| pi; < p p I :' -li 111;......*&f Ip'l'l i m :.-%t!:38 fef« 7392 Surgeon General's Office fB^f ON SYPHILIS, CONSTITUTIONAL AND HEREDITARY; SYPHILITIC ERUPTIONS BY ERASMUS WILSON, F.R.S., AUTHOE OF "A TEEATISE ON DISEASES OF THE SKIN," ETC. WITH FOUR COLOURED PLATES. PHILADELPHIA: BLANCHARD AND LEA. 1852. • \rtCA \\I7A1o PHILADELPHIA: T. K. AND P. G. COLLINS, PRINTERS. TO PHILIP EICORD, THE DISTINGUISHED CHIEF OF AN IMPORTANT BRANCH OF SPECIAL MEDICINE, * 0Tl)is iJDork, TREATING ON THE SUBJECT OF HIS EMINENT LABORS, IS HUMBLY INSCRIBED, BY THE AUTHOR. f> PREFACE. The purpose of the following pages is the elucidation of a subject of extreme interest, and at the same time, one of considerable complexity. My attention was first directed towards it, by the practical necessity of distin- guishing between eruptions of the skin, which proceeded from ordinary causes, and those originating in syphilis; and, having before me an ample field of research, I de- termined to investigate the matter as it was presented to myself, and without reference to the opinions and labors of others in the same department. This, I trust, will be accepted as a sufficient apology for my apparent neglect of the recorded opinions of the numerous eminent authors who have written on syphilis, and also, I hope, for the shape in which the work appears, namely, as an arranged series of cases, representing the subjects of my inquiry, and the sources of my conclusions. One of the first results of my attempted classification of the effects of the syphilitic poison on the skin, was ' the discovery that there existed but one eruption, and that the apparent differences in the character of the cutaneous affection, were the simple consequence of modification of development of that eruption, a modification depend- ing, for the most part, on time, treatment, and on the temperament of the patient. It was impossible to proceed so far even as this, with- vi PREFACE. out a passing reflection on the nature and laws of the syphilitic poison, and on its primary effects upon the human organism. These considerations occupy my first two chapters, and they tend to the conclusion that there is but one syphilitic poison. Syphilis, then, in all its multitudinous and Protean shapes, originates in one poison, and in its constitutional manifestation on the skin gives rise to but one eruption. The common result of the contact of the syphilitic poison with the mucous membrane of a sound person, is the production of an ulcer; but I believe, also, that its effect may, in some instances, be a purulent discharge, constituting a common Blennorrhcea, or Gonorrhoea. In these cases I further believe, and have satisfied myself of the fact, that constitutional syphilis will follow with as much certainty as if it were preceded by a chancre. I have adduced several examples of this kind in the body of the work. I trust, also, to have cleared up the mystery which enveloped the induration of the true chancre of Hunter. That induration I consider to be the result of a consti- tutional action, and, consequently, an evidence of the contamination of the system. I have recorded several instances of the successive recurrence of this form of chancre, and of induration without ulceration, as ex- amples of constitutional syphilis; in some cases as the sole, but ample, evidence of the presence of syphilitic poison in the blood. The modification which the syphilitic poison under- goes by long continuance in the blood, and its effects upon the organism of another, when transmitted in this modified shape, have furnished me with a subject of curious observation. This modification has its eloquent parallel in the effects of the vaccine poison, when intro- duced into the human system directly from the cow, and PREFACE. vii in its modified effects after a few removes, as shown in the excellent experiments of Mr. Ceeley. After the general effects of the syphilitic poison, when admitted into the blood, I have considered its local effects. These latter being isolated, and often solitary, and less clearly connected by an uninterrupted series of symptoms with the constitutional disease, serve to pre- pare the mind for the more obscure and chronic mani- festations of syphilis, which have received from Ricord the name of " tertiary symptoms;" and for the results of the transmission of the poison from parents to off- spring. The tenacity of the syphilitic poison to the human organism cannot but lead to the conclusion that, once admitted into the blood and tissues of the body, it re- mains there for life. It may not manifest its presence by any outward sign, but this cannot be received as an argument against its existence; for, at the most distant period, it may suddenly become developed as a cutaneous eruption, an intense pain in a nerve, an inflammation of a bone, of the periosteum, of a gland, or, indeed, of any one of the organs of the body. Should the individual escape, his children may suffer sooner or later; and I am firmly of opinion, that the powers of the poison may be manifested after the lapse of several generations. As may be naturally concluded, the syphilitic poison becomes altered in its mode of manifestation by time; it sinks deeper into the substance of the body; it produces a more decided organic change. These are the charac- ters which distinguish the " tertiary syphilis" of Ricord; and if the observation be true with regard to the indi- vidual, it is equally true in its application to his race. What is syphilis in the parent, may be scrofula in the child ; but the latter is no less a modification of syphilis. The syphilitic eruption on the skin of the parent may Vlll PREFACE. be a consumption in his offspring. There are, besides, other and more remote diseases which have appeared to me to take their origin in hereditary syphilis, namely, Lupus, Kelis, Lepra, and Psoriasis. I have contented myself in these pages by merely mentioning my belief, and adducing some slight evidence in support of my opinion. The fruit may ripen in other minds, or time and observation may afford me an opportunity of gath- ering stronger evidence, and at some distant day of placing the results in the hands of the profession of medicine. The subject of the treatment of syphilis cannot be approached without an eulogium on the genius of Ricord. The published opinions of Ricord are distinguished for their simplicity, their clearness, and their practical ap- plication. It is to him that we owe the practical lesson, that the virus of syphilis lies hid in the developing chancre for three days, and that within that limit of time we may destroy the poison in its concealed retreat; that, should it escape our vigilance, we may yet conquer it, in its new shape of secondary syphilis, by mercury; that, if it escape us then, mercury must give place to iodine. In this encounter between the wisdom of medi- cine, and the assaults of a destructive poison, the art is to use and not abuse our remedies; and that power must depend more upon ourselves than upon our teacher. The wrong remedy at a given moment may exasperate instead of checking the disease, and may even serve to perpetuate it in the blood. Ricord has an able representative in this country in Mr. Acton, whose volume on the " Diseases of the Uri- nary and Generative Organs" takes the first rank as a standard work on the pathology and treatment of syphi- lis. If in these pages I have ventured to differ in opin- ion with Ricord and Actori, it is from no want of respect PREFACE. ix for their judgment, but simply because the physiological and pathological actions of the syphilitic poison, as ob- served by me, have seemed to admit of another inter- pretation. With regard to the more bulky portion of the book— the chapters on the syphilitic eruptions—I claim the right of hoping that I have placed them upon a more correct basis than that on which they previously stood; and by so much increased the facilities of their study and comprehension, and in the same ratio our power of healing them. 17 Henrietta Street, Cavendish Square, January, 1852. CONTENTS. CHAPTER I. THE SYPHILITIC POISON. PAGE 33 ib. 34 ib. 35 36 The physical characters of the poison unknown Common or primary mode of transmission of the poison Comparison with the vaccine poison .... Conditions of transmission of the poison . Secondary mode of transmission of the poison . Case 1.—Contagion of the secondary poison Case 2.—Contagion of the secondary poison, apparently without the intervention of secondary symptoms in the poisoner . . . . . . . . .37 Case 3.—Secondary sores assuming the characters of pri- mary sores, and liable to be mistaken for them; recur- rent sores ........ 39 Case 4.—Recurrent secondary sores, with general consti- tutional syphilis . . . . . . .41 Case 5.—Recurrent secondary sore, with pustular syphilis 42 Case 6.—Secondary sore, derived from the contagion of a secondary poison, and unpreceded by primary disease . 43 Physiological laws of the syphilitic poison .... 47 Marriage of persons infected with syphilis .... 49 Case 7.—Serious constitutional disease set up in a newly- married wife, after a long period of apparent health in the husband ........ 49 Modification of the syphilitic poison by time, and by transmission through the blood of an infected person ... 52 Unity of the syphilitic poison......ib. Causes of modification of its actions.....ib. Gonorrhoeal syphilis........53 Case 8.—Constitutional syphilis resulting from gonorrhoea ib. xii CONTEXTS. General infection of the tissues and fluids of the body in consti- tutional syphilis ...-••■ Transmission of syphilis from infants to their nurses Effects of the elimination of the syphilitic poison by the surface tissues of the body .....-■ Special elimination by the genital apparatus .... Abortion, an effect of the special elimination by the genital apparatus CHAPTER II. PRIMARY SYPHILIS. Local actions of the syphilitic poison: the chancre Different forms of chancre The sloughing or gangrenous chancre The phagedasnic chancre The indurated chancre The syphilitic induration Case 9.—Syphilitic induration, occurring six weeks after exposure to contagion ...... PAGE 54 ib. 55 ib. 56 'Ot 58 ib. ib. 59 60 61 CHAPTER III. SECONDARY OR CONSTITUTIONAL SYPHILIS. Physiological action of the syphilitic poison in the blood . Syphilitic fever; its symptoms ..... Resemblances between the syphilitic and exanthematic fevers Syphilitic visceral congestion; pulmonary Differences between the syphilitic and exanthematic fevers . 63 64 65 ib. 66 CHAPTER IV. EVOLUTION OF THE SYPHILITIC POISON BY THE SKIN. Congestion of the skin, an effort to throw off the syphilitic poison 69 Roseola; the simplest form of congestion . . . . .70 Cause of the punctated character of some forms of roseolous con- gestion ......... ib. Division of syphilitic eruptions into non-elevated and elevated . ib. Roseola syphilitica; its characters and varieties . . .71 Lichen syphiliticus; its characters and varieties . . . 73 Tubercula syphilitica; their characters and varieties ... 74 Syphiloderma Roseolatum; roseola syphilitica ... 76 CONTENTS. xhi PAGE Case 10.—Roseola following a superficial venereal sore . 78 Case 11.—Roseola after balanitis and venereal sore; lichen after a second infection ...... ib. Case 12.—Roseola after sores with bubo, followed by a tubercular eruption ....... 81 Case 13.—Roseola orbicularis, preceded by gonorrhoea, with excoriation and secondary indurated sore ... 83 Case 14.—Roseola in successive attacks assuming the cha- racters of roseola orbicularis and roseola annulatus, pre- ceded by gonorrhoea and a secondary sore ... 84 Summary of cases of roseola.......86 Syphiloderma Papulatum; lichen syphiliticus . . .88 Case 15.—Lichen corymbosus, following a venereal sore, treated with mercury ...... ib. Case 16.—Lichen disseminatus, following indurated chancres 89 Case 17.—Lichen disseminatus, following indurated chancres 91 Case 18.—Lichen corifertus, four months after a venereal sore, treated without mercury . . . . . • 92 Summary of cases of lichen.......93 Syphiloderma Tuberculatum; tubercula syphilitica . . 95 Color of syphilitic eruptions ....... ib. Definition of the term "copper-color" . . . . .97 Tubercula corymbosa ........ 99 Case 19.—Tubercula corymbosa, occurring two years and a half after a venereal sore ...... ib. Case 20.—Tubercula corymbosa; probably originating in the secondary syphilitic poison ..... 101 Case 21.—Tubercula corymbosa; preceded by severe pul- monary congestion . . . . . . .103 Tubercula circumscripta . . .. . . . .105 Case 22.—Tubercula circumscripta; occurring four years after venereal sore . . . . . . .106 Case 23.—Tubercula circumscripta; occurring three years after inoculation by the secondary poison . . .109 Disorganization of the skin by syphilis.....Ill Case 24.—Tubercula circumscripta; occurring five years after venereal sore.......112 Case 25.—Tubercula circumscripta; occurring eight years after inoculation by the secondary poison . . . ib. Tubercula disseminata........114 XIV CONTENTS. PAGE Case 26.—Tubercula disseminata; probably originating in the secondary poison ...... Tubercula disseminata; the cutaneous eruption in Case 7 . Tubercula annulata ........ This form of eruption the type of syphilitic lepra and psoriasis . Case 27.—Tubercula annulata; after gonorrhoea Case 28.—Tubercula annulata; after superficial sores Case 29.—Tubercula annulata; after superficial sores Tubercula ulcerantia ........ Case 30.—Tubercles disappearing without ulceration . * Case 31.—Ulcerating tubercles on the face and neck; occur- ring in clusters ....... Case 32.—Ulcerating tubercles on the scalp; occurring in clusters ........'. Case 33.—Ulcerating tubercles on the scalp and face occur- ring in clusters; with severe affection of the throat and tongue ......... Case 34.—Ulcerating tubercles on the scalp and face, occur- ring in clusters ....... Case 35.—Ulcerating tubercles on the scalp, occurring in clusters ......... Case 36.—Ulcerating tubercles on the upper lip; solitary . Case 37.—Ulcerating annulate tubercle; serpiginous Vesicular Syphilis .... Pustular Syphilis .... Case 38.—Lichen syphiliticus pustulosus Case 39.—Rupia prominens Case 40.—Rupia prominens Case 41.—Rupia prominens Case 42.—Rupia simplex Syphilitic Ulcers Case 43.—Extensive syphilitic ulcers Case 44.—Syphilitic ulcers; after gonorrhoea . Case 45.—Phagedaenic ulcers .... Tubercula Gummata...... Case 46.—Ulcerating syphilitic tumor on the face Case 47.—Ulcerating syphilitic tumor on the temple 115 118 120 121 ib. 123 125 127 128 129 130 132 134 135 136 138 139 ib: 140 142 144 145 146 147 148 150 152 153 154 155 CONTENTS. XV CHAPTER V. local actions of syphilis. PAGE Syphilitic affections of the hair......157 Case 48.—Alopecia syphilitica.....158 Syphilitic affections of the nails......ib. Syphilitic onychia.........159 Syphilitic affections of the hands and feet .... ib. Case 49.—Erythema palmare; with annulate tubercles on the body.........161 Case 50.—Erythema palmare; with erythema preputii . 162 Case 51.—Erythema palmare of one hand . . . 164 Case 52.—Erythema palmare centrifugum, with alopecia . 165 Case 53.—Erythema palmare, nine years after indurated chancre.....■ . . . . 166 Case 54.—Erythema palmare, of eight years' standing . ib. Case 55.—Syphilitic erythema of the back of the hand . 168 Condyloma ..........169 Case 56.—Condyloma, following simple venereal sore . ib. Case 57.—Condyloma, followed by syphilitic tubercles and melanopathia ........ 171 Case 58.—Mucous tubercles of the scrotum . . . 173 Local actions of syphilis in the mucous membrane . . . 174 Milky stains on the tongue, fauces, and buccal membrane . 175 Fissures of the tongue ........ ib. Aphthae and ulcers of the tongue......176 Case 59.—Syphilitic tubercles on the tongue . . . ib. Local actions of syphilis in the nervous system . . .177 Case 60.—Syphilitic neuralgia . . . . . ib. Case 61.—Syphilitic neuralgia.....179 Local actions of syphilis in the periosteum .... 181 Case 62.—Abscess of the periosteum, with exfoliation of bone ib. Case 63.—Inflammation of the periosteum of the tibiae . 182 CHAPTER VI. congenital syphilis. Transmission of syphilitic poison from parent to offspring . Continuation of Case 2 in its bearings upon the children of the patient ........ 185 ib. XVI CONTENTS. mm page Case 64.—Simple venereal sore in the husband, secondary syphilis in the wife, and two successive miscarriages . 189 Case 65.—Syphilitic eruption in the child, with slight symp- toms of secondary syphilis in the mother . . .191 Case 66.—Syphilitic eruption in the child, without apparent disease in the mother ...... 193 Case 07.—Serious constitutional syphilis in the mother, and destructive effects on her offspring . . . .196 CHAPTER VII. hereditary syphilis. Persistence of the syphilitic poison in the blood . . . 201 Influence on marriage ........ ib. Several obscure cutaneous diseases, probably owing their ori- gin to syphilis ........ 202 Physiology of chronic syphilitic tubercles ..... 203 Case 68.—Chronic syphilitic tubercles on the face . . ib. Case 69.—Chronic syphilitic tubercles on the face and loins 205 Case 70.—Chronic syphilitic tubercles around the mouth . 207 Case 71.—Chronic tubercles on the face, resembling syphilis ib. Relation between lupus and syphilis ...... 208 Relation between scrofula and syphilis ..... 209 Relation between lepra and psoriasis and syphilis . . . ib. Case 72.—Chronic syphilis in the father; lepra vulgaris in his children ........ 210 Case 73.—Syphilitic tubercles on the scalp of a lad . . 212 Case 74.—Hereditary syphilitic tubercular disease, resem- bling scrofula ........ 213 Case 75.—Hereditary syphilitic tubercular disease, resem- bling scrofula......, 214 Hereditary syphilitic erythema . . . . 215 Hereditary syphilitic erythema of the fingers .... 216 Hereditary syphilitic erythema of the palms and soles . . ib. Hereditary syphilitic erythema of the face and head . . . 217 Hereditary syphilitic erythema of the nose .... 218 Case 76.—Hereditary syphilitic erythema of the nose . 219 Case 77.—Hereditary syphilitic erythema of the face and head.........221 Case 78.—Hereditary tubercular syphiloderma of the entire body ...... 090 CONTENTS. Case 79.—Syphiloderma erythematosum, haereditarium, of the face ......... Case 80.—Hereditary syphiloderma of the nose Syphiloderma lupoides; vel, lupus non exedens . Case 81.—Syphiloderma lupoides of the cheek . Case 82.—Syphiloderma lupoides in the submaxillary region CHAPTER VIII. TREATMENT OF SYPHILIS. Prophylactic treatment . Treatment of abrasions and excoriations . . . . . Curative treatment ......... Abortive treatment ......... Principles of treatment of the primary disease after the third day Mercurial treatment ........ Salivation, symptoms and treatment . . . . . Treatment of inflammatory chancre ...... Treatment of phagedaenic chancre ...... Treatment of bubo ........ Treatment of Constitutional Syphilis . Langston Parker's treatment ....... German treatment by Zittmann's decoction . . . . Treatment of successive attacks ...... Treatment of chronic or tertiary syphilis ..... Syphilitic neuralgia and rheumatism . Syphilitic inflammation of the testicle ..... Syphilitic inflammation of the fibrous tissues, periosteum, and bones Iodide of potassium ........ Syphilitic iritis ......... Dzondi's treatment of chronic syphilis . Local Treatment of Syphilodermata .... Treatment of syphilitic alopecia ...... Treatment of syphilitic affections of the hands and feet Onychia .......... Treatment of condyloma........ Treatment of affections of the mucous membrane of the mouth, throat, and tongue....... 2 xviii CONTENTS. PAGE Treatment of Congenital Syphilis.....268 Treatment of Hereditary Syphilis.....270 Treatment of esthiomenous affections ..... 273 Case 83.—Tertiary syphiloderma, assuming the appearance of esthiomenous disease . . . . . .278 APPENDIX. Case 84.—Primary, secondary, and tertiary syphilis . . 281 Case 85.—Syphilis in an irritable constitution rendered irre- gular by injudicious treatment . . . . . 282 Plate 1. Elate 2. J 1 I I DESCRIPTION OF THE PLATES. PLATE I. EXANTHEMATOUS AND PAPULAR SYPHILITIC ERUPTION. A A. Roseola versicolor vel vulgaris. B. Roseola punctata. C. Roseola orbicularis. D. Roseola annulata. E. A blotch of roseola orbicularis, from which the epiderma has peeled off and forms a white frill around its circumference. The color of the blotch is intended to show the true "copper-color." F. Roseolous blotches in process of fading, and passing away as brown- ish stains. G G. Lichen syphiliticus corymbosus. H. Lichen syphiliticus disseminatus. I. Lichen syphiliticus confertus. K. Lichen syphiliticus annulatus. The natural color of the eruptions has been adhered to as nearly as possible in this plate; and in several places, the color of the stains left by the declining and fading eruption is shown. PLATE II. TUBERCULAR ERUPTIONS. L. Tubercula syphilitica corymbosa. M M. Blotches of tubercula corymbosa assuming a circular and annu- late form; Case 21. N N. Smaller blotches found intermingled with the preceding forms in syphiloderma tuberculatum cjrymbosum. These latter may be dis- tinguished as " cupped" tubercles; Case 21. All the three forms . are frequently met with in the same person. 0. A small patch of tubercula circumscripta; Case 22. P. Larger patch of tubercula circumscripta; Case 25. The tubercles are covered with scales formed by the exfoliation of the cuticle. XX DESCRIPTION OF THE PLATES. Q Q. Tubercula disseminata; Case 26. R. Tubercula disseminata, in process of exfoliation; each tubercle being surrounded at its base by a frill of cuticle. S S. Tubercula annulata. Between the two larger rings are seen incipi- ent rings, having the characters of "cupped" tubercles. The figures were taken from Case 27. T. An annulate tubercle from the penis of the patient in Case 28. V V. Rings of annulate tubercle from Case 29. W. Cupped tubercles; the common form of the separate eruptions in infantile syphilis. PLATE III. A. Patch of rupia vulgaris from the knee of the patient in Case 42. B. Rupia prominens; below the lower eyelid is seen one of the pustules • by which rupia prominens ordinarily commences. The figure is drawn from Cash 41. C. Erythema palmare syphiliticum. D. Erythema palmare annulatum centrifugum. E. Aphthous exfoliation and syphilitic tubercles of the tongue. PLATE IV. A. Ulcera syphilitica; the figure represents the hand of the patient, Case 67, and the state of distortion occasioned by syphilis. B. State of the nose of the patient; Case 80. C. Erythematous syphiloderma of the nose; Case 77. D. Syphiloderma lupoides, or lupus non exedens. E. Syphiloderma lupoides. I Plate 3. Pr zn CltrvtlyTSi-n/laiT Thl. Plate 4, I ] ON SYPHILIS, CONSTITUTIONAL AND HEREDITARY. CHAPTER I. THE SYPHILITIC POISON. There are few subjects in the entire range of the science of medicine more attractive in themselves, or more important to the general interests of mankind, than the investigation and correct appreciation of the phenomena of the animal poison termed syphilitic. Like other peculiarly contagious poisons, the syphilitic gives rise to a local and a general action, the former constituting what is known as the primary disease, the latter the secondary or constitutional disease. The physical characters of the poison are altogether unknown; but, whatever its microscopic form may be, we are aware that it is held in suspension or solution by the fluids of the body, that it is diffused through the entire mass of the blood, and probably through the solid tissues. The common mode of transmission of the poison is through the agency of a morbid secretion poured out upon the surface of a syphilitic sore. This secretion, like the fluid of the vesicle and pustule of vaccinia or smallpox, is saturated with the poison, and, on being 3 34 THE SYPHILITIC POISON. brought into contact with the tissues of a sound person, is capable of setting up an action similar to that exist- ing in the person from whom the poison was derived. This mode of transmission meets with an apt illustra- tion in the simple process of vaccination : the vaccine poison is placed in a position favorable for its action upon the tissues of the patient; it there sets up a local or primary action, and that local action is accompanied, after a certain lapse of time, by a secondary or consti- tutional action. It has been shown by Mr. Ceely, of Aylesbury, in the instance of vaccination, that abrasion of the cuticle is by no means absolutely necessary to the success of the operation. "I have often succeeded," he says, "in procuring vaccine vesicles without puncture, on the skins of children especially, and young persons, by keeping lymph in contact with the skin, and excluding it from the air by a coating of blood. Active lymph "blended with blood casually trickling down the arm,' and drying in the most dependent parts, will often give rise to a vesicle." This observation bears directly on the contagion of syphilis; the poisonous secretion rest- ing on the unbroken cuticle for a certain space of time, is absorbed with nearly the same degree of certainty as if it were introduced into the tissue of the derma by mechanical inoculation. Another condition favorable, and indeed necessary, to absorption, besides prolonged contact, is moisture. A moist condition of the lymph of vaccinia was secured, in Mr. Ceely's experiments, by the coating of blood which covered the lymph, and a similar condition must exist in the parallel case of the absorption of the poison of syphilis through an unbroken epiderma. But in the instance of syphilis, a membrane possessed of a thinner covering than the cuticle, and one in an almost con- THE SYPHILITIC POISON. 35 stant state of moisture, namely, the mucous membrane, is exposed to the poison; moreover, a membrane pre- senting folds and nooks innumerable, in which a morbid secretion may lodge, and from which it would be diffi- cult to remove it. Hence, the transmission of the poison to the system, through the medium of the mucous membrane, is more facile and certain than through the skin. When there is abrasion of the cuticle, or of the mu- cous membrane, the process of inoculation is obvious, and unobscured by the apparent impediment presented by the epiderma or epithelium. The agent of absorp- tion, however, in every case, whether the cuticle be bro- ken or whole, is the same, namely, that property of all animal tissues which is termed imbibition, and by the aid of which the functions of nutrition, growth, and se- cretion are accomplished. The imbibition of the poison by the animal tissues is performed insensibly and slowly, and there is no appear- ance on the inoculated spot to show that any vital pro- cess is in action. This is the period which is denomi- nated latent; but although hidden from view, we know that the poison is passing into the blood, and that, at the end of a few days (from three to seven), certain local appearances will be seen, which will demonstrate its presence. The local action so excited is the primary syphilitic disease, or syphilis. I have said that the common mode of transmission of the syphilitic poison is through the agency of a morbid secretion poured out upon the surface of a syphilitic sore, and brought into contact with the tissues of a sound per- son ; but there is another mode of transmission, which we may now take into consideration. It is that in which a man or a woman having been contaminated by the poison, and having been to all appearance cured of 36 THE SYPHILITIC POISON. the consequent disease, has, nevertheless, become so sa- turated with the virus, as to possess the property of communicating syphilis to a sound person, by means of his secretions. This mode of transmission is so import- ant that I will proceed to illustrate it by means of cases which have fallen under my observation. Case 1.—A gentleman had a small venereal sore on the prepuce in the month of November; it got well speedily. In the succeeding month of February he suf- fered from sore-throat and rheumatic pains, but of so slight a nature that he took them to be merely symp- toms of a common cold. In March he married. In the month of June following, I was called to see his wife, in consultation with her medical man. She was suffering from a furuncular abscess, situated at the upper and inner part of the thigh, and my opinion was sought more on account of the obstinate nature of the sore which the abscess had left behind it, than from any suspicion of its being of a venereal nature. I was struck by the unhealthy-looking, red, and fungous surface which the sore exhibited; and making further inquiries, found that on the day before she had perceived a rash upon her skin which had now become an unmistakable roseola. She had a feeling of soreness in the throat, but without congestion, and her skin was muddy and discolored. She had no disorder of the genital organs, and her husband was free from any symptoms of disease.1 This is not an isolated case; but I select it from others on account of its freedom from complication, either 1 Three weeks after my visit I again saw her medical man, who informed me that the furuncular sore had soon got well, but that a few pimples had broken out upon her body, and that her husband had had an attack of iritis. THE SYPHILITIC POISON. 37 by time or medical treatment. The primary disease in the husband was slight, but well established; the syphi- litic fever or secondary fever was so trivial as to be taken for a common cold; and although the patient con- sulted his medical man, a relative, on-the propriety of marrying under the circumstances, the medical man saw no reason to object. I apprehend that, in this case, no one can doubt the natural secretions of the mucous membrane of the hus- band being the medium of transmission of the poison; and as there was no local disease in the wife, the poison must have been imbibed into her system at once, and thus have contaminated her blood. Then came the period of latency, during which the poison was accumu- lating and gaining strength, and then followed the out- burst of exanthematic eruption. The furuncular abscess I consider to have been of the common kind (at the time there existed a kind of furuncular epidemic) in the first instance; its angry appearance and its indisposition to heal having been occasioned subsequently by the ap-. proach of the syphilitic crisis. In the above case there can be no question as to the poisonous condition of the blood of the husband at the time of marriage; that was proved by the attack of secondary symptoms which he had experienced three weeks before; but instances sometimes occur in which the constitutional action would seem to be absent, and yet manifest proof is afforded, when too late, that the person was a fomes of contagion. The following case is an illustration of this fact:— Case 2.—A gentleman had had repeated attacks of venereal sores, the last being unusually tedious, and con- tinuing for three months. Two months after the cure of the latter, he married, believing himself to be tho- 38 THE SYPHILITIC POISON. roughly well. He was not aware of having experienced a secondary symptom of any kind. The wife, at the time of her marriage, was a fine, healthy young woman, who had never had a day's ill- ness. She was married in March, 1845, and remained well until the month of July, when she gradually fell into bad health, was languid and depressed, lost her appetite, and, in the following month of August, mis- carried. She was not, during this illness, aware of the presence of any sore on the genitals, or of any abnormal discharge. After her miscarriage she went to the sea- side, and recovered. On her return home, towards the end of September, she again became dispirited and ill, and in the beginning of October was attacked with sore-throat and eruption on the skin The eruption continued slightly to increase until the month of January, when she first consulted me. At this time her entire skin was sallow, dry, and muddy ; she was dejected, weak, and thoroughly out of health. Her tongue was white and coated, pulse languid and small, and bowels confined; the fauces were of a dull red color, and congested ; there were several tender, aphthous spots on the mucous membrane of the cheeks, and the sub-occipital and post-cervical glands were swol- len and tender; she also complained of rheumatic pains in her shoulders and elbows, and stiffness of the neck. The eruption was principally distributed over her head, neck, and face; there were a few spots also on her arms, and a very few on the trunk of the body; there were, besides, three on the mucous membrane of the vulva, the epithelium of which had been rubbed off, and they were moistened by a muco-purulent secretion. That the husband in the above case was a fomes of contagion is quite evident, but the question suggests itself—Whether a man can be constitutionally affected THE SYPHILITIC POISON. 39 with syphilis, without evincing, or having evinced at some period or other, symptoms demonstrating the exist- ence of the poison in his system ? I doubt if such could be the case, but the question serves to raise a nice point of diagnosis—as to whether the last-named venereal sore, under which this gentleman suffered, might not have been a secondary sore. Its long duration unhealed would lead to this supposition, since it is not usual for primary sores to remain so long open. I will illustrate my meaning by the following case :— Case 3.—A gentleman had three small sores on the glans, for which he took mercury until his mouth became tender. They healed in a fortnight. At the end of six weeks, without any suspicious connection, he had what he considered to be a "return of the old sores:"he again took mercury, and the sores disappeared. This was repeated a second and a third time, at intervals of six or eight weeks; each time the sores, which were of very small size, reappeared in the old place, and during the whole period he remained unexposed to contagion. He was not aware of the presence of any other symptoms; he might have had a little cold at the time of the attacks, but he did not observe it. Nine months after his first attack of disease, he again had a small sore on the glans, and as shortly before he had been exposed to risk of contagion, he re- garded this as a second appearance of primary disease. Having observed the successful result of his treatment in the first instance, he had recourse to blue-pill, and after taking twenty-four pills the sore had disappeared. Six weeks after the healing of the sore, two small tubercles appeared in the original place, and he again consulted me. He told me that he was at a loss to account for these appearances, as he had not been exposed to contagion 40 THE SYPHILITIC POISON. since his last illness; but he conceived that, as he had treated himself, he must have been an inexpert surgeon. Having obtained from him the history of his case as just detailed, I regarded the small tubercles, one of which was perforated at its summit, and exuded a small quan- tity of colorless lymph, as a secondary affection, al- though I could discover no other concurrent symptoms; and thinking he had taken enough mercury, I prescribed three grains of the iodide of potassium in sarsaparilla three times a day, which he continued for three weeks, although the tubercles had disappeared at the end of a fortnight. Two months after this time, in compliance with my request that he would come to me the instant he per- ceived any reappearance of his disease, he paid me a visit, saying that for two days he had experienced a sensa- tionbf soreness at the seat of his former complaint; then ensued some redness, and by the beginning of the third day there was a slight degree of swelling. On stretching the skin three or four hard granules could be detected beneath it. By the fifth day these granules had reached the surface, and formed a cluster of five or six minute pustular heads. On the sixth day the little pustules broke, and on the seventh the eruption was subsiding, but the base of the little cluster was still hard. Concurrently with this attack he complained of tender- ness in his throat, which had come on with the eruption; and on inspection, the fauces and arches of the palate were found to be congested. He had not been exposed to contagion for four weeks previously to the present attack. Now, if I had not known this gentleman well, and had the opportunity of observing his case throughout, I should have taken these pustules for a primary disease, resulting from recent contagion; but, coupled with his THE SYPHILITIC POISON. 41 previous history, and with the fact of his having had no recent connection, I conclude the case to have been one of secondary syphilis; and one indicating as complete a contamination of the blood and of the entire system as if the symptoms had been more decided. Indeed, since the observation of this case, I call to mind several in- stances which were at the time obscure, but which I now recognize to have been secondary syphilis invading the seat of the primary disease, and limited to that spot; and more recently I have repeatedly observed the same state. This circumstance may, perhaps, explain many of those examples of irregular venereal sore which are met with in practice; and especially the chronic indurations which we so frequently meet with in the seat of a healed sore; indurations which become inflamed from time to time without apparent reason, and continue troublesome for a long period. I watched the progress of the impetiginous eruption in this gentleman's case without giving him medicine, and he very shortly got well. The following cases further illustrate this point:— Case 4.—A gentleman, aged twenty-six, contracted a venereal sore, which soon got well. This was his first and only attack of the disease accompanied by a sore; he has had gonorrhoea several times. Since that occa- sion he has several times had a sore on the prepuce; it came on usually soon after connection; there was a feel- ing of tenderness in the part, with some little redness and hardness; then the epithelium loosened and came off, leaving a slight abrasion, suffused with a little icho- rous discharge. These sores would get well in a few days; they were clearly secondary, although accom- panied by no other symptom of constitutional affection. Two years and a half after the occurrence of the 42 THE SYPHILITIC POISON. primary sore, he became exposed to cold in the month of February, and a sudden and severe attack of general secondary symptoms took place. He had sore-throat, an eruption of lichen over the greater part of the body, and intense neuralgic pains in the head. The latter, he says, were so excessive that he dreaded the approach of night and the necessity for going to bed. He had not been exposed to contagion for more than three months previously to this attack. Between four and five months after the outbreak of the secondary symptoms above described, this gentleman applied to me for a superficial sore, which had made its appearance, without connection, on the prepuce. It was evidently a secondary sore. He had besides some tender- ness of the throat; pains in some of the joints, parti- cularly the shoulder and elbow, and one knee, and a mere vestige of lichenous eruption. The pains in the limbs were of old standing, and attributed to rheumatism. In addition to these symptoms his hair was very thin, having begun to fall off on the occasion of the previous violent attack of secondary symptoms. Three months subsequently this gentleman suffered from enlargement and pain in the testis. The whole of his neuralgic symptoms yielded to the iodide of potassium. Case 5.—A medical man contracted a venereal sore, for which he took mercury, and kept up the mercurial action on his mouth for a fortnight. The sore healed at the end of three weeks. Between six and eight weeks after the healing of the sore he had an eruption of small tubercles, scattered over his skin in various parts; accompanied by a slight feeling of sore-throat, and a little pain in the limbs. For these symptoms he took a Plummer's pill at bedtime, and from three to ten grains of iodide of potas- THE SYPHILITIC POISON. 