa- 
 tion ' that the impacted line is never double ' ; an observation in which 
 Smith agrees. 
 
 "I am able to show, among the specimens before the meeting, that 
 exceptions occur to this rule ; further, that comminution is more common 
 than Smith has estimated it to be, and. that the paths of the fractures 
 which occur in the lower fragment present a remarkable constancy in 
 position. If I rightly interpret these appearances the conclusion must be 
 arrived at that, in comminuted fractures, reciprocal impaction is the most 
 common form of the accident. 
 
 " The number of specimens which I submit is in all sixty- two. Of these 
 fifty-four are true Colles's fractures, transverse in the general direction of 
 the fracture, the lower fragment displaced backwards, with more or less 
 distortion in the direction of the inferior articular surface, the most 
 constant element of which is dependent on the elevation of the styloid 
 process. Four specimens are examples of the rare injury in which 
 the lower fragment is displaced forwards ; three are epiphysary separa- 
 tions ; and in one a fracture has occurred, detaching the styloid process of 
 the radius, with a small portion of the articular surface adjoining it. 
 
 " In estimating the frequency of comminution of the lower fragment I 
 have included under this head only such specimens as exhibit distinct 
 evidence of fracture having passed completely through the carpal articular 
 surface ; many specimens present evidences of splintering of the non- 
 articular surface of the lower fragment, and some of the upper also, but 
 I think such should be excluded in the present discussion. Applying this 
 
THE RADIUS. 423 
 
 test we find, of the specimens before us, thirty-one are simple, twenty- 
 three comminuted, a fact that is inconsistent with Smith's statement 
 ' that this form of fracture is comparatively rare.' 
 
 "Before stating the remaining facts exhibited by these comminuted 
 specimens, I may delay a moment to consider the mechanism of the 
 injury. Arguing a priori, as the path of CoUes's fracture is generally 
 transverse with regard to the long axis of the radius, and the displacement 
 of the hand tends constantly in the direction of abduction, we should 
 expect that the upper fragment, acting as a wedge, if this be the cause of 
 the comminution, should split the lower first and most constantly at that 
 border of the lower fragment next the ulna, against which the force 
 is directed, and where the lower fragment is thinnest. This is exactly 
 what the specimens before us prove to be the case. Among those of 
 the simple fractui-es which border on the comminuted in their characters, 
 we find a crack first appearing on the ulnar facette, reaching just to the 
 carpal surface, placed at the centre of the curve of the facette. 
 
 " In ten of the twenty-three comminuted, a fissure, starting from the 
 same point in the ulnar facette, runs into the carpal articular cartilage 
 along its posterior edge, breaking out into the dorsal surface of the bone, 
 either, in the least extensive injuries, at the outer side of the common 
 extensor groove, or in others running along as far as the groove for 
 the radial extensors, and, in a few, breaking out at each of these points. 
 The frequency of this position of fracture has been already noticed by 
 Packard. 
 
 " Its frequency appears to have led Ehea Barton into the error that there 
 was a form of fracture limited to this region of the bone requiring to be 
 distinguished in practice from CoUes's fracture. His idea of the mechanism 
 of the injury is quite the reverse of what we see in action here ; for 
 he supposed that pressure of the carpus in over-extension detached the 
 fragment. In the eleventh specimen of the series a branch is traced 
 passing off from the first fissure towards the anterior depression in the 
 scaphoid facette ; this fissure is seen in the bone, but, as we often find in 
 such, has left the cartilage intact. In the twelfth specimen the fissure, 
 starting as before, passes along the route indicated in the preceding, but 
 without any posterior branch. In the next five specunens the primary 
 fissure exists with its anterior and posterior branches. In three of the 
 four remaining specimens the features of the comminutions are the same, , 
 but chronic rheumatic arthritis has masked their exact details, so that it 
 is difficult to follow them. In one specimen only are the features of the 
 lines of the fracture entirely different ; in it an oblique line seems to have 
 detached the styloid process, passing from in front backwards and inwards 
 across the scaphoid facette. 
 