43 sium three times a day. This treatment he continued with occasional intermissions for three months. At the end of this period he perceived a pimple on the prepuce, which on being scratched became a pustule, and then a sore with an inflamed base. He had at the same time two pustules on the scrotum, and one on the perineum. This gentleman's case affords an example of a con- stitutional or secondary sore, occupying the seat and assuming the characters of a primary sore; for which, without a knowledge of the previous history of the patient, it might easily have been mistaken. He had no suspicious connection after that which was the origin of the primary disease. The following case is still more remarkable:— Case 6.—A gentleman, thirty years of age, Had a sore in the fossa glandis, in the beginning of January, 1850. The sore was elongated, and stretched backwards to the frsenum; and occasionally shifted from one side of the fossa to the other. The patient compared it to a crack. For reasons which I shall presently explain, he had no suspicion of its being syphilitic, nor had two medical friends, whose counsel he sought. It was accompanied, at the end of a fortnight, with tenderness and slight enlargement of the glands in both groins. For the first month of the existence of the sore, he treated it with mildly-stimulating lotions; but finding that it showed no disposition to move, he applied to a medical friend, who prescribed four grains of blue-pill, to be taken night and morning. He did so for a fort- night, by which time he was gently salivated; the sore was healed, and nothing was left of it but a slight de- gree of induration. At the time of beginning the mercurial course, he re- 44 THE SYPHILITIC POISON. members that he had a little sore-throat, together with some trifling pains in the face. February 24.—Ten days after the mercurial treatment was ended, the sore-throat returned, with neuralgia of the face and head, some painful lumps on the scalp, and conjunctivitis palpebrarum. His surgeon, being now satisfied that the case was one of syphilis, and fearing its attack upon the eyeball, had him cupped on the tem- ple, and gave him some calomel pills. In two days and a half after taking these pills, he was profusely sali- vated and totally prostrated. All the symptoms of his disease disappeared, and as soon as he was sufficiently well, he went to Brighton for a fortnight, and returned to town perfectly well. May 7.—Nearly three months after the preceding at- tack, the soreness of throat returned, with neuralgic pains in the head. He had lost faith in his surgeon, and ap- plied to a physician, who prescribed the bichloride of mercury, with extract of sarsaparilla and tincture of bark. While pursuing this treatment, several nodes ap- peared upon his shins; and another physician being taken into consultation, the treatment was changed to Plummer's pills and iodide of potassium, with tincture of bark. August 19.—While pursuing the latter treatment he again suffered from soreness of throat, the eyelids be- came inflamed, and the mucous membrane of the nose congested, pouring forth an increased quantity of mucus. September 3.—The above symptoms being on the in- crease^ from day to day, he was put upon the iodide of potassium, with the compound infusion of gentian, un- der which they immediately improved. September 6— Three days after the above treatment, he presented himself before me, at the recommendation of his physician, saying that he had been advised by THE SYPHILITIC POISON. 45 him to relinquish occupation for a while and betake him- self to the country, and asking, at the same time, what treatment he should pursue while away. His present symptoms were, a large circular patch of tubercular erup- tion, in a state of subsidence, on the middle of the fore- head, several deeply-colored retrocedent tubercles on the chin, redness and swelling of the eyelids, an increased secretion, which rendered his nasal respiration "snuf- fling," from the nose, and an oblong ulcer involving the whole depth of the mucous membrane on each tonsil. It was difficult to say, as it so often is in these cases, how much of his present symptoms was due to the ori- ginal disease—in a word, to syphilis, and how much to his treatment. I felt the necessity of determining that point, and I saw the danger of continuing any treatment which involved the use of mercury or iodine until the question were fairly settled. On the other hand, I con- sidered it to be much safer to leave him without medi- cines at all, than to give one grain which might provoke an already angry and threatening state of disease. I advised him to go at once into the country, to ab- stain from all stimulants, to take very little meat, and to become for a time a vegetarian; to be much in the open air, to take plenty of exercise, to keep his bowels in action with small doses of Epsom salts, considerably diluted, and to take medicinally from one to two quarts of infusion of elder flowers daily. Now, let me revert to the origin of this disease. This gentleman had had gonorrhoea several times, the last attack having occurred two years before, but he had never had a sore of any kind until the present. Latterly, he had been living with a mistress who enjoyed undis- turbed health, and had left him, two months and a half before the commencement of his illness, to be married. He had had no connection whatever with any woman 46 THE SYPHILITIC POISON. between the time of her departure and the appearance of the sore in his fossa glandis, and he was a person of ex- ceedingly cleanly habits, taking his bath every morning. These were the reasons to which I alluded in the commencement of my narrative of the case, as throwing a doubt over the patient's mind, and that of his medical friends, of the nature of the disease. With me they would have had no weight whatever; and if I had set myself to work to invent a case, I could not have suc- ceeded so entirely in making one which should illustrate my own views and opinions as this. Let me explain. The mistress was the source of the syphilitic poison; the poison had been imbibed by the lover without lesion of surface, or external manifestation of disease. The sore in the fossa glandis, which appeared two months and a half after the departure of the mistress, was a local manifestation of the presence of the poison in the blood and constitution of the lover; it was a secondary1 sore, the produce of a secondary poison. Again, I believe the mistress to have been perfectly free from primary disease during the whole time of her cohabitation with the patient, and that the poison which he imbibed was a modified or secondary poison. The case may therefore be summed ;—a secondary poison, giving rise to a second- ary disease; or a constitutional and modified poison, giving rise to a constitutional disease ; without the pre- sence of a primary disease in the infector, or the inter- vention of a primary disease in the infectee; the first appearance of disease in the latter being a constitutional or secondary sore. If the facts be as I have stated them, and I have every reason to believe implicitly the truth of the narrator, 1 The term " secondary" is at all times objectionable ; it is particularly so where there is no primary condition ; but I use it in deference to the received language on the subject. THE SYPHILITIC POISON. 47 and am the more ready to believe them from having seen cases equally remarkable, and bearing directly on the same point; the above is the only explanation of which they admit, and no experiments in the world can shake the force of the conclusion. The poison of syphilis may, I conceive, exhaust itself upon the spot with which it comes in contact; or it may, after lighting up a morbid action on the spot, be imbibed into the system. The latter I conceive to be the law of the syphilitic poison, the former the exception. I be- lieve, also, that at the present day, and under a more judicious principle of medical treatment, the exception may be more frequent than the law; but that alters in nowise the relation between the two. On the other hand, my own observation has proved most positively, to myself at least, that the law more frequently takes its course than is suspected, even by that profession whose hourly duty it is to watch over the progress of disease, and stay it in its devastating career. The first of the six cases just narrated serves to illus- trate that which I conceive to be the natural law of syphilis ; namely, the primary or local disease, followed by the secondary or constitutional disease; and it further illustrates the transmission of the poison to another in its secondary or constitutional form. The second case suggests the question, whether the constitution may be poisoned, without the manifestation of the disease in a constitutional form; and the four re- maining cases illustrate a mode of manifestation of the constitutional affection which might be overlooked or mistaken for primary disease. The six cases taken together are good illustrations of the varieties which may be presented by individuals sub- jected to the same morbid cause. In case 2, the mani- festation of the constitutional disease was so little evi- I 48 THE SYPHILITIC POISON. dent, that it was supposed not to have existed at all. In case 3, the constitutional manifestation was deter- mined only by a nicely discriminating diagnosis; while in case 1, the constitutional evidence was only recog- nized after it had passed away, and left a train of evils on its path. The patient in case 3 was unmarried, and therefore the sole sufferer from the effects of his disease. The other two married within a iew weeks of getting well, and the consequences were entailed upon their wives and offspring. It is doubtless due to these gentlemen to ad- mit, that if they had been aware of their real state, and of the probable result to those whom they were about to make the partners of their lives, and who would inherit their names, they would have hesitated, and postponed their marriage to any period that might have been con- sidered safe. And here the important question is brought before us—What is the period which would be consi- dered safe for a man to marry after he has been affected with constitutional syphilis? Before I venture upon an answer to this question, I will endeavor to explain what I conceive to be the law of action of the syphilitic poison. When this poison is once admitted into the human organism it has a tendency to accumulate until it attains a certain point, which may be termed the point of satu- ration. As soon as the saturating point is reached, an outburst of fever, which results in the elimination of the excess of the collected poison, takes place, and the system returns to its wonted tranquillity and calm. This pro- cess is repeated at intervals, until after a time the inter- vals lengthen, and the effects gradually diminish; from weeks, the intervals become months, and years; from severe fever, the attacks become trivial and insignificant; and at last the poison is so thoroughly assimilated, that THE SYPHILITIC POISON. 49 it ceases to accumulate in excessive quantities, and loses its power of exciting a febrile action in the blood of the infected person. But although it may be incapable of exciting disease among tissues accustomed to its presence, it still retains the power of contaminating new blood; and it is difficult to determine how long this degree of virulence continues. At first, probably, it may be so far weakened, that the wife escapes, but the offspring may suffer; and at last it is rendered so mild, that only accidental conditions call up its powers of doing evil. It remains, however, as I believe, lurking in the blood and in the tissues for many years, and probably for the rest of life. Under these circumstances, our answer to the question as to the time which should intervene between disease and marriage, must necessarily be modified by a variety of conditions; for example, by the nature of the second- ary disease, by the known susceptibility of the indi- vidual, by his state of health, his occupation, and by the treatment he may have undergone; and something must be known also of the health of the proposed wife. Tak- ing the most favorable view of the case, from two to five years should be permitted to elapse, such period being passed under the close observation of the medical man. As an example of the serious disease which may be set up in a newly-married woman, after a very long in- terval of freedom from disease on the part of the hus- band, the following case may prove interesting; and the more so, as the husband experienced no secondary symp- toms, or, if they occurred, they were so slight as to have escaped his observation. Case 7.—A young man had a venereal sore which was situated on the inner side of the prepuce. It got well in a few weeks, with the aid of a lotion of sulphate of 4 50 THE SYPHILITIC POISON. zinc, and he was not aware of any secondary symptoms having followed in its train. Three years afterwards he had gonorrhoea, which lasted two months; and three years later, he married. A fortnight after marriage, the wife, who was a re- markably healthy woman, twenty years of age, applied to me, in consequence of suffering extreme soreness of the vulva, attended with discharge. On making an ex- amination, I found the clitoris and labia much swollen, an abrasion, with a superficial ulceration of the mucous membrane in several places, and a small quantity of purulent secretion. She informed me that this state of things had been occasioned by the unintentional violence of her husband, who had hurt her very much. I ordered her to apply a poultice, made with decoction of poppyheads, to the injured parts, and to remain per- fectly quiet. Under this treatment, the local disorder got speedily wrell. A month after this time, she paid me a second visit, in consequence of the appearance of an eruption of red pimples on various parts of her body. She stated that the first pimple had shown itself at the angle of her mouth a fortnight before, that is, exactly one month after marriage; then a few came on her upper lip; then five or six showed themselves on her forehead, and that afterwards they appeared on her back, neck, shoulders, thighs, abdomen, and arms. They were three weeks before they reached the arms. On the legs below the knees, and on the hands and feet, there were none. She was, besides, looking very unwell; she felt languid and out of spirits; her tongue was thickly coated; her bowels were confined; she complained of fetid perspira- tions at night, and her skin was muddy and discolored. Being very neat in her person, and attentive to cleanli- ness, the dirtiness of her skin gave her peculiar uneasi- ness, and she excused herself more than once for her THE SYPHILITIC POISON. 51 dirty appearance. On looking into her throat, I ob- served considerable congestion of the fauces, with some degree of swelling of the tonsils. Subsequently, the tonsillitis became severe; the swelling gave rise to deaf- ness, by compressing the apertures of the Eustachian tubes, and the tonsils increased so much in size as to render the deglutition of solid food impracticable. More- over, the mucous membrane was loaded with a viscous mucus, which, in the night-time, seemed to obstruct the fauces so completely as to threaten suffocation. The suppurative stage of the tonsillitis was accom- panied by severe symptoms of constitutional irritation; the pulse was quick, the secretions were arrested; she was anxious, restless, and unable to obtain sleep, and her bodily powers were greatly exhausted. The burst- ing of the abscesses, however, gave a speedy relief to her uncomfortable feelings. While the tonsillitis was in progress, her lymphatic system became affected; there were enlargement and tenderness of several of the inguinal glands, and a simi- lar condition of the suboccipital and cervical glands, and of the gland situated just above the bend of the elbow of the right arm. The tumefaction of these glands subsided after a few days, and the tenderness gradually diminished. The preceding case must, I conceive, be regarded as one of unusual susceptibility on the part of the wife, and is by no means whal: I should have expected from a " secondary" poison, and from one which had been so lono* subjected to the assimilative action in the blood of the husband. I have already remarked, that the poison becomes gradually weakened in its powers by time, and undergoes a change similar to that which Mr. Ceely ob- served in the vaccine-virus. When first taken from the cow, the lymph was apt to set up a variety of in- 52 THE SYPHILITIC POISON. flammatory actions, but after a few removes, it lost this virulent property, and became mild and safe in its action. The same kind of modification is perceptible in the venereal poison, and although, after the lapse of years, the disease may be transmitted by the genital secretions, the effects of the poison are strikingly modified, except, perhaps, in cases where, as in that just narrated, a special susceptibility to the contagion is present. I am fully convinced that there exists but one syphi- litic poison, and that all the varieties of its manifestation, which are met with in practice, are due to modifications in the poison itself, modifications having reference to concentration, assimilation, and susceptibility. It would not be reasonable to expect the same train of results from inoculation of the lymph secreted by a recent chancre, as from a poison which has passed through the blood of a contaminated person, been filtered through his tissues, and is presented in a state of dilution in his secretions. In like manner, a person of nervous or sanguine temperament is more likely to be violently affected by the admission of a poison into his blood than one of lymphatic temperament. These modifications on the part of the giver and receiver may possibly explain some of the multiform shapes in which syphilis is pre- sented to our observation. The recognition of the contagion of constitutional syphilis, a fact too obvious to admit of a moment's hesi- tation, will go far to explain a circumstance which must have fallen under the observation of every unprejudiced investigator of the syphilitic poison and its manifestations, namely, the occurrence of syphilitic eruptions and other symptoms of constitutional syphilis after gonorrhoea. When we see a man perfectly free from any primary symptoms of disease, communicating syphilis to his THE SYPHILITIC POISON. 53 newly-married wife, by his secretions alone, can we doubt the possibility of a similar result accruing from a syphilitic secretion poured .out by the mucous membrane, as happens in gonorrhoea ? I do not sa}^ that every gonorrhoea is syphilitic; on the contrary, I know that few are so, but those few have as much the power of transmitting syphilis as an undoubted chancre. I am led to make this observation, because, in numerous in- stances of syphilitic eruptions which have come under my notice, I have been told that the patient has never suffered from any other form of venereal disease than gonorrhoea, and this has been used as an argument against the possibility of a resulting constitutional syphi- lis. It is an argument which should be received with distrust, as the following case will show. Case 8.—In 1828, a medical man had gonorrhoea, but neither excoriation nor sore. In the following year, after getting wet through, he was attacked with rheumatic fever, eruption on the skin, and iritis. Ten years after- wards he again suffered from gonorrhoea. In 1840, he was annoyed with nocturnal pains in the tibiae ; for these he took vapor baths, which brought out an eruption on the skin; and with the latter he has been troubled from that time until the present. In the month of May, 1850, he consulted me for an eruption on the face of small, soft, syphilitic tubercles. One of the tubercles was situated on the upper eyelid, two or three occupied the ala of the nose on one side; a small cluster were collected on the lower jaw amid the hair of the whisker, and there was one on the hard palate. I select this case as being that of a man well able to judge of his own symptoms, and to form a clear idea of the nature of his ailment. He told me that he felt con- 54 THE SYPHILITIC POISON. vinced that he could not have had a chancre in the urethra. There is every reason to suppose; that the whole of the secretions are poisoned in a person affected with constitutional syphilis. We are enabled to detect the presence of the virus in the skin, the mucous membrane, the periosteum, and in many of the organs of the body; and we infer its existence in the nerves and in the blood. The occasional appearance of syphilitic erup- tions on the lips of otherwise sound persons, would lead to the belief that the poison may be communicated by means of the secretions of the mouth; to which source, and to eruptions developed around the lips, must be re- ferred the transmission of the syphilitic poison from infants to their nurses.1 1 The question of the liability of a healthy woman to become infected with syphilis by a nurse-child, I hold to be a fact beyond the reach of doubt. In illustration of this point, the following case, which came under the observation of my friend, Dr. Price, of Margate, and was published in the Lancet of August 15, 1846, is peculiarly clear and interesting. It shows, moreover, the frightful consequences, present and future, of letting loose upon society so dangerous a poison as that of syphilis, and corrobo- rates my opinion of the relationship subsisting between syphilis and scro- fula. One of the congenital victims of this contagion, eighteen years of age, is now dying of phthisis pulmonalis ; may I not say of syphilitic con- sumption ? " In 1828," writes Dr. Price, " a person applied to me, having symptoms of secondary syphilis ; he feared that his wife was also affected, she being then far advanced in pregnancy." Some weeks afterwards, a healthy young countrywoman, whom Dr. Price knew to be respectable, applied to him for a suspicious-looking sore situated on one of her nipples. She in- formed him that, having lost her own child, she had been nursing the in- fant of the person mentioned above. She observed that the child had a sore mouth and a disagreeable odor. Dr. Price lost sight of this woman for several years; when he again saw her, she stated that, soon after her visit to him, she became " covered with an eruption, she lost the skin from the palms of both hands, she had pains in her limbs, and the sides of her nails were affected. In 1830, she was delivered of a male child, whose skin was covered with an eruption; the nails were diseased, and also the corners of the mouth and the angles of the eyes. The child lived three months and three days. After the child was born, the pains in her limbs THE SYPHILITIC POISON. 55 The surfaces of the body are the chief seats of elimi- nation of the syphilitic virus; hence, we find its effects most evident on the mucous membranes, the skin, the periosteum, the neurilemma, the joints, the testis, and the secreting membrane of the eyeball. The mucous and the eruption on the skin continued. She was again confined in March, 1831, but the child was dead, and she has not been pregnant since. Her health, which was excellent before, has been wretched since the conta- gion." " About six weeks after I first saw Mrs. F.," the nurse above referred to, " another respectable married woman, Mrs. H., applied to me, having a large sore on one of her nipples, a copper-colored eruption on the skin, and ulcers on both tonsils." Dr. Price ascertained that her husband was perfectly free from any trace of venereal disease, but that she was nursing the child which had been sent home by Mrs. P. The child, she said, had " an eruption similar to that on her own skin ; it had also a very sore mouth, and sores about the fundament." Dr. Price further ascertained, in respect to the last patient, Mrs. H., that she had, with the view of supplying each child with its proper share of food, carefully kept each to its own breast; nevertheless, her own child evinced symptoms of syphilis ; there was an eruption on the skin, and sores about the arms; the poison having been imbibed from the parent with her milk. That child, Dr. Price informs me, is now (1851) dying of consumption. Two years and five months after the birth of the above child, Mrs. H. was again confined. " In a fortnight, the infant became covered with the same kind of copper-colored eruptions as the other child had. Its nails came off, and in six weeks it died, a miserable object." Twelve months later, Mrs. H. was confined for the third time; in a fort- night the child became affected like the preceding, and lost its nails. It, however, recovered. Dr. Price treated both mother and children with mercury, but the dis- ease seemed to resist its influence. He then had recourse to the iodide of potassium, which carried off the remains of the eruption on the mother, and restored her to health. She has given birth since to six healthy chil- dren. Another fact of interest was developed in the course of this case. While the mother was suffering from the infection in the first instance, her hus- band was affected with " excoriations on the glans and prepuce, and exten- sive desquamation of the cuticle covering the scrotum, and the upper and inner parts of the thighs. These appearances soon yielded to treatment; but they were unquestionably the result of intercourse with his wife." Dr. Hector Gavin reports another interesting case bearing upon the same point in the Lancet for July 18, 1846. 56 THE SYPHILITIC POISON. membrane of the genital apparatus probably performs a special function in this respect; and this circumstance may explain the greater amount of accumulation of the virus which seems to take place in those organs. In this way, also, we may find an explanation of an event so constant in women laboring under constitutional syphilis, namely, miscarriage. Miscarriage is the rule in such cases; and the more severe the effects of the virus upon the ovum and its contents, the more free seems the mother from disease. On the other hand, when abortion does not take place, and the foetus is little affected by the poison, the sufferings of the mother are augmented. CHAPTER II. PRIMARY SYPHILIS. The local action manifested in a part to wThich the poison of syphilis has been applied, is similar to that which follows vaccination: a pimple is at first developed, a pustule forms on the summit of the pimple, and the rupture of the dome of cuticle or epithelium which contains the pus, brings into view a small ulcer or sore. It'does not, however, follow that all these stages should be complete; sometimes the local action is limited by the production of a pimple, and sometimes it goes no further than the pustular stage. These are circum- stances of constant illustration in vaccinia, and in the example of the variolous poison, and are equally present in syphilis. When the local action attains its complete stage, or that of ulceration, the ulcer will be found to be shallow, more or less circular or oval in form, bounded by a per- pendicular and slightly jagged border, and furnished with a smooth yellowish base, moistened by an ichorous secretion. The skin immediately surrounding the sore is moderately inflamed and somewhat thickened. This is the " progressive stage" of the simple syphilitic sore or chancre, and in this condition, with perhaps a little increase of size, it may remain for several weeks. In the next place, granulations begin to form upon its floor; pus is poured out upon its surface; and the sore 58 PRIMARY SYPHILIS. gradually fills up, and ultimately heals. This latter is the " reparative" stage of the sore, during which it is perfectly harmless and non-contagious; but during the entire period of the progressive stage, it is contagious. The natural duration of the simple chancre, when un- influenced b}^ treatment, is from three to five weeks. Instead of pursuing always the above "simple" course, which implies a healthy state of constitution of the patient, attention to rules, and regular habits, it is easy to conceive that opposite conditions to these may give rise to inflammation and its consequences; that the sore may be an inflammatory chancre, or even a sloughing or a gangrenous chancre. There is nothing, however, in the inflammatory chancre that would not be found in a sore of any other kind, occurring in a similar state of constitu- tion of the patient. But it is interesting to note that, as in a case of ordinary inoculation, the virus-forming action of the sore is destroyed by the excess of inflamma- tion, and that such a sore is rarely followed by constitu- tional infection. As a local disease, it may be sufficiently terrible, but a simple treatment, founded on the common principles of surgery, brings it by degrees into a healthy and healing state. In certain states of the constitution, usually such as arise from debility, and accompanied by great nervous irritability, and frequently an anaemic state of the system, there is sometimes found another and a more serious form of complication of the syphilitic sore, namely, phagedena. The phagedcenic sore is character- ized by rapid loss of substance, not occasioned by absorp- tion, as in common ulceration, nor mortification, as in the sloughing sore, but, by a kind of dissolution of the tissues, they become disintegrated, sometimes gelatinized, and they seem to melt away, leaving a large excavated space, extending entirely through the skin and subcu- PRIMARY SYPHILIS. 59 taneous cellular tissue to the fibrous tissue beneath. The cavity of the sore is moistened with a colorless or sanguinolent ichor; the edges are dry, thin, exca- vated, and here and there reddened or blackened by the opening of small vessels and the desiccation of effused blood; and the skin immediately around the sore is in- durated, and has an erysipelatous redness. The cure of this kind of sore requires the restoration of the consti- tution to its normal state of tone and rest; and, if the local destruction continue, the employment of strong nitric acid as an escharotic. Like the sloughing chancre, the phagedenic sore very rarely gives rise to constitu- tional infection. It will be seen that the two forms of syphilitic sore last described, namely, the sloughing chancre, and the phagedaenic chancre, are mere modifications of the simple chancre, modifications dependent on the state of consti- tution of the patient. There remains, however, to be described another form of sore which is pathologically different from the preceding, which is characterized by a peculiar hardness of the base, or of the tissues imme- diately around it, and which is therefore termed the in- durated chancre. The indurated chancre is more slow and chronic in its properties than the simple chancre. It is unattended with pain; remains stationary for weeks, and even months, and gives out scarcely any secretion, and that of an ichorous kind. The indurated chancre varies much in size; it is often no larger than a split pea; sometimes it increases to the size of a shilling, in which case it may assume a sloughing action in the centre, from the density of its base, and the consequent inter- ference with the circulation necessary for its complete nutrition. The floor of the chancre is smooth, and devoid of granulations: it is bluish or livid in color, and 60 PRIMARY SYPHILIS. the rounded rim of condensed tissue which forms its border, is often white and cartilaginous in appearance. The hardness which constitutes the chief feature of this form of chancre, is not present from the first, but usually commences on the fourth or fifth day. Up to that period the sore is of the simple kind, the induration depending upon a subsequent action in the economy. I have said that the sloughing and phagedaenic chan- cres are rarely followed by constitutional symptoms, the excessive local action which occurs in them seeming to destroy the virus-forming process which would other- wise have been set up. The calm and natural action present in the simple chancre being favorable to the development of the virus, renders it more dangerous as a source of constitutional infection. But the indurated chancre is invariably followed by constitutional syphilis; indeed, as I believe, is itself a manifestation of constitu- tional action; in other words the induration is a consti- tional affection superadded to the primary disease. In association with the indurated chancre, the inguinal glands are commonly enlarged, whatever the situation of the chancre may be. In simple chancre, enlargement of the inguinal glands is less frequent, indeed seldom occurs, unless the sore be situated in the neighborhood of the fraenum. In the sloughing and phagedaenic sores, enlarge- ment of the inguinal glands, when it happens, is occa- sioned by the extension of the irritation in the course of the lymphatic vessels, and is not the result of the pre- sence of the syphilitic virus. Indurated syphilis sometimes assumes another shape, namely, one in which the cartilaginous induration is prominently conspicuous, but where an ulcer or sore of any kind may be totally absent; or if any lesion of con- tinuity exist, it is commonly a mere abrasion of the cuti- PRIMARY SYPHILIS. 61 cle or epithelium. The following case will perhaps illus- trate my meaning better than description:— Case 9.—A gentleman, aged thirty-five, observed one morning, while taking his daily bath, a slight abrasion of the epithelium of the foreskin. The abrasion was situated on the summit of a fold of the mucous mem- brane, which appeared to be swollen. Having been walking many miles the day preceding, he regarded this appearance as the consequence of friction, and the more so, as he had had no sexual connection for at least six weeks. The abrasion was unattended by pain or sensa- tion of any kind, and but for the eye, he would have been unaware of the presence of anything unusual. Two days after the discovery of the sore, he had tenderness and slight glandular enlargement in the groins. The abrasion was situated near the fossa glandis on one side of the organ. The abrasion was dressed with a weak solution of nitrate of silver, and healed over in ten days, during which period he took a blue pill at bedtime every other night, and a Seidlitz draught on the following morn- ing. Three weeks after the advent of the abrasion, and when the latter was healed, he observed a few spots on his skin, which subsided in a few days, while others ap- peared, to pass away in a similar manner. This state of things continued for a month, when he applied to me. At this time there were a few slightly-raised erythema- tous spots on his forehead and dispersed upon his limbs, but not more than five or six upon his entire body, and he consulted me rather from the apprehension of evil than any present suffering. Upon carefully examining his skin, I discovered the presence of roseola; I learned, moreover, that although u 62 PRIMARY SYPHILIS. he had no sore-throat, and none of the muddiness of the skin usual in constitutional syphilis, he had about ten days before experienced pains in the elbows. I then requested to see the seat of the primary dis- ease, to which he objected that he was perfectly well; but upon my urging the necessity of an examination, he exhibited to me a well-marked specimen of the cedema- tous and indurated thickening characteristic of true syphilis, or, according to my appreciation of the case, of the constitutional manifestation of the disease in its original and primary seat. The appearance in question was a fold, or rather roll, of the mucous membrane, smooth from cedematous distention, occupying the side of the penis, just behind the fossa glandis, and contain- ing in its base a thick plate of cartilaginous hardness. The above case is a good illustration of the insidious character which syphilis sometimes assumes. This gentleman was ready to declare that, to the best of his belief, he was perfectly well of the local disease, while ex- amination proved it to be present in a formidable shape. According to my creed, the syphilitic poison in this case had been immediately imbibed by the blood, without lesion of surface or primary sore, and reacting, through the blood, on the seat of absorption of the poison, had occasioned the thickening (secondary) which ensued. Abrasion of the surface of this thickened fold may have been, as the patient supposed, the mechanical effect of friction during walking. The abrasion soon healed, uninfluenced by the treatment adopted, but the thicken- ing and cartilaginous induration remained behind, as a proof of the existence of the poison in the blood, and awaiting a sufficient exciting cause to favor its eruption as a local ulcer, or as a general affection. The thickening in this case rapidly disappeared under the use of a mild mercurial course. CHAPTER III. SECONDARY OR CONSTITUTIONAL SYPHILIS. After the lapse of a short but variable period, namely, from one week to three or more, the local or primary disease becomes exhausted, the sore or ulcer heals, and the patient is to all appearance well. It may be so, in fact; the poison may have gone no farther than the part which has been ravaged by the disease, it may have become exhausted on the spot, or it may have been transmitted through the bloodvessels into the stream of life, have poisoned the entire mass of blood, and, by means of the blood, all the tissues of the body. It may be there latent, but not lost, silently accumulating, and ready on a sudden to burst forth in a new shape, namely, as a general or constitutional dis- ease, as, in fact, a syphilitic fever. It is a well-known law of animal poisons, that, being once introduced into the blood, they excite in that fluid an action which has for its object the production of a similar poison, and this process goes on until the blood becomes saturated or overcharged with the morbific principle. As soon as this latter condition occurs, an inflammatory movement is set up, which results in the ejection or elimination of the poison. This inflammatory movement, or syphilitic fever, is therefore a sign of the accumulation of the poison within the blood, to such a degree as to disturb the healthy functions of the body, and is attended with symptoms 64 SECONDARY OR CONSTITUTIONAL SYPHILIS. which indicate derangement of the nervous, vascular, and digestive systems, and especially of those surfaces of the body through which it is possible for elimination to occur. The blood, it must be recollected, is charged with a poisonous principle, and it may therefore be concluded that all the organs and structures supplied with that blood must suffer to a greater or less extent. The brain evinces its suffering by mental dejection; the nerves, by a general feeling of prostration and debility. Every- thing is couleur de plomb around the patient; he is unable to pursue his avocations with comfort, and if they require the exercise of his mind, scarcely at all. He is oppressed with a sense of impending evil. Besides the lassitude and languor which evince the poisoned condition of the nerves, there is often neuralgia to an intense degree, sometimes affecting the head or face, and sometimes the joints, when it goes under the name of rheumatism. The neuralgia presents the peculiarity of being nocturnal, that is, of being most severe during the night, and often, but not always, entirely absent by day. The pulse is quickened; the tongue is coated, white, broad, and indented by the teeth. The fauces are more or less congested, the tonsils and soft palate being fre- quently swollen; there is irritation of the larynx, pro- ducing a mucous cough, and often nausea. The bowels are sometimes constipated, sometimes relaxed; the urine sometimes clear and limpid, at other times loaded with salts. The conjunctiva is congested and muddy, and the whole skin remarkable for its yellowish and dirty appearance, looking as if saturated with impure and discolored humors. Sometimes it is dry; at others suffused with a greasy secretion, and at night pours out an abundant and fetid perspiration. Such are the general symptoms of the syphilitic fever, SECONDARY OR CONSTITUTIONAL SYPHILIS. 65 or secondary syphilis, but they may not all be present, and those which exist may be complicated by local con- gestions of the mucous membranes. The symptoms which may be selected as pathognomonic of syphilitic fever are: mental and nervous depression and prostration; congested fauces, wTith sore-throat; congested and muddy conjunctiva; congested and discolored skin, the con- gestion being partial or general, and assuming the form of an eruption ; and, added to these, neuralgic pains. In this combination of symptoms we are forcibly struck with the resemblance which they bear to those of the exanthematous fevers, measles, scarlatina, and smallpox. Firstly, the nervous depression, showing the stagnating influence of the accumulated poison. Secondly, the congestion of the mucous membranes, particularly of the fauces, showing the effort made by the bloodvessels to eject the poison through that tissue. And thirdly, the cutaneous exanthema, which completes the triumph of the pressure from within, and is the sign that the poison is driven to the surface and is in process of expulsion. Even the irregular symptoms, the partial and local congestions, have their parallel among the exanthemata. Let me adduce one or two examples. A printer, aged fifty, six weeks after suspicious connection, was exposed in the winter season to the dangerous effects of a heated and impure atmosphere during the day, and cold and rain at night. At this time he became the subject of nocturnal headaches attended with profuse fetid per- spirations. One night, after more fatigue and exposure than usual, his headache was excessively severe, his breathing oppressed, he had intense pain in his chest, and seemed in danger of suffocation. These symptoms of pulmonary congestion, an effort on the part of nature to eliminate the syphilitic poison through the mucous 5 N 66 SECONDARY OR CONSTITUTIONAL SYPHILIS. membrane of the air tubes, were relieved by a general eruption of roseola. A married lady had for two years been subject to a troublesome bronchitis, which the usual means had failed to cure. It came on at first in the form of periodical attacks, and was attended with serious dyspnoea. Lat- terly, the disease had become more constant and less severe. Her application to me arose from her having an eruption on the forehead, which I recognized as syphilitic. The eruption had appeared with the first attack of bronchitis, and in her own mind, she connected the disorders together. It occurred to me, also, that the twro disorders might proceed from the same cause; that the bronchitis, like the cutaneous eruption, might be maintained by the syphilitic poison. I treated this lady as I should have done an ordinary case of constitutional syphilis, and both affections got well together. Thus far for resemblances to the exanthematic fevers, but there are also differences between the syphilitic fever and that of the exanthemata, so remarkable as to call for special consideration. The exanthematous fevers are more violent, more regular, and more transient than the syphilitic fever, in other words, they are acute, while the syphilitic fever is chronic. It is true that instances of syphilitic fever often happen, which present all the „ symptoms of the most violent fever, and are attended with delirium; but such cases are the exception and not the rule. The cause of the differences of character perceptible between the exanthematous and the syphilitic fever appears to me to be due to a radical difference in the nature of the poison. The poison of measles, scarlatina, and smallpox, probably originates in conditions extra- neous to the animal body; it reaches the blood as an element foreign to its nature, and as soon as it has accu- SECONDARY OR CONSTITUTIONAL SYPHILIS. 67 mulated to the saturating point, a violent effort is made for its expulsion. The expulsive effort obeys rigidly certain laws of order and time, and the poison being once removed, the blood of the patient enjoys an im- munity from a re-excitement of the same action for the rest of life. How different are the phenomena which characterize the poison of syphilis. The syphilitic poison originates in the human body; it is probably little more than a modification of the natural secretions; it is consequently less irritant in its nature, and it tends to assimilate with the blood and with the tissues, rather than to excite an action which may result in its removal. Hence the poison is slow in accumulating, its excitation of febrile symptoms seems rather a matter of accident than the consequence of an irresistible law; the patient enjoys no immunity from a recurrence of the morbid action, and the poison is only partially removed by the febrile effort. There is another striking difference between the ex- anthematic and the syphilitic poison. In the former, a second febrile attack never follows from the same original infection. In the latter, a second, a third, and, indeed, an indefinite succession of outbursts of the poison is the common manifestation of its action. In the ex- anthematic fever, the blood and tissues of the body are so modified by the excitation they have undergone, that they are indisposed to take on again a similar action. The poison of syphilis having once entered the sj'stem, the blood and tissues appear to become accustomed to its presence; it remains for years, or for life, and gives notice of its existence from time to time, by a variety of symp- toms. Nay, more, it is transferable to offspring, not merely to one, but, as I believe, to an indefinite series of generations. 68 SECONDARY OR CONSTITUTIONAL SYPHILIS. I have said that the occurrence of syphilitic fever seems rather the effect of accident than the result of an immutable law. I mean, that the poison itself appears to be insufficient to light up the fever without the inter- vention of an accidental exciting cause, such as cold; and the exciting cause frequently determines the shape which the subsequent symptoms assume. Sometimes the leading feature of the fever is sore-throat, sometimes neuralgia or rheumatism, sometimes iritis, sometimes cutaneous eruption, and sometimes periosteal inflamma- tion ; these differences of effect being partly due to the nature of the exciting cause, and partly, also, to the con- stitution of the individual. CHAPTER IV. EVOLUTION OF THE SYPHILITIC POISON BY THE SKIN. There is every reason to believe that the congestions of superficial membranes which take place in constitu- tional syphilis, are the manifestations of an effort on the part of nature to eject the noxious poison from the blood. We have no means of putting this hypothesis to the test of experiment, as the material nature of the poison is unknown; but from the relief which is af- forded to the nervous and circulating systems by an outburst of eruption, and from the analogous benefit experienced in the exanthematic fevers, we have every right to infer that such is the fact. Let us, then, inquire in what shape the evolution of the syphi- litic poison makes itself evident upon that membrane which is placed more immediately under our observation, namely, the skin. The functions of the skin are divided between pro- tection and secretion, the apparent surface of the mem- brane being devoted to the former, and certain crypts excavated within its tissue to the latter. The crypts of the skin, though concealed from the eye, constitute an important and extensive glandular system, richly en- dowed with capillary vessels to supply the means of secretion, and to these the principal afflux of blood takes place when the feverish impulse is received. When the skin is thrown into a state of congestion by the determination of blood to its capillaries, it has a 70 SYPHILITIC ERUPTIONS. mottled appearance, such as may be seen in a portion of the derma artificially injected with size and vermilion, or on the limbs of a child exposed to the cold. It is this appearance which produces the patchy redness of measles, and when it results from the agency of the syphilitic fever, it is termed roseola syphilitica (Plate 1, A). Roseola, therefore, is a simple congestion of the skin, its peculiar roseate tint being due to the darkness of the blood moving through the capillaries, and to the muddy and discolored state of the cutaneous tissues. In every instance of congestion of the skin, a close examination shows a greater depth of redness in the situation of the crypts or follicles than in the intervening part. This is a natural consequence of the vascularity of the crypts, the vascular plexus surrounding which de- scends for some distance into the substance of the dermal membrane. I have elsewhere distinguished this glandu- lar plexus by the name of " vertical plexus," while that which occupies the surface apparent to the eye is the " horizontal plexus." Now, if we look carefully into the patches of redness of roseola, we at once perceive the fact of the greater vascularity of the follicles, by the numerous red "puncta" disseminated through the patch. The same character is perceptible in every congestion of the skin, and is strikingly obvious in roseola and scar- latina, and in the earliest phasis of variola. If the con- gestion of the skin advance a degree beyond that of simple repletion of the capillaries; if the arteries and veins, between which the capillaries form a connecting link, are also congested and distended, a slight degree of swelling results, and the aperture of the follicle, the pore, is lifted up above the level of the surrounding skin. It may be as well to observe here, that the syphilo- dermata, or syphilitic eruptions of the skin, present two ROSEOLA SYPHILITICA. 71 principal forms, the one being simply congestive and unattended with elevation of the skin; the other, present- ing the obvious feature of elevation. To the non-ele- vated group belong roseola, syphilitic maculae, and ery- thema; to the elevated group, the small pimples of lichen and the larger pimples or tubercles of tubercular syphilis. These differences are, however, more apparent than real, and may be regarded as stages of development of the same disease. Roseola, by an easy gradation, is con- verted into lichen, or tubercular syphilis, and these latter by simple subsidence, become syphilitic maculae. Roseola syphilitica commonly presents itself in the form of undefined patches, giving to the skin an appear- ance which is best described by the term "mottled." The appearance is identical with that of common idio- pathic roseola, or measles, and is due, like the two latter, to the manner of distribution of the bloodvessels in the skin. Perhaps the congested patch represents the rami- cations of a single small arterial trunk; perhaps it em- braces that small capillary system which is normally emptied by a separate venous trunk; perhaps, again, it includes the small district of skin, the circulation of which may be governed by the ultimate divisions of one small nervous twig. The question is not one of importance, and we may remain contented with the fact. Occasion- ally the roseolous congestion is defined in its boundary, forming circular blotches; and when this is the case, it often exhibits a tendency to spread by the circumference while it fades in the centre, and so gives rise to an annulate form of roseola. This annulate spread of con- gestion of the skin is another peculiarity of that structure which is universal, and which also depends very proba- bly upon the distribution of nervous influence. Syphilitic roseola, therefore, may present itself to our examination under three varieties of form, namely, 1, as a patchy and 72 SYPHILITIC ERUPTIONS. mottled redness (Plate 1, A, B); 2, as circular blotches (C); and, 3, as congested rings (D). Besides the varieties which depend on differences of form, there are others which are due to the degree of congestion of the skin. In some, the redness of the blotches is uniform, or nearly so; others seem to deserve the appellation punctata from the more vivid redness and greater congestion of the follicular plexus; and in a third case, the latter condition has progressed so far as to lift up the follicular pore, and produce an indistinct papule, roseola papulata (Plate 1, B). As I have said before, these differences are mere differences of degree of congestion; the same disease exerting itself with greater or less force, or acting upon a structure of greater or less strength; they are all mere varieties of roseola; and as I shall endeavor to show, roseola itself is a mere variety or stage of the other forms of syphilitic eruption, for which, in its aggregate capacity, I have ventured to suggest the term syphiloderma. Roseola syphilitica, then, or the congestion of the skin, which depends on the syphilitic poison, presents varieties of form and varieties in degree of manifestation, which may be expressed by the following terms:— 1.— Varieties -in form. Roseola versicolor (Plate 1, A). " orbicularis (C). " annulata (D). 2.— Varieties in congestion. Roseola punctata (B). " papulata. When the congestion of syphilitic roseola subsides, it leaves behind it a more or less stained appearance of ROSEOLA SYPHILITICA. 73 the skin, and this is a common character of all the syphilitic eruptions. The stain generally corresponds with the form of the eruption which preceded it, and is of a brown color, of varying tint, deep, and almost approaching to black in persons of dark complexion; of lighter hue, and verging to fawn, or a dead-leaf-like tint, in the fair. Sepia, tinged with red or yellow, would, in the hands of the artist, produce all the variations of color which the syphilitic stain presents. These stains of the skin are termed maculce syphilitica} (Plate 1, F). Sometimes the roseolous congestion which precedes them is so slight, that they appear to be independent of such an origin; but this is not the case; they are always the effect of a congestive action in the skin. Maculae syphiliticae, therefore, when they are primary in their appearance, must be grouped under the head of roseola; and when they are the vestiges of the other syphilodermata, belong, nevertheless, to the non-elevated group of syphilitic eruptions. One variety of these appearances I have had occasion to describe, under the name of Melanopathia syphilitica. Roseola papulata (Plate 1, B) constitutes a link of transition between the non-elevated and the elevated forms of the syphilodermata. When the eruptive force is sufficiently powerful to elevate the pores into distinct pimples, the case is one of lichen. It is no uncommon thing to find the mottled roseolous rash forming a base upon which the papules of lichen are developed; and their appearance, under these circumstances, seems to warrant the designation which I have given to the eruption, namely, lichen corymbosus (Plate 1, G). For the papules in this case are grouped in clusters, varying from three or four to thirty in number, and suggest forcibly to the mind the idea of clusters of fruit. 74 SYPHILITIC ERUPTIONS. Sometimes the lichenous papules, instead of being arranged in groups, are dispersed singly over the surface of the skin, constituting a lichen disseminatus (Plate 1, LI); and at other times, they are packed almost as closely as the pores wrhich they represent, lichen corifertus (Plate 1, I). The transition of syphilitic roseola into lichen is so obvious, that it may be observed through every stage of its progress. A roseolous patch may be seen to develop papules by the mere swelling of the pores of the con- gested skin; and I have furthermore seen the small papules of lichen converted into those larger elevations which are known as tubercles, by a sudden aggravation of the syphilitic fever, or from exposure to cold. In a few instances, I have seen the eruption of syphi- litic lichen developed into the form of rings, constituting a lichen syphiliticus annulatus (Plate 1, K); and a lichen syphiliticus pustulosus may be distinguished as resulting from a pyogenic action in the papule, resulting from irri- tability of system, or depressed vital powers. The varieties of lichen, therefore, like those o f roseola, may be classed under five heads; namely :— Lichen corymbosus (Plate 1, G). " disseminatus (H). " confertus (I). " annulatus (K). " pustulosus. Syphilitic tubercles are simply a more developed form of the papules of lichen, involving not one pore and one follicular plexus, as is the case with the lichenous papule, but several pores and several follicular plexuses with the intermediate horizontal plexus. The distinction between lichen and tubercle is merely one of size; and it is no LICHEN SYPHILITICUS. 75 uncommon thing to find the eruption tubercular on one part of the body and papular on the rest. Indeed, it is the common character of the papules of lichen which appear on the face to assume a large size, and present the ordinary attributes of tubercles. Syphilitic tubercles present some varieties which have reference to obvious diversities of character of develop- ment. For example, some are collected into patches of variable size, and are distributed, more or less generally over the surface of the body; they correspond in manner of distribution with the corymbose form of lichen; hence I have named them tubercula corymbosa (Plate 2, L). Others constitute groups which are more or less solitary in their arrangement, and of variable size. The group is bounded by a distinct border of tubercles, which creep along the skin, and increase gradually the dimensions of the patch. The circumscribed character of such a patch suggests the name of tubercula circumscripta (Plate 2,0). Others are scattered over one or several regions of the body as separate tubercles, tubercula disseminata (Plate 2, Q); in some, the tubercles merge into each other and form a smooth bank, which expands into the form of a ring, tubercula annulata (Plate 2, S); while others, again, belonging to either of the preceding groups, are apt to take on an ulcerative action, and establish a variety which may be distinguished as tubercula ulcer- anlia. In a tabular arrangement, these varieties in the tubercles would stand as follows :— Tubercula corymbosa (Plate 2, L). " circumscripta (0). " disseminata (Q). " annulata (S). " ulcerantia. f 76 SYPHILITIC ERUPTIONS. The three forms of eruption now described, namely, 1, simple congestion of the skin constituting roseola and erythema; 2, congestion, with elevation of separate follicles, constituting lichen; and 3, congestion with elevation of a small group of follicles, or uniform tume- faction of a small portion of skin exceeding two lines in diameter, constituting tubercula, may be considered as typical examples of cutaneous syphilis, and all the num- berless modifications which are met with in practice, may be referred to one or other of the above three heads. SYPHILODERMA ROSEOLATUM. ROSEOLA SYPHILITICA. In a preceding chapter, it has been shown that the evolution of syphilis upon the skin is attended with symptoms of constitutional derangement of a more or less severe character; sometimes amounting to an absolute state of fever, and at others being so slight as to be only appreciable to the practised eye; sometimes affecting a variety of organs, and constituting a distinct pathogno- monic series; at other times being solitary and more or less obscure. Roseola is one of the simplest of the forms of con- stitutional syphilis, and presents the common characters of an exanthematous fever, usually of a mild kind, but sometimes severe. It is the form in which the general effort for the elimination of the syphilitic poison is manifested; it is indicative of a certain power on the part of the collected poison; and is the common precursor of the other forms of eruption. Like measles, which it closely resembles, it begins SYPHILODERMA ROSEOLATUM. 77 with general febrile symptoms, prostration of strength, and congestion of the mucous membrane of the fauces. Then follows the exanthem, which is spread more or less extensively over the surface of the body, being most perceptible on those parts which are covered by the clothes. The efflorescence remains apparent for a vari- able period, a few days or as many weeks; it is brightest in the evening, and under the influence of excitement, and is attended on its decline by exfoliation of the cuticle. Very commonly, it leaves behind it a fawn- colored or brownish stain, and a dry and sordid state of the skin. The period at which the roseolous rash makes its appearance is between six and nine weeks after the development of the primary disease, being a week later when there is no local disease, as in Case 1, and where consequently it dates from the reception of the poison. Case 1 may be taken as a fair example of the disease in a mitigated form, but totally uninfluenced by exciting causes or medical treatment. The causes of mitigation were, firstly, the modified nature of the poison, the latter having been transmitted through the blood of the hus- band; secondly, the existence of the furuncular sore, which had absorbed much of the poison from the blood, and was doubtless excreting it actively; the third mitigating condition was the absence of any exciting cause, such as cold. Another point, which is illustrated by case 1, is the circumstance of the roseola having been followed a week or two afterwards by an eruption of pimples and tubercles. The furuncular sore got speedily well, and ceasing to perform its office of an issue to the poison, the occurrence of the lichenous and tubercular eruption wTas the consequence. I will now detail some cases of roseola, with a view to *N 78 SYPHILITIC ERUPTIONS. elucidate the ordinary characters and concomitants of this form of syphilitic disease. Case 10.—A gentleman, of nervous temperament, habitually dyspeptic, forty years of age, and unmarried, had a small superficial sore on the fraenum, which made its appearance a week after connection. From occupy- ing the fraenum, which it had perforated, the sore had lasted two months, when he applied to me; but soon got well on the division of the little band which formed the border of the fold. His mission to me was a roseolous eruption, which, a fortnight before, namely, six weeks after the outbreak of the sore, had appeared over the greater part of his body, more particularly on the front of the trunk, the shoulders, and the inner sides of his thighs. His skin exhibited the ordinary characters of the syphilitic ca- chexia; it was sallow, muddy, and dry, the pores were prominent, and the follicles filled with a dry sebaceous sordes. He had, besides, a few lichenous pimples on the face. His pulse was quick and small, his tongue yellowish- white, with lengthened papillae; his bowels relaxed and irritable; and his fauces congested, but not sore. At a later period, he had severe neuralgic pains in the head, which destroyed his sleep at night. The roseolous rash remained on the skin for three weeks, offering occasional exacerbations whenever he committed any excess in the use of stimulants. Case 11.—A gentleman, aged twenty-five, became exposed to contagion in the month of July, 1844. On that day week, he perceived a swelling at the end of the penis, with a slight discharge on pressure. Acting on the advice of a friend, he took some aperient medicine, SYPHILODERMA ROSEOLATUM. 79 but without making any impression on the disease; the swelling increased, and was attended, first, with throbbing pain, and then with an intense burning, and the dis- charge became profuse. Having pursued the aperient plan for ten da}'s, he began to take copaiba and cubebs, and went on for another period of ten days, when, find- ing only an increase of pain, with no abatement of dis- charge, and losing his rest at night, he applied to me for advice. After detailing to me the above history of his symptoms, I inquired if he had had any scalding or pain on making water. He seemed so much at a loss to com- prehend my meaning (this being his first mishap), that I suspected he had committed an error of diagnosis with regard to the nature of his case. I requested him to show me the seat of disease, where I found, as I antici- pated, balanitis. The discharge was profuse, and the prepuce so much swollen as not to admit of retraction. I ordered him a lotion containing two grains of sul- phate of zinc, and ten minims of laudanum to the ounce of water, to be injected every two or three hours beneath the prepuce; and internally some saline medicine. The discharge quickly ceased under this treatment, but the swelling of the prepuce continued, which led me to infer that there existed beneath it a sore, although I was un- able to detect any by means of the finger. As the dis- charge had ceased on the third day after using the in- jection, I ordered him an ointment of simple cerate with liquor plumbi, to be introduced between the prepuce and clans by means of a camel's-hair pencil. In a few days, all tenderness of the part had subsided, although there was still some thickening of the prepuce which prevented retraction, and, considering himself well, the patient discontinued his visits. In the beginning of October, just nine weeks after the first appearance of the primary symptoms, this gentleman 80 SYPHILITIC ERUPTIONS. returned to me with a roseolous rash, which had broken out upon all parts of his body, with the exception of his face. He was feeling ill and dispirited ; he was restless in bed, could get scarcely any sleep; perspired very much during the night, and had considerable soreness of throat; his skin was discolored and muddy, and the roseola distinct; there was also a return of the swelling of the prepuce, which he informed me had previously got nearly well. After three weeks of treatment, he recovered from this attack, but having committed some indiscretion of diet, the roseola suddenly reappeared, and remained for ten days. About the middle of December my patient was again exposed to contagion; and three weeks afterwards, he came to me with a small circular abrasion situated upon the end of his prepuce. The sore was superficial and clean, and went on increasing in dimensions for about a week, rising by means of its granulations slightly above the level of the surrounding surface. Under the influence of mercury, it healed in ten or twelve days, and an in- duration of the tissues at its base was also removed. Six weeks after getting well of the sore, namely, in the beginning of March, he again paid me a visit; he told me that he had for a week past been obliged to ex- ert himself beyond his strength, both mentally and physi- cally; that during this period he had been much exposed to the night air, and that he feared he had symptoms of a return of his old complaint. He felt weak, he said, and dispirited, as he had done before when he was taken ill; he had been restless at night, and troubled with per- spirations; he had a commencing soreness of the throat, and his skin was muddy and discolored. Baring his arm, he showed me a number of rounded pimples, as large as millet-seeds, dispersed upon the skin; and he SYPHILODERMA ROSEOLATUM. 81 said that similar pimples had made their appearance upon all parts of his body; there were some, which were very tender, on his head, and a few upon his forehead and face, more especially at the angles of his nose and mouth. These pimples went on increasing in number and size for some days; they were of a dull red color, prominent, rounded at the summit, and disseminated. As soon as the medicine prescribed for him began to take effect upon his system, they shrunk, and the greater number subsided, leaving behind them a reddish-brown stain, which resembled that occasioned by a bruise. A few only desquamated on the summit, and appeared as if covered by a thin scale, and some few of the stains also desquamated. His throat was a good deal congested and swollen, ex- hibiting a tendency to abscess of the tonsils; but there was no ulceration. He had enlargement and tenderness of the occipital and post cervical glands, and there was also tenderness and slight enlargement of the inguinal glands, but no reappearance of unhealthy action in the prepuce. After recovering from these symptoms, I sent him to the sea-side, where he remained for some weeks, and has since had no return of the disease. Case 12.—A married man, aged thirty-five, contracted three small sores in the fossa glandis, in the beginning of October; the sores were superficial and accompanied by bubo. He got well in three weeks. This gentleman afforded an instance of a remarkable susceptibility to the influence of mercury; his mouth was made tender by eight grains of calomel. He then took one grain of calomel twice a week. In the beginning of December, eight weeks after the occurrence of the primary disease, he was exposed to 6 82 SYPHILITIC ERUPTIONS. cold and wet, and became the subject of severe febrile symptoms. In two or three days, these symptoms were followed by a roseolous rash, which came out extensively over his skin, and was accompanied by sore-throat. The febrile symptoms subsided as soon as the eruption had broken forth; but did not leave him entirely for a fortnight. The febrile symptoms were combated by the usual antiphlogistic treatment, and after their subsidence, he had exhibited to him the hydrargyrum cum creta in small doses. After he had taken six grains, his gums became again touched. When the tenderness of his mouth was gone, he took Donovan's solution in doses of from three to five drops; and in ten days his gums became tender for the third time; after a rest of a fort- night, Donovan's solution was again given him, and with a similar result. In the beginning of February he had a fresh attack of febrile symptoms, and a further eruption on the skin. In the first attack, the eruption was of the roseolous kind; this time it occurred in tubercles half an inch in diameter. In the beginning of April, I saw this patient in con- sultation. He had a muddy skin, a pale, languid com- plexion, a dull eye; his skin was moistened with perspi- ration, which gave forth a fetid odor; his tongue was large and pale, the papillae long, and the surface covered with a yellowish-white secretion; the fauces were much congested, but any ulceration that there might have been was healed. The swollen state of the mucous membrane of the fauces and the state of his tongue together occasioned nausea, and frequent spasmodic efforts to raise something from the throat; but a little healthy mucus was all that was discharged. The mu- cous membrane of his nose was congested. His pulse SYPHILODERMA ROSEOLATUM. 83 was quick and feeble; and the whole character of his system was one of anaemia and exhaustion. There were still a few of the large soft tubercles of the previous eruption on his skin, and those which had subsided were marked by reddish-brown stains. By a generous diet, sea air, and tonic remedies, this gentleman got perfectly well, and has since remained so. Case 13.—In the beginning of February, 1850, a gentleman, aged about thirty, suffered from gonorrhoea with simple excoriation of the inner surface of the pre- puce. He underwent no treatment for a month, by which time the seat of the excoriation was thickened. and a superficial ulcer had formed on its most promi- nent part. He then applied to Mr. Coulson, who pre- scribed for him a mercurial course, which he continued for three weeks, by which time the sore was healed. The mercury was then suspended. A fortnight after the healing of the ulcer, that is, five weeks after its first appearance, and nine weeks from the outbreak of the primary disease, he became affected with syphilitic roseola in circular patches (roseola orbicularis), (Plate 1, C), intermingled with urticaria, to which latter he was frequently subject. He had, besides, considera- ble congestion of the fauces, tumefaction of the sub-occi- pital glands, muddy skin, loaded conjunctiva, foul tongue, low spirits, and general febrile symptoms. His present state was occasioned by exposure, about a week before, to cold easterly winds. He soon got well of this attack under an antiphlogistic treatment, followed by the iodide of potassium and sar- saparilla, and went to the sea-side. Five weeks after- wards, on his return to London, inflamed excoriated patches made their appearance on the mucous membrane 34 SYPHILITIC ERUPTIONS. of the mouth ; a roseolous rash showed itself on different parts of his skin, and some papules on the face and head; the eruption being accompanied by a muddy skin and conjunctiva, and loaded tongue. The following case is interesting, as showing the sud- denness of contagion; the result being gonorrhoea, the fomes of contagion being one of secondary poison; then the rapidity with which the symptoms of constitutional disease followed the one upon the other. And it suggests the question whether secondary poison is not more apt to engender secondary disease than the primary poison ; and whether syphilitic gonorrhoea may not originate in the secondary poison. The facts were as follows:— Case 14.—A young gentleman, a medical apprentice, aged nineteen, had his first intercourse on the first of February, 1851. The girl was known to have had con- stitutional syphilis, but was supposed to be free from any local disease on the occasion referred to. After the act he washed himself, as he believed thoroughly, and used a syringe to the urethra. The next day he had a discharge from the urethra, which was considered to be a clap. The clap left behind it a gleet, which continued at the time of his first visit to me on the 27th of June. A month after the first appearance of the gonorrhoea, the prepuce became thickened and cedematous, and gave rise to phimosis; this state of the prepuce continuing for three weeks. Seven weeks after the first occurrence of the phimosis, an inflamed spot appeared near the root of the penis, and gradually passed into the state of a superficial sore, leaving behind it, when it healed, a reddish tubercle. Six or seven weeks after the occurrence of the sore, an eruption of red spots broke out over the greater part SYPHILODERMA ROSEOLATUM. 85 of his body. At the period of his visit to me, ten days after the appearance of the eruption, I found a number of dirty red, circular spots (roseola orbicularis), measur- ing three and four lines in diameter, dispersed over his limbs, the front of his trunk, and face. In some, the dull-red had faded into a brownish or yellowish-brown hue; in others, the cuticle covering the spots had become thickened, and was beginning to crack near the outer margin of the spot; in some, the cuticle had separated partially or completely, leaving either a thin scale over the central part, or leaving it entirely smooth, and in some few, a fresh exfoliation of cuticle had commenced, or was in progress. The edge of cuticle remaining con- nected with the margin of the spot, formed around it a kind of frill (Plate 1, E). His voice is husky; he has an uncomfortable feeling in the throat, not amounting to sore-throat; and he has felt deep-seated pains in the thighs during the past three weeks. The treatment pursued in this case was in the first instance, the usual remedies for gonorrhoea. As soon as the superficial sore at the root of the penis appeared, he began to take the iodide of potassium, which he con- tinued for a week. And for the three weeks previous to my seeing him, he had been taking the biniodide of mercury, ygth of a grain at first; then ith twice a day. I prescribed for him a third of a grain three times a day, which he took very regularly for five weeks. During this period, his gums were, on several occasions, tender for two or three days at a time; and during the last four days of the treatment, the tenderness of the gums was more marked. He did not suspend the remedy on account of the tenderness; for, after a few days, the feeling in the mouth subsided. In a week after commencing the biniodide in the doses 86 SYPHILITIC ERUPTIONS. above named, the spots began to fade, and in a month they had entirely disappeared. Three weeks after the disappearance of the rash, and two months after its outbreak, a second attack of the exanthem occurred, this time assuming the form of rose- ola annulata (Plate 1, D). The rings were dispersed over various parts of the body, more especially the limbs, and were accompanied, a week later, with pains in the joints; a little soreness of throat; slight swelling of the tonsils; pains and tenderness of the urethra, and a return of the gleet. By the aid of the bichloride of mercury and country air, all these symptoms disappeared in three weeks. Taking a summary of the five cases just detailed, we perceive that the primary disease in two of the num- ber was the simple chancre; in two, gonorrhoea with excoriation, and in the remaining one, balanitis, with possibly a simple chancre; although the presence of the latter must not be considered as at all necessary to the production of the constitutional disease which followed. The roseola made its appearance at the several periods of six, eight, nine, and seventeen weeks after the mani- festation of the primary disease. In case 10, the series of symptoms accompanying the roseola were, sordid skin, night perspirations, congested fauces; and, a week or two later, nocturnal neuralgia; and a similar series of pathognomonic symptoms were seen in 11, 12, and 13. In case 13 there is, moreover, at a later period of the disease, the additional symptom, an aphthous state of the mucous membrane of the mouth. The concurrence or immediate succession of the three typical forms of con- stitutional syphilis is also illustrated by these cases. In case 10, there were lichenous papules on the face at the same time with the roseola on the rest of the body. In case 13, a second attack of roseola was accompanied with SYPHILODERMA ROSEOLATUM. 87 lichen on the head and face. In case 11, a subsequent attack of eruption assumed the lichenous form, and in case 12 the tubercular character. These cases, also, taken at hazard, illustrate the sources of obscurity which attend the manifestation of syphilis, and the necessity for a thorough knowledge of the laws of the sj^philitic poison, to enable us to form a just diagnosis, and, consequently, adopt a sound treat- ment. In two out of the five cases there existed the complication of a morbid secondary action at the seat of the original sore, which might be mistaken for a new sore in the one case, and for an uncured primary sore in the other; both being, as I believe, the effects of the secondary poison. Thus in case 13, a month after the primary gonorrhoea and excoriation, there occurred a thickening and induration of the tissues of the part which had been excoriated; and soon after, the mucous membrane became abraded, and a superficial ulceration took place. At that time, the proper period for the manifestation of secondary disease, there was no other symptom of constitutional syphilis; but five weeks later, the period when a second crisis of the syphilitic poison might have been expected, a variety of roseola made its appearance, namely, roseola orbicularis: a similar order of symptoms was seen in case 14. In case 11, on the occurrence of the secondary symptoms, nine weeks after the commencement of the primary disease, the swelling of the prepuce returned, indicating a secondary action in the part. The case then became obscured by the exposure of the patient to a new source of contagion, and three weeks afterwards a superficial sore (secondary, as I believe) made its appearance on the prepuce. Five weeks later, the syphilitic crisis resumed its more re- cognizable character, of a cutaneous eruption. As I before remarked, these cases are important, as exhibiting 88 SYPHILITIC ERUPTIONS. the frequency of causes of obscurity, and the impos- sibility of forming a correct diagnosis without the most careful and ample consideration of all the features of the case. SYPHILODERMA PAPULATUM. LICHEN SYPHILITICUS. As an illustration of the mode of manifestation of the lichenous eruption, I will now narrate some cases, taken, as in the instance of roseola, without selection, from my note-book. Case 15.