 " There appears then sufficient ground for the assertion that the mode of 
 comminution is constant, and that it results from the impaction of the 
 upper into the lower fragment, taking effect first and chiefly on the side of 
 the fragment next the ulna. 
 
424 CARPAL EXTEEMITY OF 
 
 " A further examination of these specimens shows that, where the frac- 
 tures remain sufficiently distinct in outline to trace their details exactly, 
 the impaction of the fragments is reciprocal ; that while the posterior 
 surface of the upper pierces the lower, the anterior of the lower penetrates 
 the upper, it may even lead to its splintering. This conclusion is at 
 variance with the opinion of Voillemier ; but I believe the explanation of 
 the discrepancy between us is, that hitherto the examination of commi- 
 nuted specimens has not been made with sufficient care. I believe that 
 in many simple fractures no impaction whatever occurs, and again, that 
 in many injuries, Voillemier's third variety, the bending of the anterior 
 wall with posterior impaction, occm'S. I cannot resist the conclusion to 
 which this collection leads, that in comminuted fractures, which occur in 
 proportion to simple injuries almost in the ratio 2-3, the characters are 
 constant, and the result of reciprocal impaction of the fragments." 
 
 I feel that the foregoing observations on Colles's fracture of the radius 
 would be incomplete unless supplemented by some reference to the 
 methods of treatment now usually approved of by surgeons. Upon this 
 subject also much has been written. It would be tedious to enter at large 
 into the merits of the various methods of treatment ; yet I should not 
 do justice to the subject without putting the reader in possession of the 
 views of two surgeons who have devised sphnts for the treatment of this 
 accident, and explained the rationale of its treatment in the most prac- 
 tical and lucid manner. I aUude to Doctors Henry Bond and Alexander 
 Gordon. 
 
 Dr. Bond read his original paper before the College of Physicians, 
 Philadelphia, in December, 1851. It was published in their Transactions. 
 
 The accoimt here given is a fuU abstract derived from the ' American 
 Journal of Medical Sciences,' vol. xxiii., 1852 : — 
 
 " The usual mode of treating these fractures, as is well known, consists 
 in the use of two long straight splints, with compresses or cushions, and 
 bandages. The palmar sphnt extends from the elbow down to the 
 extremities of the fingers. Some, however, do not allow this to extend 
 below the second joints of the fingers. The dorsal sphnt extends some- 
 times only to the extremity of the metacarpe. When this dressing is 
 applied the longitudinal axis of the forearm will be continuous, or parallel, 
 with that of the hand. 
 
 •' There are several objections to this mode of dressing the fraotm-e, which 
 I wUl attempt to point out. In the first place, it violates what ought to 
 be regarded as a surgical canon in the treatment of fractures, viz., 
 to adopt such a position as will put all the muscles acting on the part as 
 much in repose, as free from tension, as possible; so that the least 
 counteracting force will be required. 2. The constrained position of the 
 hand demands tighter bandaging, in order to prevent derangement of the 
 fragments by paralyzing or subduing the muscles that are rendered tense 
 
THE RADIUS. 426 
 
 by the position assumed. 3, This constrained position and tight ban- 
 daging greatly increase the danger of that protracted or permanent 
 rigidity of the hand and fingers which is a too frequent result of those 
 injuries. 4. This mode of dressing, by long straight splints, not only in- 
 creases the danger that it will result in rigidity, but that, when it does 
 oeeiir, the hand will be left unsightly, inconvenient, or useless. 5. There 
 is another objection to it, which will be regarded by the surgeon as 
 of more or less importance, according as he is actuated more or less by the 
 feelings of humanity. I refer to the distress or discomfort which 
 must result from a constrained position and the force applied to main- 
 tain it. 
 
 " The muscles that act on the hand are least tense, or most in repose, 
 when the hand is inclined backwards, so that the metaoarpe forms a con- 
 siderable angle with the forearm,* when it is also inclined inwards towards 
 the ulnar side of the arm, and when the fingers are moderately flexed. 
 In this case it will be perceived that the longitudinal axis of the forearm, 
 if prolonged, would not correspond with that of the hand, but would pass 
 through or very near the point where the thumb and index finger most 
 easily and naturally meet. Thus, in the innumerable manipulations 
 with the thumb and fingers (as with a pen, pencU, button, needle, money, 
 &o.), their points most easily and naturally meet in this axis of the fore- 
 arm. This wUl be found to be the position of the hand when it hangs by 
 the side with all the muscles relaxed. 
 