—A young man, a carpenter by trade, aged twenty, contracted gonorrhoea and a venereal sore in the month of January, 1845. The sore got well at the expiration of two months, without leaving any after- consequences. In February, 1846, he again became the subject of venereal sore, this time situated in the fossa glandis. He was treated with mercury, and the sore healed in six weeks. While under mercurial treatment, he was fre- quently exposed to cold, having, in the prosecution of his avocations, to pass from a warm workshop into the cold air during the prevalence of a north-easterly wind. In consequence of this exposure, he became affected, three weeks after the first appearance of the sore, with severe rheumatic pains in his shoulders and knees, and at the same time was visited by a papular eruption, which broke out, first on the face, and then on the arms, legs, front of the trunk, and back. He was in this state when he first came under my notice. The pimples offered some variety in point of SYPHILODERMA PAPULATUM. 89 size, those of medium bulk being about equal in magni- tude to a millet-seed. They were of a dull-red or purplish hue, and were collected into groups or clusters, varying in number from three or four to thirty (lichen corymbosus, Plate 1, G). The majority of the clusters contained ten or twelve of these pimples; and here and there a few solitary ones might be observed dispersed among the clusters. The patch of skin on which the clusters were placed was slightly raised, wrinkled, and of a dull-red hue. After a week of treatment the greater part of the pimples had subsided, and were each covered with a little, thin, brownish scale of desiccated epiderma; there was also an epidermal exfoliation from the altered skin which formed the ground of the patch. The patches had become brownish in hue, and contrasted strongly with the color of the adjacent skin, although the latter pre- sented the muddy and yellowish tint of syphilitic ca- chexia. Some few of the pimples, however, still lingered, and contained at their summits a whitish pus, and here and there a single fresh pimple showed itself. At the end of another week every pimple was gone, and the ground of the patches was undergoing a general exfoliation. The patient had no sore-throat throughout the whole course of the complaint; but, upon inspection, a slight congestion of the fauces was evident. He had no tumefaction or tenderness of the inguinal or other lymphatic glands; and the eruption, though somewhat tender on pressure, was unattended with pruritus. Case 16.—A young man, seventeen years of age, of delicate constitution, and inclined to scrofula, suffered, in May, 1848, from enlargement of a gland in the groin, the consequence of a sprain. In the month of June he had suspicious connection, 90 SYPHILITIC ERUPTIONS. which wTas followed in fourteen days by two small hard lumps on the corona glandis. These indurated pimples discharged a little ichorous fluid from their summits for about a week, and then became small indolent ulcers, which healed in the course of a month. A week after the healing of the sores, he had a somewhat plentiful growth of warts from the fossa coronae glandis and the inner surface of the prepuce. Between six and seven weeks after the first appear- ance of the chancres, he became affected with an erup- tion of pimples, which broke out upon his back and arms chiefly, some few being distributed over other parts of the body, and two or three upon the face. The eruption consisted of large, isolated pimples (lichen disseminatus, Plate 1, H), of a dull red color; they attained their full growth in the course of a few days, and then became filled at their summits, some with a turbid, sero-purulent fluid, and others with a whitish pus. On the occurrence of the eruption, he had no sore- throat, but several of the lymphatic glands became tender and enlarged. This was the case especially with the sub-occipital and cervical glands. The latter formed a tumor of large size on one side of the neck, and at a later period I was under the necessity of opening an abscess, and liberating about an ounce of pus. In the course of treatment, fresh crops of eruption came out from time to time, and he was troubled with pains in his shoulders, but not of a severe kind. He got well slowly with the aid of the bichloride of mercury, and it was not until after ten weeks that I was enabled to suspend his treatment. Between five and six weeks afterwards he again ap- peared before me, this time complaining of soreness of throat, pains in the shoulders, and increase of size of the cervical tumor. The fauces were congested, the tonsils SYPHILODERMA PAPULATUM. 91 being swollen and irregular, but there was no ulceration, and there was no reappearance of eruption on the skin. He attributed his present symptoms to exposure to cold. Case 17.—A gentleman, upwards of sixty years of age, observed, towards the latter end of January, 1847, a pimple on the prepuce. The pimple became inflamed and painful, but the inflammation was subdued by fomentation and water-dressing, and at the end of three or four weeks was to all appearance well. He had no affection of the glands in the groin, and he assured me . that he had had no connection of any kind for many years. Being a man of influence and rank, I did not venture to ask him how, in that case, he had succeeded in obtaining a syphilitic sore ? A fortnight after the healing of the sore, that is, about six weeks from its first appearance, he discovered acci- dentally, while dressing, an eruption of dull-red spots on the front of his chest and abdomen. For this eruption he took medicine, but finding that the spots remained, and that others began to be perceptible on his arms and legs, he became alarmed, and applied to me, the eruption having by this time been in existence about two months. I found him very much depressed in spirits; his tongue loaded with a dirty-white sordes; the fauces of a dull-red color, and congested; he was restless, and perspired much at night; his skin was muddy, and of a yellowish-brown color. He complained of being unable to get his skin clean, although he had taken a warm bath repeatedly, and was in the habit of doing so. The skin presented a curious combination of roseola and lichen: in one place there were a number of dull-red spots congregated together, and forming a blotch, without any elevation, roseola; in another, the red spots were 92 SYPHILITIC ERUPTIONS. represented by decided pimples, arranged in clusters of various dimensions, lichen corymbosus; and in a third, there were separate pimples, of somewhat larger size than those composing the clusters, lichen disseminatus. The pimples on the forehead and face, of which there were ten or twelve, were of the latter character. I prescribed for this gentleman an aperient, to be taken every other night for a week, and a pill composed of five grains of blue pill, and one-twelfth of a grain of muriate of morphia, night and morning. A change for the better was soon apparent, both in the condition of the skin and in the patient's feelings, and on the twenty-first day of. treatment, when he had taken forty-two pills, and had become aware of a metallic taste upon his tongue, and the margin of the gums was marked with the red line characteristic of the action of mercury on the mucous membrane of the mouth, the mercurial treatment was stopped, and the iodide of potassium and decoction Of sarsaparilla treatment commenced. The eruption at this time was scarcely discoverable, and the induration left by the sore on the prepuce was entirely gone. This gentleman had no return of secondary symptoms. Case 18.—An Italian gentleman contracted a venereal sore in the month of November, 1849. The sore was trifling, and healed in twenty days with the aid of a simple ointment. He took no mercury. About the middle of April, 1850, namely, five months after the appearance of the primary sore, he felt a little unwell, and experienced a sensation of stiffness in the skin of his head and neck. These symptoms were immediately followed by a lichenous eruption. He had no sore-throat, and only a slight degree of feverishness. Six weeks after the outbreak of the eruption he first came under my notice; he was then covered with a SYPHILODERMA PAPULATUM. 93 multitude of small syphilitic papules, and afforded a good example of lichen conferlus (Plate 1, I). Almost every pore on his arms and trunk was raised into a small conical pimple, and the eruption presented a deeper tint than usual, from occurring in a person of dark complexion. On the face, the pimples were not so distinct; the entire skin appeared to be swollen, par- ticularly about the eyes and forehead, and upon the latter there were several round and oblong blotches slightly raised above the level of the skin, and upon which the congested pores were very evident. This appearance afforded a good illustration of the transition of the dis- tinct papules of lichen into those larger prominences which are known as tubercles, and the case was one in which the tubercles and papules of syphilis are found in the same person. At this period, although he had no feeling of soreness in the throat, the fauces were congested, and he com- plained of the rapid loss of his hair. Five weeks afterwards, the eruption was much im- proved, but he suffered an attack of syphilitic iritis. In reviewing the four preceding cases, we are naturally led to search for some explanation of the cir- cumstance of the syphilitic poison manifesting itself in the form of the raised eruption of lichen, instead of the merely congestive exanthem, roseola. The primary disease was of the most simple kind in all; a mere superficial sore in cases 15 and 18, two small indolent indurated ulcers in case 16, and a mere tubercle abraded on the summit in case 17. The period of outbreak of the eruption exhibits more irregularity than roseola and a minor degree of severity of febrile symptoms. In case 15, the eruption occurred three weeks after the first appearance of the primary disease, and while the latter was in full activity; in case 16, between two and three w= 94 SYPHILITIC ERUPTIONS. weeks after the cure of the primary disease, and five weeks after its first outbreak; in case 17, three weeks after the cure of the primary disease, and six weeks from its first appearance; while in case 18, the eruption did not occur until four months after the cure of the primary disease. The occurrence of the eruption in case 15, previously to the cure of the primary disease, seems explained by the fact of the patient being a young man of delicate constitution, and exposed to the cold while under the influence of mercury. Perhaps the same conditions may be sufficient to explain the eruption being lichenous instead of roseolous. In case 16, the subject was a deli- cate young man, predisposed to scrofulous disease, and exhibiting a pyogenic disposition, as was shown by the suppuration of some of the papules, and the formation of a large abscess in the neck. Case 17 hardly comes into the same category with the preceding, since the eruption was a mixture of roseola and lichen; but I think it more than probable, that if mercury had been ad- ministered earlier, the eruption would have been checked before it had reached the lichenous stage. Case 18 is very remarkable from the long period which intervened between the cure of the primary disease and the consti- tutional symptoms; the case was unalloyed by mercurial treatment. I am not prepared to say that the secondary disease would not have occurred if mercury had been given at first; but I believe that the iritis might have been prevented if mercury had been exhibited for the secondary symptoms. 95 SYPHILODERMA TUBERCULATUM. TUBERCULA SYPHILITICA. The tubercular eruption differs from lichen only in the size of the little elevations which give it its specific character. In lichen, they are mere pimples, averaging from half a line to a line in diameter, and representing the immediate circumference of one of the pores of the skin. Tubercles, on the other hand, have a minimum size greater than that of the pimples of lichen, the smallest measuring upwards of a line in diameter, while some that I have observed had a diameter of three- quarters of an inch, and even more. They include many pores and often a considerable portion of the skin. In other, and essential respects there is less difference between them: both result from the action of the syphi- litic poison in the skin; both may be mere transforma- tions of roseola. I have already adduced examples of the transition of roseola into lichen, and roseola into tubercula; and the conversion of lichen into tubercula is by no means uncommon. Tubercles present some differences among themselves, in respect to color, form, density, and elevation; and they also differ in the manner of their growth and arrangement. In point of color, they are sometimes of a yellowish-red color, sometimes of that deeper hue which is known as "copper-colored," and sometimes purplish and brownish. In form, they are round, oval, or oblong, in the latter case being frequently crescentic in shape. In density, they are sometimes soft and flabby to the touch, at other times firmer, but never hard ; and as regards elevation, they rarely exceed one 96 SYPHILITIC ERUPTIONS. or two lines, but are sometimes almost flat. In «rowth, they sometimes spread in irregular rings; and some- times the separate tubercles have a tendency to assume the annular character; in one case the annular disposi- tion being limited to a mere central depression (cupped tubercles), and in another, extending to a perfect ring of considerable size. The color of syphilitic eruptions is often referred to as a pathognomonic character, and it is quite true that they present in general a remarkable dulness of hue, such as would result from an admixture of brown, in various proportions, with the three primary colors, red, blue, and yellow. The early stage of development of the eruption is that which possesses the greatest amount of red; in its second stage, and even in the primary, when developed in a languid constitution, the slower circulation of the blood through the capillaries, and the consequent carbonization of the blood, gives a bluish tint to the color; in other words, forms a shade of the secondary color, purple. In a third stage of the erup- tion, when the vascularity is subsiding, and renders visible the staining effects of the yellow element of the blood upon the tissues of the skin, the color approaches towards the secondary orange, or with less red,, becomes a grayish yellow. So that the same eruption, seen at different periods, may be a red of greater or less dulness, a purplish red, or a yellowish red ; and the same differ- ences of color may be distinguished in different individ- uals from the beginning of the eruption. The color brown is called a neutral color, that is, it is neither red, blue, nor yellow; but at the same time a compound of the three. Hence the dirty hue of the skin in syphilitic cachexia is the result of the mal-com- position of the blood, and consequently, of the secretions; the excess of blue is probably occasioned by the pre- SYPHILODERMA TUBERCULATUM. 97 sence of a surplus quantity of carbon ; and the yellow, by a surplus of the pigmentary principle which gives color to the serum, the urine, and the bile. The admix- ture of this brown color with the red and purple of com- mon vascular congestion produces the dull or dirty red and purple above spoken of; and in like manner, the bright, or rather clear, yellow stain of an ordinary bruise would become a dull or dirty yellow by a similar admix- ture. In making these remarks, I am supposing the red to be the archaeus or predominating color; the eruption is primarily red, the red having a blending with blue on the one hand, and yellow on the other, but in both instances being rendered dull by the presence of brown. We have now to consider a series of tints in which the neutral ad- mixture brown predominates. The brown may have an excess of blue in its composition, and be a dark brown; it may have an excess of red, and be a red brown; or it may possess an admixture of yellow in different propor- tions, and be an orange brown or a yellow brown. Now, of all these separate tints, the red brown with a slight admixture of yellow is that which most nearly ap- proaches the hue of dull copper, and is therefore the type of the "copper-colored" eruption; the so-called copper color being, in fact, a reddish yellow brown (Plate 1, E). I have felt the necessity of giving this explanation of the precise meaning of "copper color," from having observed that medical men were not agreed as to the color to which this name should be applied, and conse- quently, that it was liable to be employed more loosely than is consistent with scientific accuracy. The copper color represents, in fact, a declining stage of the erup- tion when the congestion is subsiding, and the yellow stain of the altered fluids of the skin shines through the 7 J- 98 SYPHILITIC ERUPTIONS. purple of the blood. The "copper color," therefore, may have a greater or less amount of red or yellow in its composition, and be either a reddish copper color or a yellowish copper color. As the copper color represents only a stage of an eruption, that eruption having probably passed through the tints of dull-red, and dull purplish-red, before it reached the reddish-yellow brown of copper color, it is clear that the term is objectionable when taken as a pathognomonic sign of a syphilitic eruption. For if we see the eruption at any other period than that of its decline, the characteristic tint is absent. In the loose manner of using the term "copper- colored" above referred to, I have frequently heard the dull purplish red, the muddy red, and the yellowish red, designated by that term. These colors, however, are by no means pathognomonic of the syphilitic eruptions; they are commonly met with in chronic eruptions of other kinds; for example, in acne. Any one looking upon a case of indurated and chronic acne, associated, as is commonly the case where the eruption depends upon mal-assimilation, with a sallow and muddy skin, must be struck with the close resemblance of such an eruption to one of syphilitic origin. Indeed, I have often seen non-syphilitic eruptions possessing more of the dull and muddy hue which is generally supposed to be characteristic of syphilis, than syphilitic eruptions themselves; and in selecting undoubted syphilitic erup- tions in their earliest and best developed stage for illus- tration in my " Portraits of Diseases of the Skin," I have sometimes felt a regret that there was not more of the coppery hue present. But to have obtained this " copper color" I must have waited until the eruption was in its decline. The color of eruptions of the skin must not, therefore, TUBERCULA CORYMBOSA. 99 be relied on as proof of their syphilitic nature, although it may be fairly taken as a pathognomonic character where other symptoms tending to the same diagnosis are found to be present. TUBERCULA CORYMBOSA. SYPHILODERMA TUBERCULATUM CORYMBOSUM. The tubercular eruption which I have distinguished by the name of corymbose (Plate 2, L M), presents seve- ral points of resemblance with lichen corymbosus. The tubercles are collected in groups, having more or less of an annular disposition; they come out generally over the body ; and they seem to be the effect of a general constitutional impulse. The following case will illus- trate the usual characters of the eruption. Case 19.—A young man, of delicate constitution, aged twenty-one, employed in an occupation entailing constant confinement in a hot workshop, contracted a venereal sore two years and a half before coming under my care for his present complaint. The sore was not long in getting well, and he assured me that he had had nothing of the kind since. Subsequently to the cure of the primary affection, he has been liable to occa- sional sore-throat; on one occasion, eighteen months after the primary disease, he states that the throat was in a state of ulceration, and he was so ill as to be obliged to keep his bed for six weeks. Since that attack he remained well for a period of nine months, when, in the month of October, he became accidentally exposed for many hours to a drenching rain. He felt thoroughly chilled by this exposure, and two days afterwards was 100 SYPHILITIC ERUPTIONS. seized with sore-throat, and the present eruption. He complained also of rheumatic pains in his joints and limbs, and of copious perspirations. The eruption made its first appearance in patches on the arms, and thence extended by degrees to the entire surface of the skin. It consisted of soft, yellowish-red tubercles, with rounded summits, and but little raised above the level of the skin. The average size of the tubercles was one line and a half; when isolated they measured two lines, and there were some which reached four lines in diameter. They were dispersed irregularly over the surface of the skin, and had a general distribu- tion in patches of various size and form; in some situa- tions the patches being as large as the palm of the hand; in others, small, and scattered between the former. On a close examination it became apparent that there was a prevailing disposition on the part of the tubercles to form circles or rings, and this character was discernible even in the large patches, which seemed to be composed of a number of rings confusedly clustered together. The rings varied much in size, some having a mere central de- pression (Plate 2, N), and measuring scarcely more than a quarter of an inch in diameter, while others had an ample area and measured from an inch to an inch and a half (M). The tubercles presented some differences of appearance common to these eruptions during the pro- gress of the disease. In the first instance, while the congestion was active, they were bright in color and perfectly smooth on the surface; when the congestion was on the decline, they lost their brightness of hue, and looked faded and shrunk, the epiderma covering them having become opaque and wrinkled. Later still, the epiderma became dry, cracked around the circum- ference of each tubercle, and peeled off, leaving a fringe around their bases, and sometimes a small scale, the TUBERCULA CORYMBOSA. 101 last remains of the exfoliating cuticle, on their sum- mits. When the tubercles subsided altogether, leaving behind them brown stains, the skin presented a very remarkable appearance. The stains formed a number of brown rings, edged on each side with a narrow mar- gin of cuticle, and inclosing a centre of natural skin. In this state the eruption would pass very well among the inexperienced for a declining lepra, and the broken laminae of desquamating epiderma suggest a motive for considering it a squamous affection. Case 20.—In the autumn of 1846,1 was consulted by an unmarried lady, aged twenty-five, who came to me, accompanied by her mother, for an eruption that covered the greater part of her skin. She bore all the signs of the syphilitic cachexia; her skin was muddy and discolored, her conjunctiva dirty and anaemic, and eyes dull and inexpressive; she had, besides, sore-throat, enlarged and tender sub-maxillary, sub-occipital, and post-cervical glands, and in answer to my questions com- plained of having suffered pains in her head and face, afid also in her shoulders. On examining the skin, I found the remains of a tubercular eruption: there were tubercles in a state of subsidence, but still preserving their annular arrange- ment; rings of brown-tinted skin, from which the epi- derma had exfoliated, and along the edges of which were the upturned fringes of cuticle, and confusedly desqua- mating patches, in which the circular tracery of the original rings was scarcely perceptible. On the nape of the neck were five or six circles very distinct; and on the face were scattered several small purplish, dirty- looking tubercles. The latter were situated in the fossae under the alse of the nose, at the angles of the mouth, and upon the forehead. 102 SYPHILITIC ERUPTIONS. On the mucous surface of the commissures of the mouth, and on the internal surface of the lips, were several of those superficial ulcerations which result from aphthae. The fauces were congested and of a darkish- red hue, and the tonsils were inflamed, and very irregular in shape, from the destruction of surface caused by previously existing ulceration. Her voice was hoarse and guttural. She informed me, also, that she suffered from soreness of the vulva, with vaginal discharge; and from her own account, I concluded that she had had a crop of aphthae in that region, as well as in the mouth. The history which this young lady gave of herself was, that twelve months previously to her present illness, she had been greatly reduced by a fever, and had been sent to the sea-side to recover her health. In the sum- mer following her return she was one of a country party, and in the frolics of their day's gayety she had sat for some time on the grass, and found on her way home that she was suffering from the effects of a chill. A few days after this adventure she was attacked with sore- throat, which was so severe as to oblige her to keep her bed; and a month later the eruption first broke out. These, in artistic phrase, are broad outlines, which leave much to be filled in by the imagination, and the medical imagination will not fail to do justice to the picture. The first of the above cases is remarkable for the length of time intervening between contagion and the manifestation of the disease in the skin. The young man had had repeated attacks of sore-throat; but this was the first appearance of eruption under which he had suffered. The last of his sore-throats occurred nine months previously to his present illness, and he would probably have escaped without any further annoyance from the poison, but for the chill occasioned by his TUBERCULA CORYMBOSA. 103 exposure to rain. The syphilitic poison, having been so long in his system, had become modified, and assumed the properties-of the secondary poison; hence its action » on the skin presented the form which is most common when the virus has been long established in the system, or when the source of the disease is the secondary poison. In the case of the young lady, there is every pro- bability that the poison was of secondary origin, there having been no symptoms of primary disease; and the t violence of the attack of syphilitic disease may be attri- buted, like the preceding, to the effects of cold. I may adduce another example of this eruption, also proceed- ing from the secondary poison, but remarkable for its severity, in which the exciting cause was also a wetting- through and cold. It is the case which I have already taken as an illustration of the occasional violence of local congestions. Case 21.—A man, aged fifty, had doubtful connection in the beginning of December: in January, he had an outburst of roseola, preceded by severe congestion of the lungs. The roseolous rash continued to maintain its position on the skin for five months, namely, until the end of June, without change, and in spite of all the remedies prescribed for him by the several medical practitioners whom he consulted; when suddenly, and as he conceived in consequence of the action of the medicine he was taking at the time, or of a warm bath, the red efflorescence rose above the level of the skin, assuming a tuberculous character, and for the first time showed itself upon the face. » On his first appearance before me, namely, in the middle of July, I found his face deformed by a tubercular eruption, of a dusky-red hue. On parts of the face, and particularly on the exposed portions of the neck, the 104 SYPHILITIC ERUPTIONS. eruption consisted of distinct rounded tubercles, of large size. On other parts of the face, the tubercles had the form of oblong mounds, more or less curved, and again, in other situations, formed complete circles (Plate 2, M, N). On the forehead, the tubercles appeared to have become blended together, so as to constitute one single tuberous mass, of irregular shape, which extended across the brow, from one temple to the other. This mass was of a dusky-red color, with a tinge of yellow, which gave it a coppery hue, and there was a seeming transparency about it, which made it resemble brawn, or a portion of coarse and thickened skin, in a state of oedema, from infiltration of a yellow serum. To the touch, however, the swelling was hard, and evidently occasioned by a thickening of the skin, and not by the infiltration of fluid. The trunk as far as the waist, and the arms, were covered with the eruption, the tubercles being more or less developed, and the corymbi more or less annular. In certain situations the tubercles were less fully formed, and appeared to be made up of a number of papulae, a very little larger than those of common lichen; and many of these smaller pimples, of a dirty hue, were scat- tered amidst the patches of eruption, or grouped around the clusters of tubercles. On the lower limbs and lower half of the trunk of the body the clusters of tubercles had subsided to the level of the skin, forming so many darkish-red, or brownish stains (maculae) of a circular form. Many of these maculae were sprinkled over with the dark remains of the papules, or with the deeper-colored spots, which indicated the pores of the follicles. The maculae were, for the most part, dark in the centre, fading away gradually to the circumference, and in some situations had the appearance of the stains of a bruise. TUBERCULA CIRCUMSCRIPTA. 105 The general surface of the skin was dry, sordid, and discolored, and presented the character so frequently met with in cutaneous syphilis. He had some degree of hoarseness, which had remained since his attack of pulmonary congestion, but felt no soreness of the throat, and I could discover no indication of ulceration, either present or past. He had, besides, an excess of pulmonary secretion, and an unusual discharge of mucus from the pituitary membrane, the sequel of a catarrh which accompanied his first seizure. TUBERCULA CIRCUMSCRIPTA. SYPHILODERMA TUBERCULATUM CIRCUMSCRIPTUM. The term corymbose, or clustered, is intended to be applied, as in the case of lichen corymbosus, to those eruptions which have a tendency to make their appear- ance in groups or clusters, and at the same time to occur upon a considerable extent of the surface of the body. The eruption is essentially general in its distribution, and acute. There is, however, a kind of eruption which may represent a chronic and local form of tubercula corymbosa. It occurs in patches, varying in size from that of a crown-piece to a foot or more in diameter; the patches may be six or eight in number, or perfectly solitary; they consist of a confused assemblage of tuber- cles, among which there is an obvious tendency to assume a circular arrangement; and they are always exactly bounded by a line of tubercles, the line being either circular as regards the entire patch, or as regards smaller divisions of the patch. The circumscribed cha- racter of the patches, and the entire freedom of every other part of the skin from eruption, suggested the title 106 SYP'HILITIC ERUPTIONS. by which I have distinguished this form of syphilitic eruption, tubercula circumscripta (Plate 2, 0, P). The following cases will illustrate its characters more com- pletely. Case 22.—A young man, aged twenty-six years, had a venereal sore of the size of a fourpenny-piece, on the prepuce, six months before marriage. The sore made its appearance three or four days after connection, and was accompanied, at the end of another period of four or five days, by bubo in both groins; the latter not pro- ceeding to suppuration. In the month of March, 1848, four years after mar- riage, he had connection with a maid-servant, whom he did not suspect of disease. No apparent disorder of the genital organs resulted from this concurrence; but in the same month a patch of tubercula circumscripta, of the size of two hands, made its appearance on his left flank. Three months later, three other patches of smaller size appeared on his thighs; and at the end of another three months, three similar patches broke out on the chest and right side of the abdomen. He has had no sore-throat, and his wife has never suffered from syphilitic disease of any kind. On his application to me, in the month of December, 1848, he had a large patch of eruption on the left flank, several smaller patches on the chest (Plate 2, 0), and right side of the abdomen, and several on the thighs. The large patch, which measured nearly eight inches square, and covered almost the whole of the left side of the ab- domen, consisted, as did the others, of numerous dull-red tubercles, having an average measurement of two lines in diameter, dispersed, apparently without order, upon a ground of a dirty-brown hue, and bounded by an irregu- lar and slightly raised margin. In several places on the TUBERCULA circumscripta. 107 patch the tubercles had a circular arrangement, and formed rings more or less complete. The smaller patches were about two inches in diame- ter; they consisted of an irregular ring, formed by a slightly elevated, reddish margin, inclosing an area of a yellowish-brown color, over which the eruption had crept. Within this area the epiderma was somewhat more wrinkled than that of the surrounding skin; and in the greater number of the patches there were scattered here and there one or two tubercles, which remained in a chronic state, while the rest had disappeared. In their irregularly circular form and marginate character, these patches bear a near resemblance to lepra and psoriasis in the state of retreat; even the scattered tubercles within the circles are met with in psoriasis. But there are certain strongly distinguishing characters between the squamous disease and the leproid form of cutaneous syphilis, namely, the coppery, or dull-red color of the latter, the yellow-brown stain which they leave behind on the skin, after their decline; the softness of the syphilitic tubercles, as compared with those of psoriasis, and, lastly and chiefly, the total absence of squamae. In old syphilitic tubercles, the epiderma may frequently be seen in a state of exfoliation; but the thin, ragged films of exfoliating epiderma peeling from their summits are easily distinguished from the thick, circular morbifically elaborated scales of true squamous disease. Moreover, in a syphilitic patch of the kind I am now describing, the cuticle may generally be traced unbroken, from margin, to margin, over the whole surface of the diseased skin. If the large syphilitic patches (two inches in diameter) be examined carefully, and at various stages, with re- ference to their mode of development, they will be found to originate in simple tubercles, disposed in irregular circles of four, five, or six. The skin included within. 108 SYPHILITIC ERUPTIONS. and between these tubercles partakes of the morbid ac- tion; the tubercles become fused at several points, form- ing an elevated margin; and the margin extends by its outer lip, and increases the area within. In this way a number of small rings, measuring about half an inch in diameter, and creeping onwards by their circumference, become blended so as to form a single patch. The on- ward growth is then taken up by the peripheral margin of the collective patch (hence its irregular outline, and its obvious composition of segments of small circles), the tubercles and margins left within the greater margin subside more or less completely, by virtue of a tendency on the part of the disease to cease on the exhausted ground, and prey upon the juices of the neighboring un- tainted soil; and, after a time, nothing of the original elements of the disease remains—all is lost but the slightly elevated reddish margin, and its sombre leaf- brown area. In the above case the question suggests itself, whether the attack of constitutional syphilis, as indicated by the eruption, resulted from a secondary poison imbibed from the servant-maid two or three weeks before ? or whether the young man's constitution was already contaminated by the poison admitted into his system more than four years previously, and was now only stimulated to the expulsive point, by the reception of a new poison ? I am satisfied that the latter is the true explanation, and without seeking for other evidence in support of this opinion, I will simply remark that the eruption was of the chronic kind, such as only occurs in general when the poison has been long in the blood and in the system. This case is remarkable for the number of patches of eruption which were developed on the skin; commonly, there are not more than one or two: in the following TUBERCULA CIRCUMSCRIPTA. 109 there was only one, the poison which gave rise to it having been in the system about two years. Case 23.—A healthy-looking woman consulted me in June, 1851, for a large and bright copper-colored patch of redness which occupied the forehead and cheek on one side of her face; she had, besides, several incrusted tubercles on the scalp. The color of the patch was strikingly characteristic of syphilitic cutaneous disease; the affected skin was indented by numerous shallow pits left by the subsidence of the tubercles of which it was originally composed, and was marked by the ramifica- tions of a number of enlarged venules. Near the lower margin of the patch, a group of tubercles still remained and seemed disposed to extend their line upon the ad- jacent healthy skin; they were of a bright copper-red hue, smooth, and soft to the touch. The pits left by the tubercles which had subsided were of a deeper red than the general surface of the patch. Her history was as follows: she was 33 years of age; had been married fifteen years: and had had eight children and one miscarriage. Seven of the children were living; one died at the age of two years, and the miscarriage occurred at the fifth month. Her last child was two years and a half old, very delicate; has suffered from inflammation of the lungs, and has had an abscess in one of the cervical lymphatic glands; in brief, is laboring under the syphilitic infection, and will probably die. A year and a half since she felt ill and dispirited, and suffered very much from pains in the head, which were worse at night, and prevented her from sleeping. These pains continued for six months, but suddenly ceased on the appearance of an eruption of tubercles on the fore- head and face. The tubercles, few in number in the 110 SYPHILITIC ERUPTIONS. first instance, increased by degrees, and constituted the .large patch now existing on her face. The patch, there- fore, is of twelve months' duration. She does not remember having had sore-throat; she has none at present; nor has she pains nor any illness whatever. She considers herself to be in perfect health. She has never had any other affection of the generative organs than leucorrhoea, and from this she was suffering at the period of her illness, eighteen months back. Her husband, she says, is a healthy man, but has been away from her until the last two or three years. She is not aware that he ever suffered from any venereal affection; but during the last winter, he had a severe attack of " rheumatic fever." Now, in the case of this poor woman, the poison by which she was infected was secondary, that is, it had existed for a long period in the blood of her husband, where it had become modified, deprived of its more irritant qualities; in a word, assimilated. It had lost its power of exciting local disease, but it was still power- ful for the production of an action similar to that which had been impressed upon itself in the blood of another. Conveyed in the secretions of the genital organs of the husband to the vagina of the wife, it was incapable of exciting any ulcerative action, but it was prone to absorption, and was ready to pass freely through the mucous membrane, and into the blood of the recipient. If any local disease occurred, it was a blennorrhoea of the mildest type. Had the mucous membrane been abraded, I am of opinion that the result would have been the same; there would have been no local irritation, but the poison, so diluted and so modified, would have passed into the abraded tissues without leaving a trace of its passage. Even had the poison in this state been inoculated, it might have infected the constitution of the TUBERCULA CIRCUMSCRIPTA. Ill inoculated person, but it could not have produced a pustule or an ulcer. Subtle and apparently harmless in its nature, it is nevertheless capable of setting up constitutional actions, more serious than the envenomed secretion of the primary sore, the chancre. We see the infant born after this congress, the death-marked victim of its fatal influence; a miserable example of syphilitic glandular abscess, and syphilitic pneumonia. In tracing the history of this patient, I have noted two observations by italics, namely, " pits" and " enlarged venules ;" both are characteristic of the chronic form of syphilitic tubercular eruption on the skin. The tuber- cles seem to possess often the power of disorganizing the structure of the skin completely, without suppuration, and without ulceration; hence when they disappear, they seem to be absorbed, and with them that portion of the skin which they had assimilated to their own structure, and they leave behind them deep and per- manent pits; and where they are of large size and extent, strongly marked cicatrices. As I advance, I shall have frequent occasion to direct the attention of my readers to this circumstance; and I shall have to fall back upon the observation, in my remarks upon hereditary syphilis. The " enlarged venules" is another striking peculiarity of chronic cutaneous syphilis; the copper-colored patches appear to owe a part of their color to numerous mean- dering venules, derived from a magnified capillary plexus which is apparent to the eye. Sometimes the observation of the enlarged venules is aided by the state of the skin referred to in the preceding paragraph; it seems dis- organized, converted into a transparent body, gelatinized, and its transparency permits the view of the vessels ramifying through its texture. This observation, like the preceding, is an important aid to the diagnosis of 112 SYPHILITIC ERUPTIONS. hereditary syphilis, is a glimmering of truth in the midst of obscurity. The following case is interesting, as being the pure manifestation of the existence of the syphilitic poison in the system, unmodified by medical treatment, and after a lapse of five years. Case 24.—A fine healthy young man, aged 26, a fireman in the London Fire Brigade, and unmarried, contracted a venereal sore for the first and only time in the winter of 1845. The sore did not exceed the size of a split pea, and was accompanied by a blind bubo. He went into a naval hospital and was kept on low diet; took no mercury; and the sore was well at the end of seven weeks. Five years afterwards, he first became the subject of constitutional disease, which was manifested in the skin. He had had no sore-throat, and no pains in the limbs. The form of cutaneous eruption in this case was the syphiloderma tuberculatum circumscriptum; of which he had three patches, one of small size on the arm; one as large as the palm of the hand on the hip ; and one as large as the entire hand on the opposite hip. He stated that the eruption appeared first on the arm in the month of February, 1850; and that the patches on the hips followed subsequently. The eruption on the skin had been seven months in existence on his first application to me. In another well-marked example of the circumscribed form of tubercular eruption, proceeding from secondary poison, the period at which it occurred after contagion was eight years. Case 25.—A delicate-looking woman, 33 years of age, TUBERCULA CIRCUMSCRIPTA. 113 and married ten years, consulted me in May, 1850, for a large patch of tubercular syphilis (Plate 2, P), which occupied her shoulder, this being the only spot of erup- tion she had. It began, she informed me, six months ago, as a mere pimple, which increased by degrees to the size of a split pea. A month back another pimple ap- peared, and both began to spread out and assume a circular form; then one or two tubercles rose up between the rings and connected them, and the whole together formed a patch as large as a hand. The annular character of the patch was well marked, the boundary being formed by a broken line of confluent tubercles, flattened and surmounted by a thin covering of dry and desquamating epiderma. There were also several tuber- cles with desquamating summits sprinkled within the areae of the rings. The area included by the rings pre- sented a reddish-brown tint; and the tubercles, as they declined, left behind them a brown stain, and a shallow pit. She has one child, aged nine years, and she miscarried at the sixth or seventh week, seven years back, the miscarriage having been accompanied with inflammation of the womb from too early exposure to cold. Three or four years since, she had a patch of eruption similar to that under which she is now suffering, in the sacral region. It lasted twelve months, and went away of itself. She has suffered from that time until the pre- sent with frequent falling of the hair. She has never had sore-throat, pains in the limbs, or any affection of the genital organs. Her husband, she says, is consumptive, and has been subject, from time to time, to discharge from the urethra. He had a discharge of this kind about two years after her marriage. The term "consumptive," used by a wife 8 f4 114 SYPHILITIC ERUPTIONS. to explain a delicacy of constitution on the part of her husband, as in this case, suggests a reflection full of in- terest. Might not the term " poisoned with syphilis," or "saturated with syphilis," more correctly express his real state ? I did not see the husband, and therefore I cannot speak with regard to him. But I have seen numerous instances of disease of the lungs, and, indeed, of various of the organs of the body which have been in reality syphilitic, the simple manifestation of the syphi- litic cachexia. TUBERCULA DISSEMINATA. SYPHILODERMA TUBERCULATUM DISSEMINATUM. Instead of being clustered in their arrangement, as in the preceding forms, syphilitic tubercles sometimes take on the character of a disseminated eruption (Plate 2, Q). The tubercles in this case are larger than those of the clustered eruption, perfectly round, and but little elevated above the surface of the skin; in their appear- ance and elevation suggesting an appellation by which I once distinguished them, namely, tubercula lentiformia. In point of measured size, the medium diameter of the disseminated tubercles may be roughly stated to be four lines, and that of the clustered tubercles two lines and a half. The disseminated eruption is probably somewhat less acute in its constitutional symptoms than the corym- bose kind, but considerably more acute than the syphi- loderma tuberculatum circumscriptum, which may be considered a chronic eruption. The following case af- fords a good illustration of the syphiloderma tubercula- tum disseminatum. TUBERCULA DISSEMINATA. 115 Case 26.—A single woman, aged twenty-two, applied to me for an eruption of tubercles, which covered her face and neck, the upper part of the back, and the arms. The eruption was confined to these regions, and was most abundant on the face, the head, and the back; on the arms there were only a few isolated spots. She informed me that the eruption appeared first on her forehead, next on the face and head, and that by degrees it seemed to spread downwards. She observed at the time of the outbreak of the disorder, that her skin became remarkably discolored, and that all her efforts failed in removing what she considered to be a yellowish brown dirt from its surface. She perspired a good deal at night, was restless and depressed in spirits, and felt ill, without being able to explain the cause of her illness. After the eruption had been out for the space of a month, she began to complain of soreness of the throat, and it was at this time that I first saw her. The throat was of a dark-red color, the mucous mem- brane and tonsils were swollen and congested, but there was no ulceration. There was also some enlargement of the sub-maxillary and sub-lingual glands, and the sub- occipital and cervical glands were swollen and tender. Her face presented a very remarkable appearance; it was suffused with a yellowish brown pigment, swollen, particularly in the regions of the eyes, nose, and mouth, and studded over with the perfectly circular, isolated, and lentil-shaped elevations of tubercular syphilis. There were several of these tubercles on the upper eye- lid near its margin, several at the angle of the eye, a considerable number by the side of and at the aperture of the nose, five or six at each angle of the mouth, and some upon the ears. On the forehead they formed a complete corona veneris; they were of a dull red, almost livid color, for the most part smooth and of pretty uni- *J 116 SYPHILITIC ERUPTIONS. form size—namely, a quarter of an inch in diameter. At the angles of the mouth were one or twro fissures produced by the escape of the saliva, and these were covered with slight incrustations. On the neck the tubercles were less numerous, but a little more prominent and larger, one or two measuring more than half an inch in diameter. In this region the cuticle covering them was dry and corrugated, and in some few instances exfoliation had commenced. On the back of the neck, and between the shoulders, were about fifty tubercles, for the most part isolated; some few, however, were grouped in pairs, and in two instances, a pair had become blended together. They were all exactly circular, and more prominent than those of the neck; but the most prominent, even here, mea- sured only three-quarters of a line in elevation. In breadth, the extremes of measurement ranged between one line and six (half an inch), the size of the greater number was five lines; the next common size measured two lines and a half; while below these, were a number of smaller papules scattered among the rest, and repre- senting either the common papules of syphilitic lichen, or the early stage of growth of the tubercles. As on the neck, the developed tubercles presented every degree of completion and decadence; some were smooth, others wrinkled, others beginning to desquamate, and in others, desquamation had advanced some stages. In my observations on this case, I have remarked that the tubercles are exactly circular in form, varying in size from one-quarter to three-quarters of an inch in diameter, very slightly raised above the level of the adjacent skin, evenly convex on the surface, and subsid- ing gradually from the centre to the circumference, which merges insensibly into the surrounding skin. In point of elevation and form, they have very much the appear- TUBERCULA DISSEMINATA. 117 ance of split lentils laid upon the skin, only that they are much broader. Their color varies from a bright coppery red to a dull, dirty crimson. Their epidermal covering varies with their stage of growth ; in the first instance, when the tubercles are tumid, the cuticle is smooth, and they have a polished appearance; later, when the congestion of their vessels diminishes, the cuti- cle is wrinkled ; and later still, the cuticle becomes loosened from their surface, cracks, and separates. Sometimes, but rarely, they pass into a state of ulcer- ation, the ulcer commencing on the summit of the convexity. The manner in which the exfoliation of cuticle com- monly takes place from the surface of the tubercles is the following : the cuticle cracks in a circular direction, just within the boundary of the elevation, and then se- parates gradually from the surface beneath; the central piece separating towards the centre of the convexity; the peripheral piece separating towards the sound skin, and forming a kind of frill around its margin. A crop of tubercles may sometimes be seen presenting every gradation of this process of desquamation at the same moment. There are some in which the crack has just taken place; others, in which the edge of the central piece has been worn away, and has become reduced to a small disk, occupying only the cen- tral part of the convexity; others, in which the central piece is entirely gone; some, in which the peripheral portion is distinct; others in which it is partly, and others again in which it is wholly, removed. The tubercle may now be left quite smooth, or secondary exfoliations may commence. The latter, however, are for the most part irregular and partial, and are not to be confounded with the primary exfoliation now de- scribed. When ulceration occurs, a crust is formed on J 118 SYPHILITIC ERUPTIONS. the ulcerated surface; and, in proportion to the quantity of pus secreted by the ulcer, or the care with which it is kept, the crust may become very thick, or be a mere scale. The case (7, page 49) which I have already related as an example of serious constitutional effects resulting from the secondary poison, and noted as one of idiosyn- crasy, presented the disseminated tubercular eruption on the back, while on the face and shoulders the eruption was lichenous. In my description of this case, I re- mark : The pimples on the face were of the usual yel- lowish-red, or copper color, which accompanies the syphilitic cachexia; they were large, prominent, and smooth, measuring about one line in breadth by half a line in height, and rose abruptly from the unaltered skin. On close examination, the aperture of a follicle was apparent on the summit of each, marking the seat of the inflammatory congestion to be the capillary plexus of the follicle. The summit was evenly rounded, not coni- cal as in acne, and, unlike the latter, they were soft to the touch, and had no tendency to suppurate. At the end of a week, they had a yellowish tint at the summit, which arose from the thickening and commencing sepa- ration of the epiderma, and, still later, they were sur- mounted by a small conical crust, of a dirty-yellow color, consisting of desiccated sebaceous secretion, and remind- ing one of the conical crusts of rupia. After a time, the little cap of thickened epiderma fell off, or where the conical crust of concreted sebaceous matter had formed, this also separated, and the pimple gradually subsided to the natural level of the skin, leaving behind it a brownish stain. In their growth, maturation, and decline, these pim- ples, therefore, offer three stages for consideration:- in the first, they are smooth and soft, and the color is TUBERCULA DISSEMINATA. 119 vivid; in the second, they are denser in structure, their color is dull, and they are surmounted by a small yel- lowish crust of hardened epiderma and sebaceous sub- stance; in the third stage they are declining. On the back, the eruption was somewhat brighter in color; that on the face and parts of the body exposed to the air being always a little duller in hue than that occurring on the covered regions. The tubercles were exactly circular in shape, scarcely raised above the level of the surrounding skin, gently convex on the surface, somewhat harder to the touch than the lichenous pimples, smooth, and varying between one line and four lines in diameter. The principal seat of this eruption was the hollow of the spine between the shoulders, and the back of the neck. Like the pimples of lichen, the tubercles have their three stages, namely, first, that in which they are smooth on the surface; secondly, that in which they are covered by a thin epidermal crust; and thirdly, that of decline. During their first stage, the stage of growth, the epiderma covering them exfoliates repeatedly, and leaves around their margin an abrupt edge of cuticle, which gives them a remarkable appearance (Plate 2, R). When two or three successions of these edges appear, in consequence of several exfoliations, they form a kind of circular frill around the circumference of the papule. In their third stage, previously to decline, they not uncommonly contract in diameter, and become more prominent. This case was also remarkable, as exhibiting, besides lichen in its two forms of corymbosus and disseminatus, and the disseminated tubercular eruption, an erythema tuberosum, which made its appearance at the height of the constitutional symptoms, on the knees and on the legs. These spots were circular in form, slightly swollen, of a bright-red color, hard and thick to the touch, and /3 120 SYPHILITIC ERUPTIONS. very tender. One on the knee measured three-quarters of an inch in diameter, while the others measured about half an inch. There were six or eight of these spots on one knee, four or five on the other, and three or four dispersed on the legs, below the knees. The tubercles of the disseminated variety of the syphilitic eruption are sometimes less distinctly round than those just described, less raised, and sometimes smaller, making it difficult to determine whether to class them under the head of roseola, lichen or tubercula, although they certainly belong to the latter group. The large pimples of case 7 were of this kind: from their size it was doubtful whether they should be called pimples or tubercles. At other times, the doubt lies between roseola orbicularis and tubercula; but the elevation of the centre of the spots, although very slight, and the manner of exfoliation of the cuticle, generally determine the nature of the eruption when it belongs to the present group, assuming for the tubercles, as a distinction from the " lentiform" kind, the designa- tion of " flat." TUBERCULA ANNULATA. SYPHILODERMA TUBERCULATUM ANNULATUM. There are so many points of resemblance between the syphilitic tubercular eruption and the allied diseases, lepra and psoriasis, that we are not surprised to meet' with the terms, syphilitic lepra and syphilitic psoriasis; but, strictly speaking, there are no such affections. The corymbose form of tubercular syphilis, composed of groups of tubercles having a more or less circular arrange- ment; the more decided and more isolated clusters of TUBERCULA ANNULATA. 121 the circumscribed form; the separate tubercles becoming depressed in the centre, while they increase by the cir- cumference; all these are so many points of strong re- semblance between the syphilitic tubercular eruption and the squamous diseases. But resemblance is not identity, and I make these remarks, only as an introduction to a form of the tubercular eruption, which is especially re- markable for its near resemblance to lepra. The corym- bose and circumscribed forms of tubercular eruption, if they were classed with the squamous affections, would be grouped under the head of psoriasis. The form I am now about to describe would be ranged with lepra. The type of the present form of eruption is a tubercle, which spreads in a circular direction, so as to form a ring of variable breadth. Sometimes the tubercle itself seems to enlarge and constitute the ring, leaving an area in which the skin returns by degrees to its natural state; at other times, the tubercle would appear simply to communicate the impulse of growth to the skin immedi- ately about its circumference, a ring being formed around the tubercle, and gradually enlarging, while the tubercle remained stationary in the midst of the area. The fol- lowing case illustrates both these forms. Case 27.—A young woman, of delicate frame, aged twenty, had gonorrhoea in the month of August, some years back. The discharge continued for six weeks. Shortly before Christinas, she miscarried of a five-months child; and a fortnight after the latter event, became aware of the presence of a sore on the vulva; the sore wras not long in getting well. In the month of January of the following year, she observed an eruption on her skin, and a month later suffered from sore-throat. It was not until the end of March that she came under my care. At this period, H 122 SYPHILITIC ERUPTIONS. the eruption was scattered over various parts of her body, but principally on the neck. She informed me that it made its appearance first on the forearm by two spotf; after a fortnight, other spots appeared on her neck and hips, and shortly afterwards the rest broke out in the remaining regions of the body. At the time of her examination by me, there were as many as twelve spots upon the neck, presenting every degree of progressive development. There were papules scarcely a line in diameter; tubercles, measuring from two to four lines; circular patches three or four lines across, with depressed centre, and raised border; raised and papulated rings from half an inch to one inch in breadth, of a circular or oval form, inclosing in their centre a large irregularly-shaped tubercle; and one or two rings with a smooth area (Plate 2, S). On other parts of the body, the tubercles offered a variety of appearance. Thus, on the chin, there was one which had become covered with a yellowish crust; they were altered in their shape on the conchae of the ears, and there was one on the dorsum of the tongue. On the palms of the hands were several simple tubercles, and one had established itself beneath her thumb-nail, and gave her much pain. On the lower limbs, the eruption presented the characters of the tubercula disseminata: one of the tubercles being pustular on its surface from the irritation of scratching. Many of the patches were in the state of desquama- tion ; the exfoliation of the cuticle being chiefly appa- rent on the summits of the central papules, and along the convexity of the rings. The scales, however, were obviously nothing more than desiccated epiderma, and very thin; and not, as in the case of lepra, altered in its anatomical structure, and thick and laminated. Sometimes the central tubercle spreads with the ring, TUBERCULA ANNULATA. 123 and the whole seems to form one broad, soft patch, the ring being distinguished from the tubercle by a mere groove. In the following case there were several of these broad, fleshy, tubercular patches bounded by an abrupt border. Case 28.—A young man, aged twenty, a carpenter, had impure connection in the beginning of November, 1847. A week afterwards, he discovered several small superficial sores along the edge of the prepuce. The sores remained in a chronic state, producing contraction and thickening of the aperture of the prepuce, and were unhealed at the date of his first appearance before me, namely, on the 21st of March, nearly five months after their outbreak. The contraction of the aperture of the prepuce was such as to prevent its retraction. He had no enlargement of the inguinal glands. Three weeks after the occurrence of the sores, he first perceived an eruption of spots upon the skin. They appeared first on the right hip, two in number; then three similar spots showed themselves on the inner side of the right thigh, at its upper part; subsequently one came out upon the left thigh. These spots looked quite fresh on the occasion of his visit to me ; and, as he in- formed me, had undergone no change, saving that of increase of size. Six weeks before he came to me, seve- ral new spots appeared, three being situated on the penis; and within a week of his visit, two or three more had broken out. With the first attack of eruption he had had no sore- throat, but soon after the increased outbreak, namely, about the beginning of March, he suffered from soreness of the fauces; and when he consulted me, there was considerable redness, with superficial ulceration. The whole number of patches on the skin did not '» 124 SYPHILITIC ERUPTIONS. exceed twelve or fifteen, and they were situated as above mentioned. Of those on the right hip, one was irregu- larly circular, the other oval; the former measured one inch and a quarter, and the latter one inch and a half, in longest diameter. They consisted of a central broad and fleshy tubercle, surrounded by a raised ring; both the tubercle and the ring were of a deep, dull-red color, and the redness extended over the whole of the area included within the rin°;. The tubercle was wrinkled and smooth on the surface; the ring was marked by numerous transverse furrows, and was in a state of des- quamation, the portions of desquamating epiderma cor- responding in shape with that of the intervals between the wrinkles. On the right thigh, where there were four patches, one was a simple tubercle, measuring one line and a half in diameter. It represented the first stage of growth of the patch. Another was a raised, flat, oval-shaped tubercle, half an inch in diameter, and appearing from the elevation of its border, to be slightly depressed in the centre. The remaining two measured an inch and an inch and a half in diameter, were oblong and oval in shape, and had each a broad and irregular central tubercle (Plate 2, T). Of the three patches on the penis, the largest, measuring an inch in longest diameter, had a central tubercle; the other two were smaller, and mere rings, inclosing an area of brownish and slightly corrugated skin, over which the ring had crept in its onward growth. The resemblance of these patches to those of lepra vulgaris was very striking, and I have no doubt that they would have been called lepra syphilitica by anyone who had seen them; and yet their origin and mode of development were identical with those of tubercular erup- tions in general. They differed from lepra, however, in the absence of scales—an important point; and also in TUBERCULA ANNULATA. 125 the presence of the central tubercle : the patches of lepra are depressed in the centre, these were more ele- vated in the centre than at the circumference. In another example there was no central tubercle, and the eruption had more of the character of lepra vulgaris than the preceding cases. The patient was a medical student. Case 29.—This gentleman consulted me for an eruption, which he considered to be common lepra, and its appear- ance was certainly such that it might have deceived men of more experience than himself. I explained to him that it was a syphilitic eruption, and obtained the follow- ing statement of his medical history. He contracted a venereal sore in the month of April, and instead of remaining quiet, engaged in the occupation of fishing. He was, consequently, much exposed to the weather, frequently got wet and chilled, and, on one occasion, fell into the water. These irregularities probably ex- cited the formation of a bubo, which went on to suppu- ration, and then became sinous. The sore healed in about a month, but the bubo and its sinuses remained troublesome for four months longer. He treated himself upon simple antiphlogistic principles, and took no mer- cury. He was not aware of the occurrence of any eruption subsequently to this period, and had no sore- throat. In the month of February of the following year, he was engaged in London, pursuing his studies, and he dissected assiduously, for several hours a day, in a very cold room. He then perceived an eruption, which ap- peared in spots upon the front of the trunk and legs; and had symptoms of a severe cold, with some degree of sore-throat. Thinking the sore-throat might be a symptom of secondary syphilis, he took the iodide of fj 126 SYPHILITIC ERUPTIONS. potassium, in five-grain doses, three times a day, and a Plummer's pill at bedtime, for three weeks. He then put himself on a course of nitric acid and sarsaparilla for another three weeks or a month; and finding no improvement in his symptoms, commenced taking one- sixteenth of a grain of bichloride of mercury, with de- coction of sarsaparilla, three times a day. The mercury produced a diarrhoea, which lasted for three weeks, during which time he abstained from medicine, and then recommenced with nitric acid and sarsaparilla. He had continued the latter medicine until a short period pre- viously to my seeing him (July); but with all his efforts, there was no change for the better in the eruption, and he had come to the conclusion that it must be common lepra. On examining the eruption, I found it situated prin- cipally on the lower limbs, where there were fifteen or twenty large rings, of a medium size of two inches in diameter (Plate 2, V. V). The area of the ring was perfectly smooth, and of a yellowish-brown color; the ring itself was raised, of a dull-red color, and irregularly circular or oval in its form. On the side corresponding with the area, the elevated margin rose abruptly from the surface; on the peripheral side it declined gradually to the level of the surrounding skin. The breadth of the rings wras between three and four lines. The surface of the rings presented certain differences of appearance —in some, it was uniform and smooth; in others, the rings were marked by numerous transverse wrinkles; and others, again, were either papulated on the surface, or looked as if it formed by the aggregation and fusion of numerous tubercles. There was a slight condensation of the cuticle covering some of the rings, and here and there an indication of epidermal exfoliation. TUBERCULA ULCERANTIA. 127 The eruption quickly disappeared, on making his mouth tender with small doses of blue pill. SYPHILODERMA TUBERCULATUM ULCERANS. One of the most striking of the peculiarities of syphilitic cutaneous disease, is the gradual and almost imperceptible transition by which one form passes into another. We have seen this peculiarity illustrated in the transition of roseola into lichen and tubercle; in the close alliance subsisting between the varieties of tuber- cles ; and I have now to call attention to the same fact in the gradual conversion of tubercles into ulcerations. These observations all point to the unity of the syphilitic poison; and the varieties evinced in the manifestation of the morbid effects of the poison, are such as might be anticipated from a knowledge of the varieties of con- stitution presented by mankind, and the varied conditions to which the poison must be subjected in its numberless mutations. Even ulceration is presented to us in a transition state, in that curious phenomenon to which I have alluded in a previous page, wherein a tubercle disappears, or is removed by absorption, and leaves behind it a deeply pitted cicatrix, without any external signs of ulceration being perceptible; sometimes a slight crust is formed on the subsiding mass; at other times, and espe- cially under the influence of mercury, it sinks and is lost without a trace of change in its outward appearance. In another series of cases, a thin crust covers the summit of the subsiding tubercle; if we remove the crust, a little moisture of an ichorous nature may be perceived, perhaps a globule of purulent secretion. We might be inclined to admit that there was a slight abrasion of the surface, but scarcely that there existed a condition to which we 128 SYPHILITIC ERUPTIONS. could correctly give the name of ulceration. In a third , series, ulceration is unquestionable, but the degree of ulceration varies; it may be superficial, or deep. j Time and temperament have much to do with the manifestation of the ulcerative action. The poison may have been long rooted in the system; it may have been aggravated by mismanagement; it may have been en- grafted on a stock hereditarily contaminated; or the tem- perament, natural or induced, may be favorable to its development. In like manner, the shape which the eruption may assume may be that of the corymbose, the solitary, or the annulate tubercles. The following case belongs to the first series of pathological processes above referred to; namely, that in which the tubercle disappears, and leaves behind it a deep and permanent cicatrix, without any ulceration being perceptible on its surface. The case is further remarkable, as showing the effects of the syphilitic poison after forty years of residence in the blood. Case 30.—A gentleman, sixty-eight years of age, consulted me for a patch of eruption, somewhat larger than a crown-piece, situated immediately in front of the ear. On examination, it had the appearance of a red- dish-colored cicatrix, bordered by an abrupt margin, in the course of which were several small tubercles covered with thin yellowish crusts. The surface was uneven, depressed below the level of the surrounding skin, and indented here and there as if by ulceration. The hair of the whisker was destroyed, and in the ridges between the indentations were seen the ramifications of several small veins. i He informed me that the eruption had occupied its present situation for more than four years; that it began as a small tubercle in the midst of the whisker; that he tubercula flcerantia. 129 frequently picked it with his nails; and that it had gradually extended to its present dimensions.* It had never ulcerated; small scabs formed from time to time on the summits of little elevations; but when the scabs were picked off, there was no sore beneath them. The little elevations subsided slowly, and, when they were gone, a depressed cicatrix was left in their place. It gave him no pain, but there was a little itching occa- sionally. Feeling confident that the disease was one of syphilitic origin, I obtained from him the following account of him- self: In the winter of 1805 he had two or three small sores on the prepuce, which healed in about two months. He took mercury for their cure, the first and only time in his life, and was gently salivated. After this, about thirty years ago, he had a scaly eruption on the face, but the connection between this attack and the venereal sores, fifteen years before, is by no means clear. He was subject to sore-throat during the early part of his life, but has not been so since. SYPHILODERMA ULCERANS CORYMBOSUM. In the succeeding case, the effects of the syphilitic poison on the skin are shown, after twelve years of occupation of the system; the eruption assumed the corymbose character; in the first attack, the ulceration could not be detected for a thin crust which covered the summit of the tubercles; in the second, the ulceration was evident, but superficial. Case 31.—In the year 1838, a gentleman, educated for the medical profession, had a venereal sore on the prepuce. It was treated with poultices, and healed in ten days. A year afterwards, he suffered slightly from 9 , 130 SYPHILITIC-ERUPTIONS. sore-throat for about two months, but is not aware of having Imd any secondary symptoms. Between six and seven years after the sore, he became affected with a tuberculous eruption, which commenced on the side of the face near the ear, and travelled slowly towards the nose. The tubercles never formed sores; but when they disappeared, they left behind them deep pits which must remain unchanged for the rest of life. This eruption continued for two or three years, and its nature not being understood, no proper treatment was employed. Three years after the disappearance of the tubercles on the face, this gentleman consulted me for an eruption which was situated on the back of the neck and shoulders. It consisted of a cluster of tubercles in a state of ulcera- tion, and covered with yellowish spongy crusts; a few of the tubercles retained their normal form, and were un- broken on the surface. He soon got well of this eruption with the aid of the bichloride of mercury. The deeply ulcerated tubercles are more common than the superficial, and their common seat is the head and face. The following are examples:— Case 32.—A gentleman, aged 29, a member of the medical profession, consulted me during the year 1849 for several small unhealthy-looking ulcers situated on the head, and behind one ear. They were of small size, deeply excavated, intermingled with depressed cicatrices on which the hair was destroyed, and surrounded by a dull-red, tuberculated, and thickened state of the skin. He was doubtful as to their nature; but I had no hesita- tion in pronouncing them to be syphilitic, and, as such, examined him with regard to their origin. He informed me that, six years ago, he had a venereal sore on the corona glandis. The sore was of small size, TUBERCULA ULCERANTIA. 131 flat, and without induration; and healed, in a short space of time, with no other application than black- wash, leaving behind it scarcely a trace of its existence. He had no bubo, or other indication of absorption of the venereal virus by the system, and took no mercury. Between two and three months subsequently to the appearance of the venereal sore, he had an attack of sore-throat, with papular eruption on the face. The soreness of the throat resulted from a superficial ulcera- tion of the tonsils, the ulcerated surface being coated with a grayish secretion. It got well in about six weeks, but returned from time to time for as many months. The papular eruption on the face subsided in three weeks, and did not again appear. He had no enlarge- ment of the lymphatic glands. For the secondary affec- tion, he took mercury irregularly during six months. Between four and five years after the syphilitic com- plaint, this gentleman was seized with typhus fever, which reduced him very much. While recovering from the fever, he suffered severe pain in a circumscribed spot upon the tibia—a symptom of periostitis—and he had pains, like those of rheumatism, in the head. The pains lasted for about a week, and gave way under the influence of small doses of iodide of potassium. Eighteen months after the invasion of the fever, a crop of tubercles made their appearance on the scalp and behind the ears. The tubercles soon passed into a state of ulceration; some healed, while new ones broke out, and although once or twice they were all healed for a short time, they continued to annoy him up to the period of his consulting me, six months after their first appearance. Indeed, at this time the ulcerations were more numerous and of a more unhealthy character than they had ever before been. The treatment which he had pursued for this attack, 132 SYPHILITIC ERUPTIONS. consisted of the iodide of potassium in four-grain doses, three times a day, nitric acid, nitro-muriatic acid in decoction of sarsaparilla, and externally the oxide of zinc ointment. He had been married for twenty months at the time of his visit to me. His wife and child were perfectly well, and had not evinced any symptom of syphilitic disease. Case 33.—A gentleman recently married, about thirty-five years of age, consulted me for an eruption, accompanied with ulceration, which affected his lips, ears, the submastoid region of the neck, and the scalp. He had lost the soft palate and greater part of the ton- sils by ulceration, and had thickening of the tongue with cicatrices of that organ, and thickening of the mucous membrane of the nose. He considered the disease to be the consequence of a venereal sore which he had had eight years before. At the age of eighteen, this gentleman contracted a venereal sore, which was situated on the prepuce, and followed by a bubo. He took mercury until his gums were sore, and got quite well. At the latter end of the month of July, 1841, he again contracted syphilis, in the shape of a small indurated chancre, which was situated on the inner surface of the prepuce, near the fossa coronae glandis. This sore gave him no inconvenience, and at the end of two months was perfectly healed. In the beginning of October, that is, two months after the first appearance of the sore, he was attacked with an eruption of lichenous papules, and sore-throat. The papules were distributed over all parts of the body; some retained their original size, but others increased in growth, and assumed the character of soft tubercles; TUBERCULA ULCERANTIA. 