 " When the hand is placed in the position above described, so as to take 
 off tension fi-om all the muscles, there will be so little tendency to dis- 
 placement of the fragments that a very gentle pressure of compresses and 
 bandages will be adequate to maintain them in their proper relation to 
 each other. The dressing may be removed earlier, so as to give motion 
 to the hand and fingers without danger of producing derangement of the 
 fragments, and the gentle pressure of the dressing will be less likely 
 to deprive the tendons and sheaths of their lubricity, and thus to cause 
 permanent adhesions. 
 
 " There are cases, as before observed, where such violence is done to the 
 bones and soft parts, especially in elderly persons of a rheumatic or gouty 
 diathesis, that it may be impossible to avoid permanent adhesions 
 and rigidity. In such cases, if the usual authorized mode of treatment 
 be adopted, the result wiU be a most awkward, unsightly, useless 
 member. 
 
 " But if the hand can be placed and retained in the unconstrained 
 natural position above mentioned (to say nothing of the better chance of 
 escaping permanent stiffness), in the first place the unsightly deformity 
 wUl be avoided, and, in the next place, the hand will not entirely have lost 
 its uses. For the hand, thumb, and fingers, being placed very nearly in 
 the position of their most frequent uses, the interossei, the lumbricales, 
 
 * Malgaigne calls this la flexion habituelle de la ma/vn en arriere. 
 
426 CABPAL EXTREMITY OF 
 
 and the several short muscles of the thumb wiU, by causing only a 
 very limited motion, enable the hand to perform very many of its useful 
 functions. 
 
 " I can say with confidence, not only from a priori reasoning, but from 
 some experience within the last few years, that the dressing of a limb on 
 the principles here inculcated will vei-y materially conduce to the comfort 
 of a patient. I shall here make no comment upon what is said about 
 paralyzing the muscles by tight bandages, nor upon the power of the 
 body to accommodate itself, by a very painful discipline, to very distress- 
 ing necessities. 
 
 " The importance of the position of the hand in the treatment of 
 fractures of the radius has been fully recognised for a long time by 
 eminent surgeons. In these cases Mr. CUne did not allow the splints or 
 the sling to extend below the wrist. His object was to let the hand, by 
 its own weight and without any impediment, incline towards the ulnar 
 edge of the forearm ; and, while the ulna acted as a counter-extending 
 force, this inclination of the hand would prevent the fragments from 
 over-riding or overlapping each other, and make it very easy to keep 
 them in apposition. He understood well the mechanism of this accident- 
 When the radius alone is broken the ulna affords all requisite counter- 
 extension, and in proportion as the hand is inclined towards the ulna will 
 the lower fragments be drawn down, so that there wiU be hardly a 
 chance for one fragment to overlap the other ; certainly there will be 
 little difficulty in keeping the fragments in apposition with very gentle 
 means. But Mr. Cline's method of dressing, in order to accomplish the 
 indication, was too indeterminate ; he could not depend upon maintaining 
 steadily the same degree of inclination of the hand, and one might 
 suppose that there would be danger of producing artificial joints. Never- 
 theless, I am persuaded that with Mr. Chne's method of treatment with 
 short splints there would be fewer cases terminating in deformity and loss 
 of the use of the hand than when the arm and hand are tightly swathed 
 in long straight splints. 
 