133 while another set, about twelve in number, situated on the inner side of the thighs, the back, and the head, passed into a state of ulceration. One of these tuber- cles on the arm formed a rupial ulcer, which continued open for nearly five years. It healed in 1846. During the whole of the above period, and subsequently, he has been free from any enlargement of the cervical or other lymphatic glands. The eruption on the skin and sore-throat continued during the three following years; the eruption subsiding and fading on the body and limbs and retreating towards the head. In 1843, he had an attack of rheumatism; and in the beginning of 1845, after much suffering from inflammation of the tongue and entire cavity of the mouth, the inflammation of the fauces healed. In 1846, he lost a piece of bone, by exfoliation, from the palate; during the following year he suffered much from inflammation and swelling of the lips; and in 1848 was troubled by the ulceration of the eruption still re- maining on the scalp. In the winter of this year his mouth was again inflamed and sore, and the tongue swollen, the ulceration continuing on the scalp and neck. During the summer of 1849 he went into the country, and got quite well, with the exception of some tubercles still remaining on the scalp and face. On his return to town, the cutaneous disease on the scalp and face again became troublesome, and in the month of October there were numerous small ulcerations on the scalp, and several small but deep and foul ulcerations in the sub- mastoid region on one side; inflammation and swelling, with abrasion of and discharge from one ear, and swell- ing of the lips, particularly the upper, with tubercular eruption around the mouth and chin. Until the early part of 1846 this patient was treated in Edinburgh, and went in succession through courses of 134 Syphilitic eruptions. mercury and iodide of potassium, with sarsaparilla. At the period above mentioned, he came under the care of an eminent London surgeon, and continued under his treatment until the winter of 1848. He then took Donovan's solution on the recommendation of a medical friend, and for the last few weeks previously to his visit to me had been doing nothing. Case 34.—A gentleman, aged thirty-seven, a married man, with several children, and suffering under tuber- cular syphilis in a state of ulceration, the disease being situated on the upper part of the forehead and upper lip, gives the following account of himself:— He states that, when a boy of sixteen, he contracted a syphilitic sore, which was situated on the apex of the glans penis. It increased rapidly, so as to form an ulcer of considerable size, and was accompanied by a bubo, which ran on to suppuration, and burst spontaneously. He took mercury for some time, but without producing any effect on his mouth; and has had no sore-throat or cutaneous eruption subsequently. At the age of thirty-six, that is, twenty years after the preceding attack, he again became the subject of primary syphilis, the sore being situated on the edge of the prepuce. The venereal sore was attended with a slight enlargement of one of the inguinal glands, and got well in ten weeks. He took bark with nitric acid until the sore healed, and then went under a course of blue-pill and sarsaparilla until obliged to desist, from soreness of the mouth. Soon after the healing of the sore he became affected with sore-throat. The fauces were much congested, and there was a large patch of white lymph covering the posterior wall of the pharynx. He suffered also from severe pains in the lower limbs. TUBERCULA ULCERANTIA. 135 Between two and three months after the attack of the primary sore, his skin became covered with an eruption of tubercles, which in the course of three months sub- sided by degrees. Some of the tubercles, however, passed into a state of superficial ulceration, the ulcers being covered by thick rapial crusts. He had also a painful enlargement of the sub-occipital and post-cervical lymphatic glands, and a return of sore-throat. He first came to me about twelve months after the out- break of the secondary eruption, and fifteen months from the time of contagion. At this period he was suffering from an increased degree of inflammation of the fauces, pharynx, and larynx, and had a cluster of tubercles and ulcers on the upper part of the forehead, and upon the upper lip. He informed me that these tubercles were a part of the eruption of the secondary attack; that they had not gone away with the rest, but remained in the state in which I saw them, and were gradually becom- ing more ulcerated and troublesome. Case 35.—A gentleman, about forty-five years of age, consulted me, April, 1850, for a syphilitic tubercular eruption in a state of superficial ulceration, situated on the scalp. He informed me that fourteen years back he had a slight sore, which got well in a few days, although he continued to take mercury for a fortnight. He does not recollect having suffered again in his health until five years afterwards, when he had a very severe influenza. The following year (1842) he had acute rheumatism, attended with stiffness of his joints. In 1846, he suffered from periostitis and nodes, attacking principally his arms; and in 1848 the present eruption commenced as a small cluster of tubercles seated over the right mastoid » 136 syphilitic eruptions. process, from which situation it has extended by degrees to the entire scalp. During the long period which has thus briefly been referred to, the notion of syphilis being the cause of his disease was never once entertained either by himself or his medical attendants. He was supposed to be labor- ing under scrofula, was sent to a warm climate, and was regarded, not merely as incurable, but as being assured of an early grave. On his first visit to me, I told him, to his surprise, that his case was, and had been, one of syphilis, and that as such he would perfectly recover. My prognosis is verified; he is now (1851) enjoying better health than he has known for years, and is fast approaching a complete cure; the disease on the scalp being nearly gone. SYPHILODERMA ULCERANS SOLITARIUM. The cases just narrated are instances of the ulcerative action occurring among a cluster of tubercles, several of the la'tter presenting a state of ulceration at the same time. Sometimes, however, the tubercle and its ulcer are solitary, and if other symptoms of syphilis be want- ing, the case is obscure and requires experience for its correct diagnosis. I have known ulcers of this kind mistaken by the highest authorities in the country, and the knife proposed to the patient, where a short course of mercury, or of the iodide of potassium, has entirely dissipated the evil. The upper lip is a common situation of this kind of tubercular ulcer, and I have seen it several times just in front of the ear. Case 36.—A gentleman, of weakly appearance, aged forty-nine, consulted me, in the month of May 1851, for TUBERCULA ULCERANTIA. 137 an obstinate ulcer situated on his upper lip. It began six months back as a broad and hard tubercle, and had resisted all the treatment employed for its cure. It was about the size of a sixpenny-piece, had an irregular sur- face, and secreted an ichorous fluid. This gentleman had no other indication of syphilis than several milky stains on the mucous membrane of the cheeks. He was married, six years, and has two children. He has had no symptom of venereal disease for the last eight years. Before that period, and commencing as early as twenty- five years back, he had several attacks of gonorrhoea and one of syphilis. The latter occurred eight years since. It began as a pimple upon the glans penis, and increased to an ulcer of the size of a fourpenny-piece. It healed in about three weeks with the aid of a lotion. Soon after the healing of the sore, he had an attack of " rheumatic fever," attended with sore-throat, but he does not remember any eruption being present. Subse- quently he had a little eruption scattered over his body, but has had no appearance of the kind for the last four or five years. I put this gentleman on a treatment adapted for syphilis, without using any local application whatever, and at the end of a month his medical man wrote to inform me that the sore was fast healing. In another case of this kind, the caustic had been used repeatedly, but after a time the tubercle returned in the old place. SYPHILODERMA ULCERANS ANNULATUM. When the large circles formed by the broad tubercles of cutaneous syphilis pass into a state of ulceration, they have a remarkable appearance, and the term "serpiginous" rises to the mind in considering them. I 138 SYPHILITIC ERUPTIONS. once saw a man partially bald, whose head was covered by these serpiginous wheals. They were coated with a thin squamous scab, and came out upon his temples like a pair of ram's-horns. The following is a case of this kind of eruption, where the circles formed a necklace, which descended for a short distance upon the breast and back. Case 37.—A healthy-looking man, forty-nine years of age, the father of three children, consulted me for an eruption of rings of various size, having broad margins, slightly ulcerated, and coated with thin scales of epi- derma and desiccated secretion, which occupied the root of his neck, and extended for some distance downwards upon his chest and back. He informed me that, at the age of twenty-one, he had suffered for the first time from venereal disease, his com- plaint being gonorrhoea with a superficial sore. He was treated with mercury to the extent of salivation, and got well in six weeks. Two years later, he had another attack of gonorrhoea, which was accompanied by a troublesome sore and bubo. And four years after this, he had gonorrhoea, with a venereal sore, for the third time. His third attack of venereal disease occurred two years after his marriage, and lasted two months. Some weeks after getting well, an eruption of red spots, with- out any elevation of the skin (roseola), made its appear- ance on the trunk of the body and arms; and from that time until the present, a period of sixteen years, he has been the subject of occasional outbreaks of eruption, but without being aware of their syphilitic nature. These eruptions for the first eight years were flat, and even with the skin. During the next six years, when they appeared, they were elevated, and subject to epidermal exfoliation; and for the last two years have assumed the PUSTULJS SYPHILITICA. 139 annulate form, at first being perfectly smooth, and presently exhibiting a tendency to ulcerate superficially. With the outbreak of eruption on the skin he had sore- throat and nocturnal pains in the limbs; these symptoms have been repeated from time to time, and with them soreness of the tongue, and an aphthous state of the mucous membrane of the mouth. VESICULAR SYPHILIS. As, in the accompanying pages, I have confined myself strictly to my own experience, and limited my remarks to observations made with my own eye, I am constrained to pass over the subject of vesicular syphilis. I have never seen a case of constitutional syphilis deserving of a place under this head; and the few authors who refer to it admit "that the occurrence is one of extreme rarity. Indeed, I can hardly conceive the eruption of syphilis to assume the characters of eczema or herpes. Rupia is out of the question; for that is obviously a pustular eruption, and will be considered in its place, in a subse- quent section. PUSTULAR SYPHILIS. The only eruption coming strictly under the denomi- nation of pustular syphilis is rupia; an affection depend- ing specially on a pyogenic condition of the constitution. Other forms of pustule must be considered as instances of suppurating papules and tubercles. I have myself fallen into the error of denominating a pustular eruption, produced under the impulse of constitutional syphilis, "impetigo syphilitica;" upon further reflection, I think it would have been more correct to have regarded it as a lichen passing into the state of suppuration. Such 140 SYPHILITIC ERUPTIONS. cases are by no means rare, and a pustular lichen may be fairly admitted among the occasional phenomena of that eruption. I recollect an instance in which the greater part of the papules developed on the arms and legs of a syphilitic patient were gradually converted into pustules. The syphilitic ecthyma seems to me to be also doubtful, but not so positively unlikely as the pro- duction of smaller pustules. Even in the instance of ecthyma, it is necessary that we should be well assured that the case is not one of suppurating tubercle. The case to which I was led to give the designation " impe- tigo syphilitica," was remarkable for the rapidity and completeness of the suppuration; I will narrate its prin- cipal features. Case 38.—A young man, of delicate constitution, had suffered from enlarged cervical glands for about twelve months, when he became affected with chancre. Two months after this event, the glands began to increase in size, and ultimately gave rise to a large abscess and pro- fuse suppuration. At the same time an eruption of pimples, surmounted with pustular heads, broke out upon his skin, and he had a periosteal tumor on the forehead. A month after the disappearance of the pimples and subsidence of the periosteal swelling, he was seized with severe sore-throat, which accompanied an acute febrile attack; and six weeks later had a reappearance of the eruption, which rapidly took on the pustular character, and suggested the idea of an impetigo. The eruption disappeared in a fortnight; but in another ten days it again burst forth upon the arms and lower limbs. In my notes upon the appearance of the eruption in this case, I remarked that it offers to the view at the same moment all the stages of development, growth, and PUSTULE SYPHILITICA. 141 decline. There are minute red pimples, for the most part solitary; larger pimples, about a line in diameter, on the summits of which pus is making its appearance; and fully-formed hemispherical pustules, having a me- dium size of one line and a half in diameter, filled with yellow pus, and surrounded with a bright red areola, from half a line to a line in breadth. Then, in progress of decline, there are pustules in which the purulent matter has assumed a duller tint towards the centre; others, in which, besides the alteration of color, there is a depression of this part of the pustule from incipient desiccation, giving them an umbilicated character; others, in which the brownish centre extends nearer to the circumference, substituting by degrees a scab for a pustule; and others, again, where the scab has become hard and brown, the redness around its circumference beginning to fade and assume a purplish tint, and the epiderma of the inflamed areola to exfoliate. A few of the scabs are black from the effusion of a little blood, consequent on injury to the pustules, by scratching or friction. Lastly, there are purplish spots left after the fall of the scabs, and brownish stains which serve to indicate their position for weeks after the cure of the eruption. In reviewing this case, it is obvious that the patient possessed, as an heritage, a pyogenic constitution. He was scrofulous; perhaps syphilitic from his birth; the glands in his neck had been angry and enlarged for twelve months, when the fatal poison was received into his blood. This occurred in the winter season, when he was mercurialized to the extent of salivation. Every- thing seemed to conspire against him;—a morbid con- stitution ; inoculation with a dangerous poison; the season; and the treatment. Under the weight of so many adverse circumstances, it cannot be matter of 142 SYPHILITIC ERUPTIONS. surprise that an outbreak, which, with more favorable conditions, might have been a lichen, should have become developed into a pustular eruption. Pustular syphilis may therefore be regarded as the manifestation of a virulent poison in a morbid constitu- tion, the latter condition being either hereditary or accidental. Both these conditions were present as influential causes in the case of rupia which follows:— Case 39.—A young man, aged 20, of delicate con- stitution, was in the month of January accidentally thrown into the water, and nearly drowned. His health was much weakened by the accident; and in the De- cember following he became affected with syphilis. He had a small chancre beneath the prepuce, and bubo; the former healed without any trouble; but the latter suppurated, and kept him confined to his bed for nine weeks. Six weeks after the commencement of the chancre, an eruption of red tubercles made its appearance on his face and head. The tubercles were round, and as larae as a split pea, and after increasing in size for a few days, became filled in the summit with a bright yellow pus. Two or three days later, the centre of the pustule had become brown, and was beginning to desiccate into a yellowish-brown scab. The margin of the scab, where it was continuous with the epiderma, was still yellow from the effusion of fresh pus, while a narrow halo of redness indicated the inflamed skin around its circum- ference. After another period of six weeks from the outbreak of the preceding attack, he was seized with sore-throat, and severe pains in the limbs, which increased at night; the fauces were much inflamed, and there was ulceration of the tonsils and pharynx. RUPIA SYPHILITICA. 143 His face at this time was studded all over with yellowish-brown crusts; there were several on the scalp, and a few on the limbs and back; altogether the number distributed upon the face and head amounted to sixty- eight. The eruption presented itself in all its stages of development and growth: there were simple tubercles, others surmounted with yellow pus, and others covered with crusts possessing every gradation of growth. The crusts bore the aspect of being laminated; some were irregular; others were pretty evenly limpet-shaped; while a few were broken into small fragments, and had a mulberry-like appearance. On the eyebrows, they had uprooted the hair and carried it with them, so that, on superficial inspection, they seemed tufted with hair. There was also some difference of color; in the most recently formed crusts a reddish-yellow predominated; the older ones were brown, with a tinge of green or yellow; and those which had been caught by the dress or by the bed-clothes were black from being stained with blood. The elevation of some of the crusts was three-quarters of an inch, and such crusts had generally the conical shape, that particular form being partly the result of freedom from injury, and partly the consequence of the slow and gradual peripheric extension of disease in the skin. On the side of the cheek one of the crusts was thicker below than above, from gravitation of the im- prisoned pus; and on the upper lip, near the margin of the prolabium, there were two of a circular and conical form, which curved downwards to the mouth, and were not unlike the beak of a hawk. The largest of the crusts was situated on the front of the thigh, and measured nearly two inches in diameter; it was dark colored from effusion of blood, and thin. In its relation to the surrounding skin, the exterior 144 SYPHILITIC ERUPTIONS. pellicle of the crusts was continuous with the epiderma; this portion of the pellicle was of a lighter color than the rest, and covered a layer of newly-effused pus. By a little pressure, the pellicle in this situation might be broken through all round, and by a slight increase of force, the crust might be removed entirely, showing it to be a hollow cone filled with a thick and tenacious pus, and based upon an indolent and unhealthy ulcer. The ulcers which constitute the base of the crusts of rupia have been aptly termed " atonic." When they have made but little progress in depth, they present a coarsely granular surface, interspersed with irregular patches of undestroyed skin. A little later, when the ulceration reaches the deepest stratum of the corium, the tissue of the latter may be detected among the granulations, forming an open network; while at a still later period, the corium is entirely de- stroyed, the exposed subcutaneous tissue is frequently smooth, or the granulations are few and scattered, and the hollows are filled with whitish and yellowish lymph. The edges of these ulcers are generally pale and smooth, without being raised, and they are undermined to a greater or less extent. When the ulcers of rupia heal, they leave behind them ugly cicatrices, with more or less of a purplish hue of the skin, and often a browish stain. Case 40.—A delicate-looking young man, eighteen years of age, became affected with chancre and bubo in the month of December. While under the influence of mercury, and before the sore was quite well, he was exposed to the weather, and got wret through. At night he was seized with severe pains in the knee, hip, and shoulder joints; he had pains in the shins, with perios- teal swellings, his throat became sore, a profuse saliva- RUPIA SYPHILITICA. 145 tion took place, and some inflamed tubercles made their appearance on his face and head. The tubercles quickly suppurated and formed conical crusts; and when a crust was displaced, a granulated, foul-looking ulcer was found beneath it. With care and proper treatment he soon got well. In both the preceding cases it is quite evident why the syphilitic eruption took on the suppurative character, and became manifested as a rupia instead of a crop of tubercles; and they show the necessity of watching very closely persons of a delicate constitution who become affected with syphilis. If it were our wish, it would seem that we might, in such persons, convert the simplest form of syphilitic exanthem into a rupial affec- tion, by preparing our patient with a few doses of blue- pill, and then putting him into the rain to get wet through, or giving him a dip in a fish-pond. There are, also, many other hygienic conditions, which contribute to the same end. Occasionally, we see rupia presenting a solitary and chronic character, and manifesting itself under circum- stances which appear insufficient for its production. The following is an instance of this kind. Case 41.—A strong-looking married man, aged twenty- nine, eighteen months after a venereal sore, perceived an inflamed tubercle on his breast, w^hich soon became covered by a crust, and at its fall left behind it an unhealthy-looking ulcer; soon afterwards, a second tubercle, followed by a rupial crust and ulcer, appeared upon his arm; and a few weeks later, a third, sur- mounted by a conical crust, came upon the lower part of his forehead, near the eyebrow (Plate 3, B). The original sore appears to have been of the simplest kind, and soon got well; and, as far as he knew, he had had 10 146 SYPHILITIC ERUPTIONS. no other secondary symptoms. He had, however, in his occupation as a gardener, been much exposed to the weather. He had been teased with the rupial eruption for six months before he applied to me. Some constitutions evince an irritable impatience under the presence of the syphilitic poison, and take on the more extreme forms of manifestation of their repug- nance, without any of the accidental circumstances above referred to. The following is a case of this kind. The patient was a young man of nervous temperament; he took syphilis only once; he went under no mercurial treatment, and the poison may be said to have been left to itself, to exhibit its effects upon his constitution, un- checked and uncontrolled. Case 42. — A gentleman, aged twenty-nine, the brother of a medical man, consulted me, in the month of June, 1850, for a venereal eruption situated on the outer side of the knee (Plate 3, A). The disease pre- sented the appearance of a patch, somewhat less in size than the palm of the hand; it was uneven, indented by numerous pits, and had a brownish color. On its margin there were two rupial crusts, beneath which was collect- ed a sanguineous pus, covering a foul and excavated ulcer. Besides the principal patch, he had a small brown cicatrix on each calf. He states, that six years back he had on the prepuce a small hard sore, of about the size of the half of a horse bean. The sore was poulticed, and he took a Plummer's pill every night for a week. At the end of a fortnight the sore healed, leaving behind it no induration of the skin. Three months after the sore, a few pimples made their appearance on the face; he had no sore-throat, and has never suffered any. For the eruption, he took three RUPIA SYPHILITICA. 147 grains of the iodide of potassium, with decoction of sarsaparilla, night and morning. After having taken this medicine for two or three weeks, he happened to dine out, and drank more wine than usual. The next day he was sick, and felt languid, and a day or two after, a general eruption of pimples, broke out over his whole body, assuming the characters of the corymbose form of lichen. The eruption lasted three months, during the whole of which time he continued the use of the iodide of potassium and sarsaparilla. Twelve months after the outbreak of the lichenous eruption, a soft, red tubercle made its appearance on the calf of one leg. The tubercle inflamed and suppurated, and became a rupial ulcer, which lasted for two months. The seat of the ulcer is indicated by a depressed cicatrix and brownish discoloration. At the end of another twelve months he had a second inflamed tubercle on the calf of the other leg. It went through the same course as the preceding, lasted for the same period, and has left behind it a similar scar and stain. A year and a half later, the eruption under which he is now suffering made its appearance, at first in the form of a small tubercle, not larger than half a pea : this in- creased by degrees, new tubercles formed, some became inflamed and suppurated, leaving rupial sores, while others healed. Sometimes the patch has appeared al- most well; at other times there have been four or five ulcerations present at the same time. In this state the patch has continued now for twelve months. SYPHILITIC ULCERS. The ulcers covered with thick crusts and constituting the eruption known as rupia, form a natural link of 148 SYPHILITIC ERUPTIONS. transition from the superficial ulcerations of syphilitic tubercles, to those deep, unhealthy, and often sloughing ulcers, which may be distinguished, par excellence, as syphilitic ulcers. The following case will illustrate the kind of disease to which I refer:— Case 43.—A gentleman, thirty years of age, had, about nine years back, a venereal sore in the fossa coronae glandis; the sore did not exceed a split pea in size, and got well in three weeks. Immediately after the healing of the sore, a bubo appeared in the groin, and went on until it burst spontaneously. He was con- fined to bed with the bubo between six weeks and two months. He took mercury for a period of about three weeks; his mouth was made tender but not sore. A few months after getting well of this attack he con- tracted a second sore; and again took mercury for about three weeks, until his mouth became tender. He has since had several attacks of gonorrhoea, and an excoria- tion on the glans penis. The excoriation occurred in the month of February 1846, and quickly got well, scarcely attracting his attention. Three weeks after the occurrence of the excoriation, namely, in the middle of April, he became the subject of tubercular eruption which broke out upon his face and arms; and has continued until the present time, becoming more extensive, and from time to time fading on one part to appear soon afterwards upon another. The cutaneous disease has been accompanied through- out with sore-throat. The treatment pursued for the secondary disease was as follows:— Mercury and sarsaparilla, three months; iodide of potash and sarsaparilla, five months; mercury, until it ULCERA SYPHILITICA. 149 produced tenderness of the mouth, three weeks; iodide of potash again, seven months. He then went under the care of another surgeon, and recommenced with iodide of potassium (large doses) with sarsaparilla, four months; and the surgeon getting tired of him, sent him to the sea-side, where he remained from the end of November until May. During his residence by the sea, he still took the iodide of potassium from time to time. At this period, and for some time previously, he had been suffering with rupial ulcers, and finding that they got no better, while his strength was much exhausted, he repaired to a water-cure establish- ment in Germany. He derived benefit to his general health, from the water-treatment, but perceiving the syphilitic disease still far from being cured, he sought the advice of Chelius, of Heidelberg, under whose care he remained for two months. In the month of December 1848, he returned to England, and for the first time became attacked with severe pains in his joints and limbs, with nodes. In the following February he went back to Chelius, and continued under his treatment until May. In June he visited Munich, and put himself under the care of Dr. Horner; and in September was sent to drink the waters at Aix-la-Chapelle, where he remained for six weeks. It was after this prolonged course of suffering and physic that he first came under my notice, in the spring of 1850. At this time his face was covered with a circumscribed tubercular eruption of a deep coppery- red color. His nose was distorted, one nostril being constricted, and he had a deep ulcer on the tongue. There were several patches of the tubercular eruption distributed over the left side of his body, and on the left le0, were six unhealthy-looking phagedaenic sores; two on the back of the leg and calf were of large size; 150 SYPHILITIC ERUPTIONS. their edges were angry-looking and excavated; the skin around them was red and indurated, and they were filled with a transparent, reddish, jelly-like secretion. The following case is less violent than the preceding; and however much wre may feel disposed to object to the vigor of the treatment in the former case, we cannot do so in this, but must attribute the obstinacy of the disease and the severity of its manifestation to idiosyncrasy. Case 44.—A gentleman, aged forty, consulted me for an eruption upon the face and lower limbs, under which he had been suffering between three and four years. The face around the nose, the nose itself, and the upper lip, were marked by deep and irregular pits; on the bridge of the nose and extending upwards to the forehead were two large and oblong cicatrized pits, white and flat on the floor, and bounded by healthy skin. The nose was swollen, and the skin traversed by the ramifications of several large veins. On the upper lip, the skin was red, but not otherwise altered, the border of the diseased skin being well defined and of a deeper color than the rest. Near the ala of the nose on the side of the face was a circular patch of tubercular skin, of a yellowish- red hue; the patch was of about the size of a half-crown, and exhibited the declining stage of a spreading tuber- culous ring. On the outer side of the right ankle he had a foul ulcer and several deep scars; on the left ankle and leg were similar traces of extensive ulcerative action, and near the knee two small ulcers. He had no congestion of the fauces, no enlargement of the lymphatic glands, and had had no pains. Even the ulceration on his face and limbs was unattended with pain. ULCERA SYPHILITICA. 151 He states that, in the winter of 1844, he suffered from gonorrhoea, the first illness he ever had, and the only complaint of a venereal kind; the discharge lasted for two months. He does not believe that there was any abrasion of the skin; certainly he had no sore. The gonorrhoea was hardly gone, when, without premonitory symptoms of any kind, he was suddenly seized with roseola. He became aware of the presence of this eruption on proceeding to shave, and he observed a difference in its appearance on different parts of the body. Thus, on the forehead and face, it was protuberant from tumefaction of the skin ; but in other parts it was flat. On the face, also, there was a mingling of papules and tubercles with the general swelling. He was per- fectly well the night before, having dined with a relative, but without committing excess, or being exposed to cold; and his feelings under the eruption were those of un- disturbed health. A physician of eminence being called in to see him, he was ordered a dose of purgative medicine every morning; a Plummer's pill at night, and warm baths. He continued this treatment for nine days, when the Plummer's pill was directed to be taken twice a day. He did so for two days; by which time he had taken thirteen pills, when, with as much suddenness as the outburst of eruption, severe salivation took place, accom- panied by sore-throat. The eruption had subsided before the salivation occurred, but the latter continued for three weeks. After the salivation had subsided, he remained well for twelve months, when an eruption of small tubercles made their appearance on the forehead, and persisted for several months. He took the iodide of potassium, with sarsaparilla, for three months; then cod-liver oil, 152 SYPHILITIC ERUPTIONS. and then tonics. The tubercles on the forehead have left behind no trace of their existence. A twelvemonth later (1847), he had an attack of in- flammation on the lower part of the forehead over the root of the nose; shortly afterwards, a similar inflamma- tion occurred on the side of the nose, and, at the same time, a corresponding action in the integument of the ankle. These places suppurated, and became deeply- excavated foul ulcers, which destroyed the derma, and healed very slowly, leaving behind them the cicatrices above referred to. Then chronic ulcerating tubercles appeared from time to time upon and around the nose, and continued to trouble him for some time. A year and a half after this attack, namely, about twelve months ago, inflammation occurred in the integu- ment of the right ankle, and of the left leg just below the knee; .these suppurated like their predecessors, and became foul ulcers, which healed slowly. Latterly, within the last month, they have opened again, and are at the present time stationary. In the next case, which I shall briefly narrate, the patient was hereditarily syphilitic, and the severe effects of the disease are to be attributed to its occurrence in a constitution of a feeble and irritable nature. Case 45.—A gentleman acquired a venereal sore at the age of nineteen; the sore got well in six weeks; but was followed twelve months afterwards by rupial ulcers, which have continued to increase from that time until the present, a period of eleven years. Six years after the date of the first primary sore, he had a second, which got well, like the former, in six weeks. He has never had any sore-throat or neuralgic pains, and he married at the age of 27. He has one TUBERCULA GUMMATA. 153 child, twelve months old, and has again become a father. On the occasion of his first vist to me, in the autumn of 1850, he had a large phagedaenic sore on the calf of the right leg; a smaller sloughing sore near the tendo- Achillis, and several cicatrices, each as large as a half- crown. On the left leg, near the ankle, was another unhealthy-looking sore, of considerable magnitude. The skin surrounding the sores was of a deep-red color, in- durated, and apparently infiltrated; the edges of the phagedaenic sore were dry, black, and excavated perpen- dicularly, and the floor was covered with a gray magma. There was no trace of pus, and in the large sore no secretion of any kind. SYPHILITIC ULCERATING TUMORS. Tubercula Gummata. The modification of syphilis by time is one of the most curious of its phenomena, and at the same time, one which enables us, by tracing its mutations, to recog- nize it in a form so very different from its original shape that nothing but the inductive process to which I allude, could determine its identity. In a gentleman whose case is related in a subsequent chapter (case 67), who had given evidence of the presence of the syphilitic poison in his blood for upwards of twenty-five years, there are now developed, since the completion of this period, several round tumors (tubercula gummata) in and beneath the skin, which evidently originate in the same cause. The tumors are about the size of marbles, three or four in number, and hard and somewhat elastic to the touch. They are situated in the left forearm, 154 SYPHILITIC ERUPTIONS. two or three being to all appearance in the cellular tissue under the skin, and one in the skin itself. The latter is slightly red and tender, and looks as if it would pass into a state of ulceration. The peculiarity of these tumors is the great distance of time which intervenes between their occurrence and the reception of the poison. And, in this particular, they seem to deserve a place by themselves under the title of "chronic syphilis;" or, if it be preferred, tertiary syphilis. In their hardness they remind us of cancer, and are very likely to be mistaken for that disease. When they ulcerate, ulceration takes place very slowly, and generally on one side, while by the other they con- tinue to grow; hence the ulcer has more or less of a horse-shoe form, and the tissues over which it has passed heal, but leave an indelible cicatrix. The ulcer is slowly destructive, and exhibits no tendency to granulate; sometimes it dissects out certain tissues with great neatness. The situation in which I have seen these ulcers in a state of progress, is the integument immedi- ately in front of the ear; the following is an example:— Case 46.—A gentleman, aged fifty, has an ulcerated sore immediately in front of the tragus of the left ear. It has occupied its present position three or four years, but latterly has been enlarging. It is now of about the size of a half-crown piece. On the side next the temple, it is bounded by an elevated mound of thickened skin, into the base of which the ulcer seems to burrow. The ulceration has dissected out two ligamentous bands in front of the tragus, and has isolated them completely. It is devoid of granulations, gives rise to no pain, and secretes no pus. The surface exudes a small quantity of a transparent and colorless ichor, which, left to itself, dries up into a thin scab. TUBERCULA GUMMATA. 155 This gentleman had gonorrhoea thirty-five years back, but no other symptoms of syphilis. One of his brothers had erythema palmare. Case 47.—A gentleman, between 50 and 60, has a tumor of this kind excavated at its base by a deep ulceration, the latter being covered with a slough. He has suffered from the disease sixteen years; and although existing for so long a time, the ulcer now is scarcely larger than a shilling. It is of the horse-shoe form, and has burrowed into the base of the hypertrophied skin constituting the tumor. The ulcer is situated imme- diately in front of the tragus. The skin of the temple in front of the ulcer, and, indeed, as far as the angle of the eye, presents the appearance of a cicatrix, and along its border is an impetiginous eruption, which has crept over, and is the cause of the cicatrized skin. In this portion of the skin, and particularly in the neighborhood of the ulcer, are a number of those enlarged venules spoken of in case 23. This gentleman had gonorrhoea many years ago, but remembers no other symptom of syphilis. CHAPTER V. LOCAL ACTIONS OF SYPHILIS. Local actions in the Skin. Besides the more general effects of the syphilitic poison on the skin, there are others which are local or partial; such actions being either present as symp- toms among the general phenomena, or having an independent existence. SYPHILITIC AFFECTIONS OF THE HAIR.—ALOPECIA. The fall of the hair, alopecia, sometimes follows the syphilitic fever, in the same manner as it is met with as a sequela of measles, scarlet fever, or fevers of any other type. Under the influence of the constitutional actions present in these fevers, the formation of the epiderma and hair is temporarily suspended, the epiderma as a consequence exfoliates, and the hair falls. Where the fall of the hair is a chronic action, it probably depends upon insufficient nutrition of the skin; a condition espe- cially characteristic of the syphilitic cachexia. In a disease so important and serious as constitutional syphilis, the fall of the hair, even as a symptom, is not calculated to excite more than a passing notice. If it be sought for, it will be found very frequently : but occasionally it is brought under our attention by the immediate inconvenience to which it gives rise. Case 18 n 158 LOCAL ACTIONS OF SYPHILIS. is an example of that circumstance, and I was therefore induced to make a note of its presence ; but my silence upon this point in the narration of other cases is not to be taken as a proof of its absence in them. In several instances, I have been consulted for alo- pecia, and have been led, in consequence, to examine my patient carefully, for the detection of any other symptom which might indicate its dependence on the syphilitic poison. Sometimes I have succeeded in dis- covering such a symptom, however obscure, and then the treatment applicable to constitutional syphilis has been remarkably successful. In one case, the concur- rent symptom was a tendency to neuralgia; in another, a muddy skin, with occasional sore-throat; and in a third, a milky spot or a fissure on the tongue. The following is an example of alopecia, depending on syphilis:— Case 48.