 " Sir Charles Bell long ago inculcated the importance of the inclination 
 of the hand in the treatment of fractures of the forearm, and he has 
 given a plate iUustrating his opinion. Boyer is very explicit on this 
 point. He says ' the extension should be made by inclining the hand 
 towards the ulnar edge of the forearm.' Yet this obvious principle and 
 this explicit direction are wholly disregarded in the present usual mode of 
 dressing with long straight splints and tight bandages. Dupuytren, 
 whose lectures on this subject should be studied by every surgeon, devised 
 a splint — his attelle cubitale — with the special object of maintaining this 
 inclination of the hand towards the ulna. Nothwithstanding this great 
 man devoted such deep attention to this subject, there were serious 
 defects in his apparatus, which have been pointed out by subsequent 
 French writers. 
 " I have attempted to devise a mode of dressing these fractures, having 
 
THE RADIUS. 427 
 
 reference to the principles advanced in this paper, and that will meet the 
 following indications : — 
 
 "1. To maintain such an inclination of the hand upon the- forearm 
 as shall most effectually relieve the muscles from tension or put them 
 in repose. 
 
 " 2. To maintain the hand and fingers in a position that, if rigidity 
 should result, the member shall be as little an incumbrance and retain as 
 many of its uses as possible. 
 
 " 3. To make it easy of application, requiring no extraordinary skill or 
 dexterity, and httle liable to be deranged or displaced. 
 
 "4. To make the dressing easy and comfortable to the patient, while it 
 does not lack efficiency. 
 
 " My own experience of its use within the last three years convinces me 
 that I have to some extent accomplished these indications. How far 
 this shall be corroborated by others can be known only when others shall 
 have had time, opportunity, and disposition to test it. 
 
 " To enable others to test the principles herein maintained, in the mode 
 of treating these fractures, I offer the following directions for preparing 
 the dressing, with some explanations as to its appKcation : — 
 
 " 1. With a light board of proper thickness for a splint take a profile of 
 the forearm and hand of the patient, placing the hand in its habitual 
 inclination towards the ulnar side of the arm, and extending the profile 
 from the elbow downwards, so that it shall reach the second joint of the 
 fingers on the inside, when these are moderately flexed — as much flexed 
 as they are when the points of the thumb and fingers are brought into 
 conta.ct. The lower end of the board must be out off obhquely (at 
 an angle of fifteen or eighteen degrees) in a direction corresponding with 
 that of a body grasped in the hand, when the hand is inclined to the ulna 
 as above indicated. 
 
 " 2. Cover the boa»d thus prepared with sheeting or other strong fabric. 
 This may be done by winding around it, from end to end, a narrow 
 rolling bandage, covering all of it as nearly as may be with few or 
 no duplications. This is the most expeditious method. A neater one is 
 to cut a piece of sheeting, of the general form of the board, but extending 
 beyond the board on every side, and fastening it upon the board either by 
 a few stitches drawing towards each other the overlapping edges, or 
 gluing down those edges upon that side of the board which is to 
 be towards the arm, and which edges are to be covered with the paste- 
 board. 
 
 " 3. Prepare a block of soft hght wood, fi-om seven-eighths to eleven- 
 eighths of an inch thick, and from two to two and a half inches wide, 
 according to the size of the patient's hand, and of a length corresponding 
 with the width of the board in the pahn of the hand. This block is to be 
 carved and rounded, so as to adapt it to the form of the hand and make 
 it easy for the thumb, and in the grasp of the hand when it is placed on 
 the board. It is to be fastened there by screws or nails, so that the 
 
428 CAEPAL EXTREMITY OF 
 
 remote edge of it shall correspond exactly with the lower oblique end ol 
 the board. 
 
 " 4. Upon that part of the board not covered by the palm-block fasten, 
 by raeans of small carpet tacks, a piece of bookbinder's pasteboard, 
 extending on each side beyond the edges of the board about an inch. If 
 the pasteboard be very thick and stiff make a shght incision in it along 
 the edge of the board, in order to bend more easily the two projecting 
 portions of it, thereby making a kind of box for the lodgment of the arm. 
 " It seems to me that this spUnt, or one constructed on the same 
 principles, will meet the above-mentioned indications in the following 
 manner — 1st. The form given to the board retains the hand in its 
 habitual inclination towards the ulnar edge of the arm, accomplishing the 
 object aimed at by Dupuytren's attelle cuhitale with as much certainty, 
 with more simplicity, and more comfort to the patient. 2nd. The 
 palmar block retains the hand in its habitual inclination backwards, and 
 it gives the fingers that moderate flexion which most relieves the muscles 
 from tension, and likewise that position which, if stiffness should result, 
 win not only save the hand from a most inconvenient, ungraceful de- 
 formity, but will reserve to it the power of performing very many of its 
 most frequent and useful functions. In addition to these advantages this 
 block contributes much to the comfort of the patient. 3rd. The object in 
 covering the board with a strong fabric, as above described, is to retain 
 the bandage with certainty in its place without applying it with a 
 dangerous tightness ; for,- by fastening the roller to this covering with 
 pins, the surgeon need never have his patience tried by finding his dress- 
 ing deranged at his next visit. I can speak with confidence on this 
 point from having used it repeatedly in cases where this quality was fully 
 tested. 4th. The pasteboard is not an essentially necessary part of the 
 splint, but it wiU be found to contribute to the comfort of the patient and 
 the convenience of the surgeon. , 
 
 " The requisites for dressing with this splint are flannel or other soft 
 fabric, to cover or line the inside of the splint ; two compresses ; a roller ; 
 sometimes, but not always, a dorsal splint. 
 
 " The flannel or other fabric with which the splint is hned should extend 
 a little beyond the edges of the pasteboard, and the same piece may be 
 extended over the palmar block ; but it wiU be better to cover this block 
 with a separate piece. For this jjurpose take a piece of flannel large 
 enough, when it is doubled, to coyer the block. Through the doubled 
 edge, with a proper needle, carry a small string (such as ligature-twine), 
 and tie this around the splint immediately above the block. The covering 
 of the block thus applied may be conveniently changed without removing 
 the arm from its bed. 
 
 " Two compresses will generally be required : the anterior or palmar, and 
 the posterior or dorsal. The proper construction and application of the 
 former of these are a most important point in this dressing, and certainly 
 not less so when long, straight splints are employed ; and deformity of 
 
THE RADIUS. 429 
 
 the radius or wrist will most frequently result from negligence or want of 
 skill in its use. If the compress be deficient in thickness, and the 
 bandage be apphed with its usual tightness, there will not fail to be either 
 a curvature forwards or a sigmoid flexure, which are the usual deformities. 
 If the thickness of this compress be excessive there may be a curvature 
 backwards, which I think seldom occurs ; but there will be such undue 
 pressure by such a compress as to increase the danger of adhesions, and 
 to aggravate the discomfort of the patient. 
 
 " These preparations being made, the fragments, if deranged, are to 
 be reduced, and the splint applied. I have very seldom, if ever, found 
 any difficulty in replacing the fragments. Let an assistant, grasping the 
 hand (not the fingers), incline it towards the ulnar side of the arm, 
 according to the direction of Boyer, making steady, but not very vigorous, 
 tension, and, with his thumbs and fingers, the surgeon will easily press 
 the projecting fragments into their proper relation to each other. In 
 making this extension Dr. Dorsay directs the assistant to ' grasp the 
 hand.' Dr. Barton says an assistant ' makes extension from the fingers.' 
 It seems to me that Dr. Barton errs on this point. The objections are, 
 first, that by grasping and pulling the fingers the flexor muscles are 
 brought into so much more tension that they will offer more resistance to 
 the extending force. In the next place, by pulUng at the fingers the 
 hand will be brought more nearly into a direct hne with the forearm, 
 instead of being inclined towards the ulna, the utihty of which incliuation 
 in such cases is, I think, so obvious that it would be superfluous to cite 
 authority or to attempt a demonstration. 
 
 " After the forearm is laid into the splint apply the dorsal compress. 
 This compress is seldom essentially necessary in these cases, but it may 
 always be advisable to use it. Its thickness is comparatively unimportant, 
 especially when a dorsal splint is not employed. It may be made of 
 folds of a bandage of about the width of the vprist, and so long as to cover 
 the lower fragment of the radius and the wrist, but not extend upon the 
 hand. After adjusting this compress apply a roller, beginning upon the 
 lower fragment of the radius, carrying it down over the wrist, the meta- 
 carpus, and the first joints of the fingers, leaving the thumb free ; then 
 returning with the bandage to the upper end of the splint, and attaching 
 it in several places by pins to the woven covering of the splint. If 
 the compresses have been properly made and adjusted it is unnecessary, 
 with this splint, to apply the bandage with anything hke the tension 
 ordinarily employed in dressings with the long straight splints ; and those 
 accustomed to the use of these splmts will be Kable to err on this point." 
 