—A gentleman contracted a venereal sore, the nature of which was doubted at the time by his medical attendant, and a week was allowed to transpire before he commenced taking mercury. He then took blue-pill until his mouth was affected; the sore healed in three weeks. Three months after the sore, his hair began to fall off in considerable patches; and a month later, he had sore-throat. On the occasion of his visit to me, the hair was falling abundantly; it was parched and shrunken, as if dead; and the scalp was dry and scurfy. Upon examination, I found the stain of a syphi- litic tubercle on the nape of his neck. SYPHILITIC AFFECTIONS OF THE NAILS. The nails, like the hair, are apt to suffer from the arrested nutrition, caused by constitutional syphilis. I ONYCHIA SYPHILITICA. 159 have seen several instances, in which they have ex- hibited a tendency to peel off; or were altered in struct- ure, being discolored or brittle; thinner or thicker than natural; or apparently fibrous in texture. Sometimes these changes are accompanied by an erythematous in- flammation of the matrices of the nails or of the fingers themselves. The matrices of the nails possess no immunity from eruptions developed on other parts of the skin. I have mentioned a case (27), in which a tubercle was deve- loped under the thumb-nail; and ulcerations occurring under and around the nails (syphilitic onychia) are by no means uncommon. They are also very painful, and are apt to throw out an inflamed and irritable fungous growth. A case of this kind I have now under treat- ment, and the patient is fast getting well under the gen- eral remedies applicable to constitutional syphilis. SYPHILITIC AFFECTIONS OF THE HANDS AND FEET. Syphiloderma erythematosum Palmare et Plantare. The hands and the feet suffer from another peculiar affection, which may be termed Erythema Palmare et Plantare. It is an affection far from uncommon, and generally goes by a name to which it is by no means entitled, namely, psoriasis. There is a psoriasis pal- maris, which belongs to the group of squamous diseases, but that to which I am now referring, although attended with desquamation, or rather exfoliation of the cuticle, is not a squamous disease. Erythema palmare (Plate 3, C) commences usually in the middle of the palm of the hand, in one of the grooves of flexion as a reddish spot, over which the cuti- cle becomes hard and yellow, from destruction- of its 160 LOCAL ACTIONS OF SYPHILIS. vitality, and soon after cracks and exfoliates, leaving a red surface beneath covered by a new epiderm. Some- times this process commences at the same moment in both hands ; sometimes it exists in one only; some- times it takes place in the soles of the feet, as well as in the palms of the hands. Often there is only one of these dry, red, cracking, uncomfortable patches on the hand; at other times there are several; for example, around the ball of the thumb, on the wrist, in the lines of flexion of the fingers. The exfoliating erythematous patch may continue in the state now described for weeks, months, or years, with little or no change. Sometimes it exhibits a tend: ency to spread, and then it creeps slowly along the fingers to their tips, along their borders, around the bor- ders of the hand, or upwards upon the wrist. Occa- sionally and less frequently, it reaches the backs of the hands and backs of the fingers, and I shall presently have to narrate a case in which its principal seat was the back of the hand. But whether it be partial or general in its attack on the hand, it is always the same red, inflamed, hot, cracked, exfoliating surface ; some- times, but rarely, the tender skin, newly exposed by the peeling off of the skin above, cracks, then a little blood escapes, and the crack heals ; sometimes the dry cracked cuticle is the cause of the fissure of the skin ; rarely, a little suppuration takes place. Sometimes the patch exhibits a tendency to enlarge by centrifugal growth, erythema palmare centrifugum, and presents the annulate character already referred to under the head of syphilitic tubercles. In the case of a centrifugal growth, the border is defined, the area presents the red, dry, cracked, and exfoliating character above described. The ring may be small or large, running out upon the fingers in one direction, and upwards upon the ERYTHEMA PALMARE SYPHILITICUM. 161 wrist in the other. As soon as it becomes stationary, a new inflammatory action may begin in the centre of the ring, and a second, a third, and a fourth ring may be formed in succession, affording a curious and remarkable instance of cutaneous disease. Sometimes the ring possesses a tubercular character, and is slightly raised, is, in fact, an instance of the an- nulate tubercle in the palm of the hand. I have delin- eated a case of this kind in my " Portraits of Diseases of the Skin," under the name of erythema annulatum pal- mare (Plate 2, D). I had not at that time detected the syphilitic nature of the affection, and I had only seen one or two cases; I have examined many since; and, with a slight alteration in the arrangement of the words, I think I may still retain the name I then gave to it, namely, erythema palmare annulatum. The erythema palmare annulatum differs from the forms previously described, in getting well in the area while the circle expands. The circle may remain for a long time cracked and angry, but the area recovers its healthy structure and appearance completely. The following is an example of the erythema palmare centrifugum, in combination with other symptoms of syphilitic cutaneous disease. Case 49.—A medical man, thirty-eight years of age, of slight figure, and far from robust in appearance, con- sulted me in the month of August, 1850, for an erythe- matous eruption in the hand, and tubercular patches on other parts of his body. The disease of the palm was a circular ring, the epiderma being hard and dry, and slightly raised, and the area of the ring dry and cracked. He had several such rings of small size on his wrist, a half circle on the breast, and a large broken circle with a cluster of scattered tubercles within its area on the 11 162 LOCAL ACTIONS OF SYPHILIS. buttock. These eruptions had been in existence for ten years; that on the hand had got well and broken out repeatedly, but the patch on the buttock had continued from its first appearance, being sometimes better and sometimes worse. This gentleman was astonished at my diagnosis of his case, as the idea of syphilis had never entered his mind, and he gave me the following account of his " previous history. He said that, twenty years ago, when eighteen years of age, he had two small superficial sores on the glans penis, for which he took blue pill night and morning, but not to the extent of affecting his mouth. The sores got well in a fortnight. A week after the cure of the sores, he had inflammation of the fauces, and two small patches of eruption on the forehead. For this attack, he took Plummer's pill and sarsaparilla, using a lotion of bichloride of mercury to the throat. The throat has remained tender ever since, being every now and then dry, rough, and relaxed, but he has had no such affection of it as to call for treatment; and no symptoms of disease of the skin until the present eruption, which occurred ten years afterwards. Case 50.—A medical gentleman consulted me in June, 1851, for a cutaneous disease of the hand, which I recognized as erythema palmare centrifugum syphili- ticum. It occupied the whole of the palmar surface of the hand and fingers, and extended partly to the backs of the latter. He also drew my attention to a similar state of the skin of the penis. The leading features in the appearance of his hand were, a vivid redness of the entire surface, bordered by an abrupt margin of a deeper red than the rest; a swollen state of the diseased skin, a raggedness of surface arising from irregular exfoliation of the epiderma; and a cracked ERYTHEMA PALMARE SYPHILITICUM. 163 and bleeding state of the deeper grooves of flexion of the fingers. The cuticle had been repeatedly thrown off from the inflamed surface, and the centre of the palm was smooth, of a vivid pink color, and covered by a thin coating of newly formed and smooth epiderma. On other parts of the surface of the hand, the newly formed cuticle was in a state of exfoliation. The inflamed skin of the penis had resulted from the extension of two patches of annulate tubercle, the bor- ders of which formed the boundary of the disease. The border was several lines in breadth, and covered by a broken layer of desquamating epiderma; while the area of the patches was red, furfuraceous, and exhibited a tendency to crack in the direction of the lines of motion of the skin. The medical history of this gentleman is as follows: He is forty-nine years of age, and has been married six years. Fourteen years back, he had a severe attack of " rheumatic fever," or as I should term it, syphilitic neuralgia. This attack was immediately preceded by pleurisy and other symptoms of severe illness. The rheumatic fever lasted for six weeks, and was accom- panied by an eruption on the skin, which had the ap- pearance of petechiae (doubtless syphilitic roseola), and terminated in general exfoliation of the epiderma. From that period until the present, he has been liable to occa- sional rheumatic feelings, and the eruption in clearing away from his body centered in the hands, where it maintained undisturbed possession for six years. At this period, the cutaneous disease entirely disappeared, and the gentleman, thinking himself well, married. His reprieve was of short duration, for, after a few months, the disease returned in his right hand, where it has remained ever since, and also made its appearance on the penis in the manner already described. 164 LOCAL ACTIONS OF SYPHILIS. The annoyance of this complaint is not inconsiderable, inasmuch as the loss of the epiderma, or rather its extreme thinness, renders the skin exquisitely sensitive to the touch of surrounding objects, and makes the ordi- nary actions of life painful and irritating. About the time of the attack of " rheumatic fever," he also suffered from ulcerated sore-throat; and the soreness of the fauces continued for twelve months. He has not since been troubled by this symptom, and is not liable to congestions of the throat. On mentioning to him my conviction of his case being one of constitutional syphilis, he told me that, although he had been repeatedly exposed to the dangers of con- tagion from impure connection, he had never had a symptom of primary disease; that is, nothing that ever attracted his attention or called for treatment. With regard to the disease, there is no doubt as to its nature in my mind, and I can only come to the conclusion that this case is an illustration of absorption of the syphilitic poison by the system, without the development of the local or primary disease. Case 51.—A young lady, twenty-three years of age, but married seven years, consulted me for erythema palmare, confined to the palm of one hand. She said that the disease had made its appearance in the spring, during the three last years, and generally got well in the summer. She also informed me, in answer to my inquiries, that she had had an ulcerated sore-throat in the winter pre- ceding the first appearance of the cutaneous disease; the sore-throat had returned during the following winter, and continued through the summer; and that she had since had occasional repetitions of the soreness. She complained, also, of having had nocturnal pains in one ERYTHEMA PALMARE SYPHILITICUM. 165 knee, and piles, which latter, from her description, I believe to have been condyloma. She has had five children, the first was stillborn; the second survives; the remaining three were miscarriages, the last at three months. Her husband, she says, was delicate, and thought to be consumptive until his marriage, from which time he has become healthy and robust; while she, in an equal degree, has fallen off in strength. I am at a loss whether to attach any importance to this observation; it struck me, when I noted it, as a possible instance of an here- ditarily contaminated constitution becoming relieved of its poison by the creation of a new, and probably a natural outlet; while the unaffected system of the wife suffered in similar proportion. As I do not know the husband, I was unable to ascertain whether he had acquired the poison by contagion; but from the account I had of him, I thought it improbable. Case 52.—A gentleman, thirty-two years of age, con- sulted me for erythema palmare centrifugum in one hand. There were two circular patches, one in the centre of the palm; the other, on the palmar surface of the index finger. He reports himself perfectly well; hardly remembers to have suffered a day's illness, ex- cepting gonorrhoea, which he has had several times, the last five or six years back. With the gonorrhoea, he sometimes had a slight abrasion of the skin, which al- ways got well in the course of a few days. At the present time, besides the erythema palmare, he has a muddy skin; his hair is thin, having been fall- ing during the last three or four years; but he has no depression of spirits, no sore-throat, and no pains in his limbs of any kind; indeed, he has never been subject to 166 LOCAL ACTIONS OF SYPHILIS. either. His bowels are always regular, and his appetite good. He has never taken mercury. The only other traces of the syphilitic poison observ- able in this gentleman, were an uneven and granular appearance of the surface of his tongue; a milk-like spot near its tip, and several milky-looking spots on the buccal membrane, which gave it a mottled character. He had some time since a slight ulceration of the tongue. Case 53.—A medical man had a small indurated chancre, at the age of twenty-two. The sore was situated on the glans, and was as large as a split pea. It was treated with nitrate of silver, and got well in ten days, but was followed by bubo. He took mercury until his mouth became sore, the quantity of mercury not exceed- ing a scruple. He had no secondary symptoms. Nine years after the chancre, a circular, erythematous patch, attended with cracking of the skin and exfoliation of the cuticle, appeared on the palmar surface of the metacarpo-phalangeal joint of the middle finger of one hand. It increased in size to the diameter of a crown piece, and has resisted every kind of treatment for the space of nine months. I prescribed for this gentleman the bichloride of mercury in the fluid extract of sarsaparilla, and in three weeks the eruption had healed. Case 54.—A healthy-looking man, aged thirty-nine, consulted me for erythema palmare of the left hand. It presented the usual appearance of a cracked and ex- foliating epiderma, a red and tender derma. There were several patches on the palmar surface and sides of the fingers, and the disease had crept around the lateral borders of the hand, and occupied a part of the back. ERYTHEMA PALMARE SYPHILITICUM. 167 There were also a few patches on the wrist. The latter were bounded by a slightly raised and map-like border, and had more or less of a circular form. The disease had been in existence eight years without much change. During that period, it had been well three times, twice for a short period each time, and once for twelve months. It is a source of much uneasiness to him, from feeling hot and tender; and particularly when, as sometimes happens, the derma cracks in the lines of motion of the skin. He says that, three or four years before the appearance of the disease in his hand, he had a venereal affection, for which he took mercury until his mouth was made tender. He had also a feeling of soreness in the groin. A few weeks after this attack, his throat was sore and ulcerated, and he has been subject ever since to an occasional recurrence of soreness in the throat. With the sore-throat, the lymphatic glands of the neck were swollen and tender. He had also severe pains in the thighs and legs; and at the present time, is liable to occasional pains in the head. He distinctly remembers that he never had an eruption upon the skin, with the exception of a slight peeling of the skin of the .feet which came on with the disease of the hand. For treatment, he had tried in vain a number of remedies; two years back, he commenced taking arsenic, with antimony and guaiacum, and although he has con- tinued it until the present time, it has been unproduc- tive of any good effect. The points of interest about this case are, the absence of any syphilitic affection of the skin, excepting that in the palm of one hand; and the long and unavailing trial which was given to arsenic as a remedy. Had the case been one of psoriasis, it would undoubtedly have yielded to the arsenical treatment. The length of time 168 LOCAL ACTIONS OF SYPHILIS. intervening between the primary disease and the syphi- loderma, namely, three or four years, and the duration of the latter, namely, eight years, are the common fea- tures of the disease. In cases 54, 53, and 49, recorded in this chapter, the respective periods of appearance of the syphiloderma after the primary disease were five, nine, and ten years. In cases 54, 51, 49, and 50, the duration of the disease up to the time of coming under my treatment was three, three, ten, and twelve years. In cases 50 and 51, there had been no recognized pri- mary disease; in case 51, no other syphiloderma but con- dyloma ; and in case 53, none whatever. In cases 49 and 50, a syphiloderma accompanied the palmar affec- tion ; in the rest, it existed alone. In the succeeding case, the syphiloderma occupied the back and not the palmar surface of the hand. Case 55.—A gentleman, thirty-eight years of age, married, and the father of several fine children, con- sulted me for an inflamed state of the skin of the hand. The disease occupied the back of one hand, the wrist both in front and behind, and the ball of the thumb. It was of a vivid red color, and swollen; the cuticle had been cast from the entire surface, and was still undergoing the process of exfoliation in various parts, and in patches of various size and form. Moreover, there were numer- ous chaps and fissures through the newly-formed cuticle, and several ridges of a tubercular character on the back of the wrist. On inquiring into his previous history, I learned that, eight years before, he had had a sore of small size on the prepuce, for which he took mercury. During the follow- ing year, he had occasional appearances of stains on the skin; and during the last three years, has been troubled CONDYLOMA, OR SOFT TUBERCLE. 169 by the present form of the disease, which has been some- times better and sometimes worse. CONDYLOMA. When syphilitic tubercles occur on parts of the body where there is naturally an increased degree of moisture, or where they are kept in a softened condition by mor- bid secretions, they are apt to assume a state of chronic growth. Such tuberculous growths are termed soft tubercles, or condylomata. Their common situation is the perineum, particularly in the female, where their growth is favored by the secretions of the vulva. They are also found occasionally between the greater labium and the thigh, on the scrotum, between the scrotum and the thigh, around the anus, and in the groins. I have also seen them in the axilla. I will now relate a case in which this kind of growth was developed in the groin ; the case is further interest- ing, as showing the succession of cutaneous eruption, from roseola to annulate tubercle. Case 56.—In the month of August, 1848, a widow lady, aged thirty, observed, while bathing, a small flat sore, about three-quarters of an inch in diameter (as large as a sixpenny piece), upon the inner side of one of the greater labia. She covered it with a piece of gold-beater's skin, and took twelve mercurial pills, one night and morning. The mercury affected her mouth, and the sore soon got well. Between three and four months later, namely, in the beginning of December, she perceived two sores, similar in appearance to that above described, only slightly elevated, in the groin. These she bathed with vinegar and water: they healed in about a fortnight, but left 170 LOCAL ACTIONS OF SYPHILIS. behind them two reddish elevations, which remained in a chronic form. Following immediately upon the healing of the sores in the groin, namely, on the 14th of December, she became ill and feverish, and a rash broke out over the whole body. The rash was roseola, with here and there a cluster of pimples sprinkled on the patches (lichen corymbosus). She suffered, besides, with slight pains in her joints, but had no symptoms of sore-throat. For this attack she took the iodide of potassium, with decoction of sarsaparilla, secundum artem, for six weeks, but was out of health altogether for three months; and even when she had recovered her strength, had still several papulae and brownish stains around the nose and mouth. In the month of May she had a partial eruption of papulae, lichen disseminatus, on various parts of the body, but chiefly on and around the ears and on the face. For this outbreak, she again took iodine and sarsaparilla, and went to Brighton, where she recovered after two months. In the beginning of October she had a renewal of the eruption in a slight degree. A few pimples broke out about the nose and mouth, and a tubercular ring ap- peared on one thigh. This was followed by two similar rings on one arm near the wrist, and a fourth ring upon the opposite arm. For the present attack she followed a dietetic treatment, under the name of homoeopathy, for six weeks, and, obtaining no relief, applied to me at the latter end of November. On her appearance before me, I found her suffering under the common symptoms of the syphilitic cachexia; her complexion and skin were muddy and discolored with brownish-yellow stains. There were several large purplish tubercles around the mouth and at the angles CONDYLOMA, OR SOFT TUBERCLE. 171 of the nares; and, on the arms, were the above-mentioned circles of elevated tubercles. She had no congestion of the fauces, and had not suffered from sore-throat from the beginning of her complaint. Her tongue was clean, her functions regular, and, with the exception of her skin, she felt in perfect health, her application to me having reference rather to the restoration of her beauty than to relief for any infirmity of strength. The periods of occurrence of the secondary symptoms were, for the first attack, between three and four months after the primary sore; for the second attack, between four and five months; and for the third, the same; the disease having lasted from the first until the commence- ment of my treatment, fifteen months. Another case of condyloma was followed by erythe- matous eruption, and a peculiar modification of the pig- ment of the skin. I have already recorded this case under the name of melanopathia syphilitica; its leading features I will mention here. Case 57.—A young married woman, twenty-three years of age, of delicate constitution, and the subject of a constant leucorrhoea, became affected, four months after marriage, with condyloma. The condylomata, two in number, were situated on the perineum; they were circular in form, flattened, divested of cuticle, and poured out a copious sero-purulent secretion. They were also very tender, gave her pain when walking, and occasionally when at rest; and continued to annoy her for eight months before they subsided and healed. She had no other symptom of syphilis. Seven months after the first appearance of the condylo- mata, she became attacked with an eruption of " red, flat spots," probably flat tubercles. The spots were few 172 LOCAL ACTIONS OF SYPHILIS. in number, and distributed on the face and temples, behind the ears, and on the neck, the back, and the arms. On the lower limbs, there were not more than three or four, and those only on one leg. This eruption got well of itself in two months. The last of the "red, flat spots" to subside were three which were situated on the right leg, and these, instead of disappearing, became of a dark color, and formed part of a deep brown mottling of the skin, which subsequently took place. This mottling had the form of a network which seemed to correspond with the distribution of the cutaneous vessels, and extended up the inner side of both legs from the ankle to the middle of the thigh. It was thickest at the middle of the leg, and became less apparent about the knee, to increase again a little above that joint. She informed me that the ground upon which the dis- coloration rested, was sometimes red, and sometimes blue, proving the implication of the vessels of the skin, and its original dependence on a congestion of the capil- laries, similar to that of roseola. A close inspection of the dark patches showed, moreover, that the part of the skin where the change had been greatest was the follicles. The apertures of the latter were marked by a deeper tint of color than the adjacent parts; which gave a spotted character to the patches. This discoloration bore a close resemblance to the ap- pearance of the legs of the women of France, who are in the habit of using the "chauffrette," as a means of keep- ing themselves warm, that form of discoloration being called ephelis ignealis. But in the case of my patient there was no such cause in existence, and the melanopa- thia was entirely attributable to the syphilitic virus. Another example of mucous tubercle is the follow- ing:— CONDYLOMA, OR SOFT TUBERCLE. 173 Case 58.—In the month of August, 1849, I saw, in consultation with Mr. Hardwick, a gentleman, aged twenty-four, who, four weeks after suspicious connection, had his attention drawn to an itching pimple, situated on the front of the scrotum, near its base. By scratch- ing, this pimple was converted into a small ulcer. A fortnight after its appearance, the patient sought the ad- vice of Mr. Hardwick; the ulcer was then as large as a fourpenny-piece; had a hardened base, with a raised edge and depressed centre, and was accompanied by tenderness in both groins. There was no trace of any erosion of the skin on the penis; nor had there been any. At the end of a month, the ulcer got perfectly well with- out any mercurial treatment having been used. A fortnight after the cure of the ulcer, the patient inadvertently slept in a room with the window open, and in the morning awoke, feeling unwell, and suffering from stiffness of the neck. These symptoms were fol- lowed by thirst, a dry and furred tongue, languor, de- pression of spirits, soreness of throat, and itching of the scalp. At the end of four or five days, there appeared an eruption on the legs below the knees, the front of the trunk, the head and forehead, and the scrotum. On the legs and front of the trunk this eruption was roseo- lous ; on the forehead and head, and on the scrotum, it was tubercular. The febrile symptoms were relieved by its outbreak. On his visit to me with Mr. Hardwick, I observed on his forehead a corona veneris consisting of tubercles and spots, of a brownish-red hue. The smallest of the tuber- cles were not larger than the pimples of common lichen, while the largest were four or five lines in diameter, and between these extremes might be selected others which exhibited progressive stages of growth. The tubercles were but slightly elevated; and as they advanced in size, 174 LOCAL ACTIONS OF SYPHILIS. appeared to enlarge by the circumference without in- creasing their prominence, so that the larger kinds had a slightly raised border, with a depressed area (cupped tubercles), upon which the epiderma was in a state of exfoliation, and bore a close resemblance to the small circles of lepra. On the scalp, the patches were more numerous, and covered by a thick, dry, furfuraceous desquamation. On the scrotum, the tubercles had the same character as those of the forehead, but were somewhat more pro- minent. There was a thick cluster on the front of the organ, and one or two in the groove between it and the thigh. Some of them were in a state of ulceration, but all were moistened by a copious secretion, which rendered the epiderma white and opaque, and gave them the cha- racter of mucous tubercles, or secreting condylomata. The roseolous rash on the front of the body and on the legs had disappeared, but there were a few isolated tubercles distributed over his body. The whole skin was dull and muddy; he had a little soreness of the throat still remaining, apparently in the larynx, and the sub-occipital glands were enlarged and tender. LOCAL ACTIONS OF SYPHILIS IN THE MU«OUS MEMBRANES. It is one of the well-known phenomena of animal poisons, that when they accumulate in the blood to the point of saturation, and when an effort is made for their expulsion, the mucous membrane of the fauces is one of the first structures of the body to evince the existence of the expulsory action; hence, the congestion of the fauces which accompanies measles, scarlatina, smallpox, and syphilis. The mucous membrane of the fauces undergoes all those modifications of manifestation of the syphilitic virus, which have been previously described SYPHILIS OF MUCOUS MEMBRANES. 175 as being presented by the skin. There is simple con- gestion, representing roseola; inflamed patches and rings, and milky stains, representing erythema; aphthae, repre- senting papules; circular spots, more or less raised, re- presenting tubercles; and ulceration, carried to every degree, from mere superficial abrasion of the papil- lary layer to deep ulcers, which lay bare bloodvessels and expose bones. I pass over the greater part of these appearances, as being merely symptomatic of constitutional syphilis, and unattended with further interest. There is, however, an appearance, very frequently met with on the tongue and mucous membrane of the mouth, upon which I desire to bestow a few words. It is the appearance to which I have given the name of "milky stains." The milky stain apparently results from a slight degree of opacity of the epithelium, and is therefore not unlike that change which we meet with in the epiderma of the palm of the hand in erythema palmare. The epithelium thus altered, is thrown off by exfoliation, and a smooth surface, from obliteration of the papillae, is left in its place. I have so frequently seen this peculiar milky appearance of the mucous membrane of the mouth in constitutional syphilis, that I regard it as a pathogno- monic sign, and one of great value when no other symptoms are present. The erythematous patches which appear on the tongue, and those circular spots which often rise up into the form of distinct tubercles, are always attended with obliteration of the papillae of the membrane; the sur- face is red, and as smooth as glass; and sometimes a considerable extent of the tongue, nay, the entire organ, is in this state. There is another condition of the tongue in old cases of constitutional syphilis, and which I am also inclined 176 LOCAL ACTIONS OF SYPHILIS. to regard as pathognomonic. I mean the deep grooves or fissures, sometimes longitudinal, and sometimes both longitudinal and transverse, which are met with on the surface of the organ. These fissures are not the result of ulceration, but appear to me to be produced by that kind of interstitial absorption, which I have before described as existing in the skin. The fissures are sometimes associated wTith the milky stains, the obli- teration of the papillae, and sometimes with a swollen state of the whole organ. The milky stains are the exterior manifestations of an altered state of structure of the tongue; the altered texture is removed by absorption, and the fibres, drawing the sides of the organ together, throw the mucous membrane investing these points of absorption into a fold, the convexity of which is directed inwards. Aphthae and the smaller kinds of ulcerations are usu- ally met with on the sides of the tongue. The following is an instance of the development of tubercles on the tongue, and the case is further interest- ing from the occurrence of the primary sore in an un- usual situation. Case 59.—A gentleman, aged forty-two, a widower, consulted me in the month of August, 1850, for symp- toms of constitutional syphilis. He stated that, in his younger days, he twice had slight gonorrhoea, which soon gave way to treatment. That in the middle of February of the present year, more than a month after suspicious connection, he ob- served a small pimple at the root of the penis. The pimple slowly increased in size until it became an ulcer, which was hard to the touch, and as large as a finger-nail. Under the advice of his medical man, he dressed the sore with black-wash, and used inunction for the space of tubercles on the tongue. 177 six weeks, by which time his mouth was tender, the sore quite well, and the hardness of its base gone. Six weeks after the healing of the sore, he became aware of the presence of a slight elevation on the sur- face of his tongue. This was found to be occasioned by two flat syphilitic tubercles. For this affection he took the bichloride of mercury, with tincture of bark, until his gums were again tender, by which time the tuber- cles had disappeared. Two months later (July), he observed a few large pimples on the penis, then a few of the same on his arms, and afterwards a tubercle on the tongue, and a sore on the lip. On this latter occasion, he visited me with his medical friend, and I prescribed the iodide of potassium in three-grain doses, with sarsaparilla, three times a day. He continued this treatment for twenty-five days, and took a vapor bath every third day, when the eruption having entirely disappeared, he was permitted to discon- tinue his medicine. He was advised, however, to take a vapor bath every third day for some time longer. LOCAL ACTIONS OF SYPHILIS IN THE NERVOUS SYSTEM. The only evidence we possess of the special action of the syphilitic poison on the nerves is derived from the extreme state of pain which is frequently met with in association with constitutional syphilis. Sometimes this pain seems located in the nerves themselves; at other times it appears to be the manifestation of a morbid state of the tissues around a joint. It is remarkable also that the exacerbations of pain are most severe at night, when the body is composed for rest; hence they have been named nocturnal pains. I will adduce a few examples. Case 60.—A young military officer, of delicate consti- 12 178 LOCAL ACTIONS OF SYPHILIS. tution consulted me, in the month of June, for an erup- tion on the skin. It consisted of pimples of a dull-red and brownish color, scantily dispersed over various parts of his body, but chiefly on the face and arms: lichen syphi- liticus disseminatus. The eruption was on the decline, the pimples were faded, and upon some the cuticle was in a state of desquamation. He looked pallid, his skin was yellowish and muddy, and the conjunctivae dis- colored. He said that he had no soreness of throat; but, upon looking into it, I found the fauces of a dull-red color, and congested. On inquiry, I learned that he had contracted a venereal sore in the month of December preceding. The sore was of small size, and situated on the prepuce. It healed in three weeks, but was followed by enlargement of an inguinal gland, which showed a little tenderness from time to time, and at the end of four months sup- purated. He took mercury for the cure of the sore, but not to such an extent as to cause tenderness of his gums. At the time of his visit to me, there was no hardness at the seat of the sore, and the inguinal gland was well. In the middle of May, namely, four months after con- tagion, he was suddenly seized with a severe pain in the head, which passed off in the evening under the excite- ment of a ball. Next day the pain returned with in- creased intensity, and continued without intermission for a fortnight, when it began to abate. It was always worse at night, and seemed to increase when he laid his head upon the pillow. During the following week, he had still some pain at night, but not of the very severe kind noted above. He described the pain as being a violent throbbing all over the head, but chiefly in the temples. He had, besides, an occasional aching pain in his knees. SYPHILIS OF THE NERVES. 179 The neuralgic pains were accompanied by the ordi- nary train of febrile symptoms and profuse perspirations, but he had no sore-throat. Nine days after the invasion of the syphilitic fever, the lichenous eruption appeared as scattered pimples on various parts of his body, and suggested to the physician who attended him the idea of chicken-pox. Fresh pimples appeared from time to time for the space of twrelve days, since which time there has been no new eruption, and that already out is evidently on the decline. His treatment had been antiphlogistic during the continuance of the febrile symptoms, and was suc- ceeded by the decoction of sarsaparilla, and bromide of potassium. Case 61.—A gentleman, aged thirty-four, a widower, consulted me, in company with his medical friend, for an eruption which had occupied his skin for more than two months. The eruption was of a mixed kind; roseola in circular blotches (R. orbicularis), and lichen disseminatus, the pimples being small, and some few surmounted with pustular heads. On examining his throat I found it congested; there was the impression of a superficial ulcer, now healed, on one tonsil. His tongue was coated and yellow; skin and conjunctivae muddy. He informed me that, five years before marriage, now seventeen years since, he contracted a venereal sore, which was situated on the prepuce. He took medicine for its cure, but his mouth was not made tender. The sore healed in a month without after consequences. Nine years subsequently, namely, five years back, a second sore made its appearance on the seat of the 180 LOCAL ACTIONS OF SYPHILIS. former one. It was a sloughing sore, and was two months before it healed. In the month of October, 1849, this gentleman became affected with gonorrhoea, which continued for six months. In January, the sore appeared for the third time, without connection, on the old place, and continued in a chronic state until the latter end of March, when it gradually healed. As the sore healed, he began to be troubled with pains in his arms, legs, and shoulders, and night perspirations. A few days later, he was attacked with a severe neural- gic pain in the right orbit, and the pains extended by degrees to the entire head, the temples and vertex being chiefly affected. He described the pains as being " mad- dening," and resembling a "pulse which beat all over his head," and " shooting in every direction." The pains set in at about four in the afternoon, and continued until eight the next morning with unmitigated severity. During the rest of the day the pain was of a slighter kind, and bearable. These pains lasted for five weeks, and were accompanied by periosteal swellings in the scalp. In about a week after the commencement of the neuralgic pains, an eruption broke out upon the skin, in the shape of a lichen with pustular heads, and roseola in circular and slightly raised patches. This eruption, of a deeper hue than at first, and intermingled with brownish stains, still remains. A week later, he first felt the soreness of the throat, and in three weeks a deep ulceration had formed. The seat of the sore on the prepuce presents a decided and somewhat considerable thickening of the subcuta- neous tissue. SYPHILIS OF THE PERIOSTEUM. 181 LOCAL ACTIONS OF SYPHILIS IN THE PERIOSTEUM. Periosteal inflammation would seem to be much more rare at the present day than in times past; probably from the more judicious use of mercury. When in- stances of the kind do occur they are generally accom- panied, as in the following example, with symptoms indicative of an irritable state of constitution. The source of contagion in the present case was probably the primary poison, hence the symptoms are much more severe than is usually the case where the husband is the cause of the disease manifested by the wife. Case 62.