 No account of the treatment of CoUes's fracture would be complete 
 without some allusion to the ingenious apparatus devised by Dr. Alexander 
 Gordon.* His "improved splint " is not readily described in words : it 
 
 * A Treatise on the Fractures of the Lower End of the liadius, &o. 
 By Alexander Gordon, M.D. London : Churchill, 1875. 
 
480 CARPAL EXTREMITY OP 
 
 is figured in most of our surgical handbooks ; but to see it and use it is 
 the only satisfactory method of ascertaining its form, mode of appli- 
 cation, and practical merits. It consists of two portions ; one an anterior 
 splint which goes on the front of the forearm, and has a comfortable 
 support for the ulnar side of the hand, which is maintained in a partially 
 flexed position ; the second a curved splint, which, with a firm pad, is so 
 appUed on the back of the forearm as to press forward the carpus, and 
 with it the lower fragment of the fractured radius. 
 
 " In consequence," says Dr. Gordon, " of the displacement, outwards 
 and backwards, of the lower upon the upper fragment the lower end of 
 the ulna becomes imnaturally prominent in front and internally. This 
 is observed immediately after the accident ; but if the primary deformity 
 persists, the prominence of the lower end of the ulna will become more 
 marked, its posterior surface more curved, its inner border more convex, 
 and its head twisted so as to look outwards. The displacement backwards 
 of the carpus on the carpal surface causes absorption of the posterior half 
 of that surface, increasing its obliquity, and giving to it an aspect looking 
 more backwards. This is one cause of the shortening of the posterior 
 surface of the radius. 
 
 " In consequence of the accident the fractured surfaces have suffered 
 more or less contusion, they inflame and soften. The backward pressure 
 of the carpus, acting continuously on the fractured surfaces behind, 
 causes interstitial absorption of a large quantity of the cancellous struc- 
 ture of the lower end of the bone. 
 
 " The outward and upward pressure produces effects even more de- 
 cided. In one of twenty-seven specimens the styloid process has become 
 almost horizontal and very much thinned, in five it is much absorbed, and 
 in twenty-one it presents various degrees of absorption and displacement 
 backwards ; but the most marked displacement is that of the cancellated 
 tissue outwards, to the extent of three-fourths of an inch in the worst 
 instances. Eemodelling of the whole of the cancellated tissue posteriorly 
 and externally, with vertical shortening and transverse elongation, are 
 the effects of the altered bearing of the carpus on the lower end of the 
 radius. The compact tissue in front is not shortened, but it has become 
 more or less convex. Behind, at the seat of fracture, the radius has 
 become concave from the displacement backwards of the lower end of the 
 lower fragment : there a new formation of cancellated bone has taken 
 place, strengthening the bone at the broken part, helping it to resist the 
 upward and backward pressure, and masking the exact course of the 
 fracture behind. 
 
 " This new disposition of bone behind, with the shortening of the 
 radius externally and behind, have led many surgeons to suppose that 
 these alterations must necessarily be the result of impaction ; an opinion 
 which I hold to be now untenable, and which the production of the 
 fracture artificially, controverts in the most decided manner. Colles's 
 fracture is not, nor can it be, an impacted fracture ; its mechanism 
 
THE BADIUS. 431 
 
 declares impaction to be a mere phantom of the imagination, resulting 
 from the erroneous interpretation of pathological facts." 
 
 It is impossible to concur in the last assertion. Impaction cannot be 
 called a phantom of the imagination in face of the specimens accumulated 
 by Professor Bennett, and the actual dissections of recent cases made by 
 Callender, and published in Bartholomew Hospital Beports. 
 
 WEST, NEWMAN AND CO., FBINIEltS, Oi, HAITON QABDEN, LONDON. 
 

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