—A married lady, aged thirty-eight, consulted me for a small red tumor, as broad as a shilling, situated on the bridge of the nose. It had occupied that situation for twelve months, was tender to the touch, and evidently the result of periosteal inflammation. She had also a disagreeable feeling within the nose from swelling of the mucous membrane, a snuffling, nasal respiration and unpleasant odor. Her complexion was yellowish and muddy, she was depressed in spirits, had ulceration of the tonsils, and severe nocturnal pains in the head. She referred the commencement of her present illness to a period of three years back, at which time she first suffered from sore-throat. The attack was severe, and accompanied by deep ulceration. She had also an eruption of pimples scattered over her body, and violent pains in the head. From that time until the present, she has been subject to frequent returns of ulceration of the tonsils, and intense nocturnal pains in the head and shins. The attacks of sore-throat were preceded by great depression of spirits and languor, and the pains in 182 LOCAL ACTIONS OF SYPHILIS. her lower limbs left behind them a feeling of heaviness in her feet. She has been married twenty years, and had eight children and four miscarriages, the latter at the period of three months. Two of the children were born since the occurrence of the syphilitic fever, three years back, and have con- sequently fallen victims to the syphilitic poison; one was in a state of asphyxia at its birth, and died at the age of fourteen weeks. The other, about two months old, has already been under my care, for ulcerations around the apertures of the face, with ichorous discharge, and inflammation of the mucous membrane of the nose, mouth, and trachea. In reference to the origin of the disease, the lady in- formed me that her husband had had an illness which excited her suspicion, about three months before her own attack. He was, however, only poorly for a few days. Case 63.—An elderly gentleman was brought to me in the month of May, 1850, suffering from a confluent lichenous eruption, which had all the appearance of the patches of lichen agrius without their intense itching. It occupied the face and arms chiefly, and was evidently of syphilitic origin. He informed me that in the month of December, 1848, he became the subject of a superficial venereal sore which healed in five weeks, but left behind it a callous state of skin and sub-cutaneous tissue. He took mercury until the sore was healed, and until it produced tenderness of the gums. In February, 1849, two months after contagion, he had an attack of syphilitic fever with sore-throat, but without cutaneous eruption. SYPHILIS OF THE PERIOSTEUM. 183 In April, namely, two months later, he had a second attack of syphilitic fever, accompanied with sore-throat and cutaneous eruption. In October, six months after the preceding, he had a third attack of syphilitic fever with sore-throat, but no eruption. In April, 1850, after the lapse of another six months, the present eruption made its appearance, but without febrile symptoms of any importance, and without sore- throat. He had, however, with this last attack, pains in his shins, and several circumscribed spots along the course of the tibiae, which were tender to the touch, and over which the integument was inflamed. CHAPTER VI. CONGENITAL SYPHILIS. The transmission of the poison of syphilis from parent to offspring is a fact so well established, that no argu- ment can be necessary to give weight to its truth. In this, as in all other phenomena depending on the imbi- bition of an animal poison, there exists that same amount of variety of effects which is met with in the manifesta- tion of the poison when received into the blood; some- times the child born of infected parents escapes entirely, sometimes it is stricken in the womb, sometimes as em- bryo, and sometimes as foetus. It has appeared to me, that where the tissues of the mother suffer most, the child has the best chance of escape. Occasionally, the foetus appears to act as a conductor of the poison from the mother, and the latter enjoys a temporary immunity while the former is destroyed. In case 2, contained in the first chapter of this work, I have narrated the circumstances of syphilitic contami- nation of a young lady who was married in March, 1845, and miscarried of a seven months' stillborn child in August of the same year. In January, 1846, she came under my care in consequence of the symptoms of con- stitutional syphilis, and soon got well; so well, in fact, that in March she must have conceived, and in November was confined at the full period. In the beginning of February, 1847, she brought the child to me to show some 186 CONGENITAL SYPHILIS. spots which had appeared three weeks before on various parts of its body. She said, that at birth the child was fine but fractious; now it was hoarse, had excoriations at the angles of the mouth, nose, and eyes, and a san- guinolent discharge from the nose. She had also noticed some spots, like those she formerly had, on her abdomen, and had a slight soreness of the throat. The spots on the skin of the child were like those of the mother, namely, circular, of a dusky-red color, and cupped, that is, having raised edges and depressed centres (Plate 2, W). My next visit from this lady occurred in the begin- ning of the following year, namely, on the 27th of March, 1848, when she was again the bearer of an in- fant, at this time six weeks old. She informed me that after I had seen her former child, the eruption had some- what increased upon his thighs, body, and eyebrows, and had continued to trouble him for some months, when the patches exfoliated, and the skin resumed its natural appearance, and that he was now a strong, healthy-looking little fellow, a year and a half old. She further stated that the spots on her own skin continued, without alteration, for five or six months, and then disappeared. Subsequently, about two months before her confinement, a few fresh spots showed them- selves, but went away in three weeks; since which she has been quite free, and has felt well. The infant now brought to me was well, with an excep- tion presently to be mentioned, at birth, and at the age of five weeks appeared to have taken a severe cold. Its mouth and lips became dry and parched; it had cough, and its throat and air passages seemed clogged with a thick, viscid mucus. It was nearly in this state at the sixth week. When I saw it, the mucous membrane of the mouth, as far as could be seen, was congested, and CONGENITAL SYPHILIS. 187 spotted with white films of aphthae, the voice was hoarse and husky, and the lips and angles of the mouth cracked and excoriated. There was a viscous secretion from the nose; the child was emaciated, and its skin dry. The exception to which I alluded was a red and inflamed state (erythema) of the feet, which was appa- rent at birth, and was followed soon after by a similar state of the hands; the cuticle was thrown off in large flakes and by repeated exfoliations, leaving the skin beneath very tender, and giving rise to cracks of various extent, in the direction of the joints. Some of these cracks extended quite around the fingers, were of con- siderable depth, and bled a good deal. It was sad to witness the state of suffering in which the poor child appeared to be. I prescribed for the mother of the infant small doses of blue pill, night and morning, together with occasional doses of purgative medicine; and pursued such general indications for the relief of the infant as the case ap- peared to require. I learned after three months that both mother and child were well, but have received no report of them since. In my observations appended to this case, I remark, upon the relation subsisting between the mother and her offspring. That in the first instance the poison was new to the tissues of the mother, and acted violently upon them, and upon the new organic being which was undergoing development in her womb. The conse- quence was abortion. In the case of the second concep- tion the virus was as it were naturalized; its stimulant properties were subdued, and it spread through the em- bryo and foetus without producing any abnormal action. The mother at this time was well; less poison was pro- bably generated in virtue of the developmental action in operation in her economy; besides, the emunctories 188 CONGENITAL SYPHILIS. were performing their office healthily. The child was consequently born in good health, and it was not until a new influx of poison had taken place from husband to wife, and then to the child, that the latter became affected. This influx may have been the natural result of the restoration of suspended intercourse : or it may have been the consequence of some derangement of func- tion in the economy of the mother that checked the ac- tion of the emunctories or increased the energy of the morbid ferment. The third child was differently circumstanced; it was born while the mother was yet suffering under secondary symptoms, shortly after certain spots had dispersed, and while an excess of poison was present in her system. The child, consequently, bore traces of the disease on its hands and feet at its birth; and soon after, the causes which affected the other child coming into action, it betrayed a more serious invasion of constitutional syphilis. In what other way can we explain a second living child suffering more severely than the first—in other words, the syphilitic virus being more potent in 1848 than it was a year earlier in 1847? The subsequent history of these children developes the argument still further. They are weaned from their mother; they no longer draw poison from their mother's milk; the functions of nutrition and secretion are healthily performed, and they throw off the poison en- tirely, and become fine children. This, unhappily, is not always the case; sometimes the poisonous ferment takes up a permanent abode in the blood; it interferes with nutrition and sanguification; induces a state of the system favorable to the development of organic diseases of various kinds; or lays the foundation for scrofulous degeneration, and all its serious consequences. In the case of syphiloderma tuberculatum circum- CONGENITAL SYPHILIS. 189 scrip turn, related at page 109, it is mentioned, that in a child born after the syphilitic contamination, and now two years and a half old, the constitution is destroyed. The child is delicate, has suffered from inflammation of the lungs, and has an abscess in one of the cervical glands. In case 62, one child was sacrificed a few months after birth; and another, at the age of eight weeks, is a present example of constitutional syphilis. The following is another instance of the same kind, and I have preceded it by a narrative of the state of health of the husband, to show from how trifling an origin so much mischief may spring. Case 64.—A gentleman, of middle age, whom I saw in consultation in the early part of 1850, states, that about Christmas, 1847, he became the subject of chancre, which was situated on the integument of the middle of the penis, and shortly after he had two enlarged glands in the groin. The sore got well in about a month, and he was treated with mercury until his mouth became tender. In the month of February succeeding, he was attacked with an eruption of red blotches (tubercula corymbosa), which broke out upon every part of the body, including the face. The blotches remained prominent until the end of May, when the greater part disappeared. He also had sore-throat, which, little inconvenient at first, became afterwards very troublesome. During these four months he was again placed under mercurial treatment; and in the month of June went to the sea-side. During the next four months, from June until Sep- tember, there was still some of the eruption lingering upon parts of the body; and the soreness of throat con- tinued. At the conclusion of this period, the sore-throat 190 CONGENITAL SYPHILIS. being somewhat increased, and there being a fresh out- break of eruption, he put himself under the treatment of Mr. Key, and remained under his care until Christ- mas, 1848. The treatment during this interval consisted of mercury and the iodide of potassium, and at its conclusion he considered himself well, with the excep- tion of a lingering soreness of mouth. In the spring of 1849, he had again a little show of eruption, and that eruption has continued in small quantity, and in recurring attacks, with sore-throat, until the present date (March, 1850). He has now several tubercles on his scrotum and penis, and the stains of others on different parts of his body. He has a sensation of soreness of the throat, which is congested, and he has several superficial ulcers on the mucous membrane of the lips and tongue, one of these ulcera- tions, on the inner side of the upper lip, being as large as a fourpenny-piece. In this case, then, we have an example of a mild type of venereal sore, followed in six weeks or two months by a secondary eruption and sore-throat, which have continued with remissions for more than two years, and are still in a state of activity. We have next to consider the influence which this patient exerted over his wife, to whom he had been married six years, and by whom he had had two children. It was not until September, 1848, nine months after the occurrence of primary disease in the husband, that the wife began to exhibit signs of bad health. She was then very much out of spirits, and, a month later, was attacked by an eruption on the skin, with sore-throat, severe pains in the limbs, and profuse nocturnal per- spirations. The eruption yielded to treatment, but returned from time to time, and lingered about the CONGENITAL SYPHILIS. 191 region of the pudendum after it had disappeared in other parts. In May, 1849, this patient gave birth to a seven- months child, that had been for some time dead. She got quite well after her delivery, and appeared to have recovered entirely from the syphilitic disease. A few months later, the eruption again made its ap- pearance about the pudendum, she felt a soreness of her throat, and became afflicted with a severe neuralgic pain in one arm. In February, 1850, she was again delivered of a seven- months child, which, like the preceding, had been dead for some time. As in the former instance, the delivery seemed to be a source of relief to all her sufferings, and even the neuralgic pain in her arm became considerably abated. Case 65.—In the summer of 1851, a woman brought to me her infant, aged six months, suffering under an extensive erythematous eruption, evidently of syphilitic origin. The eruption was of a dull-red hue, slightly raised above the level of the surrounding skin, smooth as though tumid, lustrous like metal, exfoliating in some situations, and distinctly circumscribed, the border being slightly raised, and paler than the rest of the patch, reminding one of the wheals of urticaria. On the nates and thighs were several circular spots about as large as a sixpenny-piece, very slightly raised, particularly at the border, and depressed (cupped) in the centre (Plate, 2, W). I have already mentioned this form as being characteristic of infantile syphiloderma. On the face the erythema was chiefly situated around the eyes, nose, and mouth, and on the cheeks in the course of the tears. The eyelids were inflamed and swollen, the eyes moist, and there were excoriations at 192 CONGENITAL SYPHILIS. the outer angles. There were also excoriations around the apertures of the nose, and at the commissures of the mouth. The nose was filled with mucous secretion, and the nasal respiration snuffling; the cry was hoarse. On the limbs, the eruption occupied chiefly the outer sides of the arms and legs. The eruption had been three months in existence. The mother informed me that she was twenty-eight years of age, and had been married six years. Before marriage she was delicate, subject to pains in the head, and irregular menstruation, which still continues. As a child, she was troubled with enlargement of fhe cervi- cal lymphatic glands. Since her marriage she has been stronger than before. She has, however, been subject to leucorrhoea, the discharge being sometimes yellow, to occasional scalding on making water, and tenderness of the vulva. Four months after her marriage she miscarried; and, fourteen months later, miscarried between the third and fourth month. In a confinement which took place subse- quently to this period, the child was stillborn; and on a fourth occasion she miscarried between the sixth and seventh week. Her present child is the produce of a fifth conception. Five or six weeks after her first miscarriage, she suf- fered very severely for several months with an ulcerated sorevthroat; and nine months afterwards had periostitis of the left tibia. The periostitis was accompanied with great pain, which increased at night, and has left behind it a broad patch of thickening of the bone. The node is still tender to the touch, but during the last two years has given her less trouble than before. About six months back, she was attacked with inflammation of the tip of the little finger, which went on to suppuration; the inflammation extending along the finger to its root, CONGENITAL SYPHILIS. 193 and to the adjoining part of the next. The abscess is now well, but has left behind it a considerable degree of loss of substance. Her husband is twenty-nine, and of delicate constitu- tion : he has had two very severe attacks of rheumatism, but never any sore-throat or eruption on the skin. She has never known him to have any other illness. The poison in the above case I infer to have been secondary, from the absence of any apparent primary disease in the husband or the wife, and the general mildness of its effects upon the wife and child. The wife probably owed her own immunity to the direction taken by the poison towards the uterus and its contents. When this source of elimination was suddenly checked by the first miscarriage, she then suffered herself; firstly, with sore-throat, and afterwards with periostitis. The rheumatism of the husband was probably syphilitic. In the previously described cases of syphilis trans- mitted from mother to child, the mothers bore obvious signs of, and were themselves sufferers from, constitu- tional disease. This, however, is not always the case, as may be instanced in the following case:— Case 66.—In the autumn of 1849, a lady brought to me her infant, aged fourteen weeks, to obtain my opinion * with regard to an eruption on the skin, under which the little sufferer had been laboring more than two months. She stated that the spots had made their ap- pearance, in the first instance, on the heels; that they next showed themselves in the cleft of the buttocks, and extended to the legs; and that subsequently they came out on the head, and then on the arms. At the time of my seeing the child, the eruption had subsided on the feet and limbs, leaving behind it an ex- foliation of the epiderma. The head was covered with 13 194 CONGENITAL SYPHILIS. dandruff and scurf, while on the nates there were numerous tubercular spots of a circular figure, about the size of a sixpence, with raised margin and depressed centre (cupped), of a dull-red color, and bearing a close resemblance to the spots of lepra divested of their scales. The child was thin and weakly, its skin muddy and rough; the conjunctivae congested, and the eyes weeping; there was a copious discharge from the nose, a thick mucous secretion clogging the mouth and fauces, a viscous phlegm in the trachea, which impeded breathing, and a hoarse cry, which indicated swelling of the mucous membrane of the larynx; the child was, besides, very uneasy and fractious; had been suffering from a some- what severe diarrhoea, and was still relaxed in its bowels; at the angles of the eyes, nose, and mouth, the mucous membrane and skin were excoriated, and poured out an acrid secretion; and there were similar excoria- tions on the lips, which had produced a tender state of the nipples of the mother. The mother was a delicate-looking woman, somewhat over thirty-five years of age. She had suffered much from anxiety and want of rest during the illness of her infant, but she had never, so far as I could ascertain, had any symptoms of venereal disease, either in the form of sores or discharge; nor had she any suspicion of the nature of the disease under which her infant was laboring. The more common form of manifestation of constitu- tional venereal disease in infants, is for the skin: exco- riations and fissures around the apertures of the body, the seeming consequence of acrid humors; erythema of the feet and hands, with epidermal exfoliation; and small circular and slightly elevated tubercles, with de- pressed centres (cupped tubercles), looking like lepra, CONGENITAL SYPHILIS. 195 in process of peripheral extension, and without its scales. For the mucous membranes: there is an acrid discharge from the eyes, nose, and mouth; moist excoriations at the angles of each of those apertures; aphthae, and con- gestion of the mucous membrane of the mouth and fauces; a clogged state of the air-passages; tumefaction of the membrane of the trachea and larynx; and, not ^infrequently, diarrhoea. These symptoms are illus- trated by the case just related. In my notes upon this case, I have observed that it is painful to reflect that lactation, under such circum- stances, becomes a powerful emunctory to the mother; and that, by means of this outlet, the poison is conveyed from herself to her infant. The mother of this child, doubtless, owed her own safety from an outbreak of con- stitutional disease chiefly to the action of this emunc- tory, and partly to her removal from London to the sea- side, and her temporary separation from her husband. The power of morbid secretions to occasion excoria- tion of the skin needs no illustration, as it is evinced in medical practice in a hundred ways. In the present case the diseased secretions from the mucous membrane of the infant, flowing outwards upon the skin, caused the excoriations at the angles of the eyes, nose, and mouth, as I have frequently seen them produce a similar effect around the anus, in the groins, and in the neigh- borhood of the genitals. The same morbid secretion occasioned excoriation of the nipples of the mother. Here, then, we have, passing before our eyes, the phenomena of generation of an irritant poison, by a vital-chemical action taking place in morbid fluids; and we are enabled thereby to form an idea of the mode in which the syphilitic poison may be engendered by con- nection between persons of unhealthy constitution, inde- pendently of extraneous origin. 196 CONGENITAL SYPHILIS. In illustration of the destructive effects, both to off- spring and parent, of the syphilitic poison, I may adduce another and striking example. Case 67.—A good-looking woman, thirty-four years of age, and married fourteen years, consulted me in the autumn of 1850, for a number of sores situated on the right forearm. These sores were of the rupial kind, obviously syphilitic, and had been in existence for three years. They had been treated by several practitioners of eminence, with caustics and various local applications, and had been considered to be of scrofulous origin. They had commenced by an abscess, which formed on the back of the hand, and was opened: the sore result- ing from this operation, instead of healing, increased in size, and extended so deeply as to produce contraction of the extensor tendons, and consequent deformity of the fingers. Before it healed, other sores formed, some over the joints of the fingers and wrist, and others over the muscular substance of the arm; all extended deeply into the subjacent tissues, and the joints became diseased and altered in form. At the period of her application to me, the ulcers were better than they had been for some time, in consequence of her having spent the summer by the sea-side; but there was, nevertheless, a frightful degree of distortion and disorganization (Plate 4, A). The ulcers were of the horseshoe shape, creep- ing onwards by the convexity, and healing on the con- cave side. The convex border was raised into a kind of mound, beneath which the ulcer seemingly burrowed, while the tongue of healing skin stretching into the concavity of the curve, and forming the concave edge of the sore, was thin and uneven, and presented the white and shining hue of a newly-formed cicatrix. The secre- tion of the sores was a semi-purulent ichor. On the CONGENITAL SYPHILIS. 197 back of the hand, on the wrist, and in several other situations, were the depressed cicatrices of deep and extensive ulcers. The other symptoms indicative of the cause of her disease, which she presented, were, a muddy complexion and skin, a congested state of the soft palate and fauces, and a feeling of soreness of throat. In reference to her early medical history, she informed me that she had been delicate as a child, but enjoyed good health, without being strong, up to the period of her marriage. She had never suffered from any erup- tion on the skin previously to that event, and her brothers and sisters, four in number, were all strong and healthy. She married at twenty, and within the first year gave birth to a fine child, which is now living and well. Three years after her marriage, she had a profuse gonorrhoea, with enlargement of the inguinal glands; but she is not aware of having had any excoriation or sore on any part of the pudendum. She recovered from the gonorrhoea in a few weeks ; but before she was quite well, she was called up in the night to attend upon her child, she herself being at the time in a state of per- spiration, and, as she thinks, under the influence of mercurial medicine. The effect of exposure to cold was an ulcerated sore-throat, and severe neuralgia of one side of the head and face. These symptoms continued for three weeks; but since then she has had sore-throat, and neuralgic pains in the ear and face, at intervals, up to the present time. The neuralgic pain comes on sud- denly, lasts for half a day, and then suddenly ceases, to return in the same manner on the following day. We find thus established, a primary disease, appa- rently nothing more than gonorrhoea, immediately suc- ceeded by secondary symptoms of syphilitic disease; 198 CONGENITAL SYPHILIS. namely, ulceration of the mucous membrane of the fauces, and neuralgia, together with a slight eruption on the skin, in the form of a few lichenous papules on the face : the date of this series of symptoms being three years after her marriage, that is, eight years before the first appearance of the ulcerative form of disease in the integument of the hand, and between eleven and twelve years antecedently to her application to me for relief. Nearly twelve long years of pain and disease, the dis- ease being still in a state of full activity, and all this the result of an infection received from her husband, that husband never, as far as my patient knows, hav- ing evinced in his own person any marks of suffering or disease. But there remains an episode to which I will now proceed. A year and a half after the birth of her first child, she became pregnant again, and miscarried at the end of six months, the child having been dead for some time before birth. A third child was born dead at the eighth month; the mother suffering very much at the time from what she calls " piles," but which, from her description, I believe to have been venereal condylomata. A fourth child was born at the seventh month, and lived three days. A fifth and a sixth child were born at between two and three months. A seventh child nearly accomplished the full period, and lived for fourteen months. It had inflammation and discharge from the eyes, and died after vaccination, from the conjoined effect of a variolous eruption and congestion of the lungs. An eighth child was born at two months. A ninth child went the full time, but was born dead CONGENITAL SYPHILIS. 199 in consequence of fright experienced by the mother a fortnight before its birth. At the present time she is seven months advanced in pregnancy of a tenth child, and is feeling better than on any previous occasion since the first. She states that she always suffers in health during pregnancy; and that, with the exception of the first, the ninth, and her present pregnancy, she has always had a sanguinolent discharge, like that of the catamenia, during the whole period. The sores on her arm, she remarks, are better during the progress of pregnancy. CHAPTER VII. HEREDITARY SYPHILIS. In reviewing the handful of cases collected together in these pages, if there were no other evidence of the fact, we could not do otherwise than come to the con- clusion that the poison of syphilis is of a most enduring kind; that, being once received into the blood, it remains there for years, and possibly—indeed, certainly—for the rest of existence. In juxtaposition with this admitted law of the syphi- litic poison, is another equally positive, namely, that a person possessed of this poison is capable of conveying it to another; and if that other be his wife, he may, through her means, convey it also to his child. Now, if it be true that the syphilitic poison once received into the blood remains there for life, the infect- ed wife must remain infected as long as she continues to live; and, by a parallel reasoning, the infected child must remain infected until death. The question, then, comes before us—What if an in- fected child, grown to manhood, should marry ? and with still greater force—What if an infected child, grown to manhood, should marry the daughter of an infected wife ? There can be no doubt but that some evidence of the latent poison will be exhibited either by themselves or by their offspring. Such evidence is exhibited; and I feel convinced that a considerable proportion of those 202 HEREDITARY SYPHILIS. diseases which pass under the name of scrofula, are the produce of the syphilitic poison—are, in fact, not scro- fulous, but syphilitic. Had I been furnished with this view of the syphilitic poison at the commencement of my study of the diseases of the skin, I should have been saved much perplexity and much labor in their investigation. But I do not now regret that I did not possess this information, and that I was therefore compelled to unravel for myself the mystery which hung about some of these complaints. In my early studies I met with a number of peculiar affections which I felt at a loss to classify, and was in an equal difficulty to treat. They were of small extent, excessively obstinate, perversely chronic, and when, by good luck, they did get well, they left behind them an indelible trace of their visitation. They belonged to none of the varieties of cutaneous disease, if not to lupus, and yet they differed in several respects from lupus. I could form no other conclusion than that they were scrofulous. I set myself to arrange them, and here also I met with difficulty, on account of the variety of appearance which they presented; a degree of variety which would have scattered them among all the orders of Willan, and destroyed their affinity; I therefore pur- sued the safer course of keeping them always before my eye, and watching them narrowly. I am not now speaking of the cutaneous diseases of childhood, in which a syphilitic taint might be traced from the period of birth; but of a form of disease show- ing itself for the first time after puberty, or even in adult age; modified, if it depend (as I feel satisfied it does) upon the syphilitic virus, by an assimilation in the blood continued for years, and appearing at a dis- tance of time so remote that any connection with an hereditary poison would seem more than unlikely. I do HEREDITARY SYPHILIS. 203 hot seek to conceal the difficulties of the case, and I do not ask for belief until my views have been carefully and extensively tested upon the patient; but I shall pre- sently have to claim the discovery of a principle of treat- ment founded on these views, which in my hands has proved most satisfactory and most successful. The laborious exploration of the intricate and obscure pas- sages of truth is for the few; the results of the researches of the few are the share of the many. I must now carry my reader's memory back to what I have said of syphilitic tubercles; elevations of the skin of small extent and height, of a dull purplish-red, yellowish-red, or brownish-red color; opaque or trans- parent, sometimes superficial and sometimes deep; when deep, producing a total disorganization of the structure of the skin, and converting it into a tissue of an inferior type; when superficial, disappearing without leaving any trace behind; when deep, leaving an indelible trace, a deep pit, or a broad cicatrix, in which the deep layer of the corium and its vessels are distinctly seen; sometimes disappearing without any lesion of surface ; sometimes ulcerating superficially, sometimes deeply, sometimes vertically, and sometimes creeping along the surface frequently associated with a plexus of large venules; always chronic; persisting for years, and some- times for life. Let me adduce an example of the form of syphilitic tubercle to which I am now alluding, that my reader may experience with me the obscurity which envelopes the subject, but which I hope to be the means of remov- ing. Case 68.—A healthy-looking man, a valet, thirty- eight years of age, consulted me for two small clusters of tubercles situated, the one on the cheek, the other 204 HEREDITARY SYPHILIS. over the upper part of the sterno-mastoid muscle; besides these, he had not a spot upon his body, nor a syphilitic symptom of any kind; he seemed to be in perfect health. The tubercles were round, perfectly smooth, and a little softer to the touch than the adja- cent skin. Those on the cheek were of a bright-red color, with a tint of purple; those on the neck were of a dusky-red hue, surrounded by a delicate plexus of minute veins, which emptied itself into several large venules. The tubercles had occupied their present loca- tion with very little perceptible change for seven years. Occasionally, a tubercle subsided, and left behind it a yellowish-brown stain, but produced no alteration in the level of the skin; the patches, however, did not grow smaller : for a new tubercle seemed to be added whenever an old one disappeared. Now, what were these smooth, polished, seven-years- enduring tubercles ? They were very like the tubercles of lupus, but then they subsided without ulceration, and without a scar; no one in his senses could have called them scrofulous, occurring in a fine healthy man, who had passed the age of thirty when they appeared; if they were syphilitic, where were the concurrent symp- toms ? There were no concurrent symptoms, but there were signs written on the patches themselves which were unmistakable; let me retrace them;—the size and form of the tubercles; not their color, because that was different from anything of the kind I had seen before; but the plexus of venules and their scattered trunks; and the stains which the tubercles left behind them on their disappearance. I pronounced them to be syphilitic, and obtained the following account of the man's medical history. He had been married fourteen years, and had had the venereal disease three times, twice before and once HEREDITARY SYPHILIS. 205 subsequently to marriage. His wife and three children escaped the contagion. The first attack under which he suffered was one of small sores; the second a gonorrhoea, with bubo. He took mercury for these attacks, but it purged him, and was immediately given up. The last attack, to which I refer his present constitutional symp- toms, occurred ten years back; he then suffered under a gonorrhoea and several small sores, which got well in the course of a few days, with the aid of a lotion. He took no pills, and believes that he had no mercury; his mouth was not affected. Shortly before the outbreak of the present eruption he had sore-throat, and was hoarse, and for the space of three years suffered occasionally in the same manner. Four years since, he experienced pains in the shin-bones, the pains recurred occasionally, but were at no time severe, and for some years past he has not had them at all. They were unaccompanied by redness of the skin or swelling of the periosteum. He has had no enlarge- ment of the lymphatic glands, and no loss of hair; and has no sensation of soreness of the throat. However, on looking into the throat, I found the fauces in a state of congestion. Another case, in which there was ulceration of the tubercles, I may also refer to in this place, as showing another feature of the tubercles, and also the great length of time during which the syphilitic poison may remain latest in the system, and yet retain all its destructive energy. Case 69.—A gentleman, about forty years of age, had a tubercular eruption, which was situated on the fore- head, on one side of the face near the ear, and across the lower part of the loins. The eruption consisted of large, indolent, dull-red tubercles, having the density of 206 HEREDITARY SYPHILIS. the surrounding integument, and scattered irregularly over a patch of altered skin of small extent, the chief tubercles being situated at the margin of the patch. There were six or eight of these tubercles grouped together on the middle of the forehead, forming a patch about an inch and a half square. On the side of the face, the tubercles, three or four in number, were isolated; while on the loins there was an oblong patch, which extended completely across the upper part of the buttock. The patch was of a brownish-red hue, and there were along its margin, and here and there within the included area, between fifty and sixty tubercles. Some few were isolated, but the greater number were in round or linear groups of from six to twelve each. The general size of the tubercles was a quarter of an inch in diameter. The patch looked as if the eruption had crept over its entire surface; it had the appearance of being collapsed and shrunken, and was thrown into numerous wrinkles; while in several places there were cicatrized pits, result- ing from the ulceration of some of the tubercles. This gentleman informed me that he had had a vene- real sore in the year 1825. The sore gave him little inconvenience, and got well in about six weeks. He took mercury for its cure until his mouth became af- fected. After the sore had healed, he remembers that he was very subject to sore-throat, but he never had any eruption on the skin. In the course of years, the "dis- position to sore-throat wore off, and he has not been troubled with anything of the kind of late. He has had no venereal sore since that above mentioned, but has suffered twice or three times from gonorrhoea. The ex- isting eruption made its appearance about seven years since, and has continued without much change until the present time. When it first broke out on the back, the lumps became sore, as he conceives, from pressure HEREDITARY SYPHILIS. 207 or friction, and formed small ulcers, which gradually healed. But as the ulcers got well, or the tubercles subsided, others continued to make their appearance. During the last two or three years he has had no ulcers. He does not remember to have suffered from any pains in the joints or in the limbs. I have before me the notes of another case of local tubercular eruption, situated on the lips and chin of a woman of about thirty-five years of age. Case 70.—The eruption consisted of a cluster of even- ly-rounded tubercles, measuring two lines in diameter, and having an elevation of about half a line. The cluster formed an oblong patch of about an inch and a half square, and occupied the side of the chin. There were, besides, a very small patch, and about six isolated tuber- cles, all of a similar kind, the smaller patch being upon the upper lip, and the isolated tubercles upon the margins of the lips and upon the prolabium. The tubercles were perfectly smooth on the surface at their first appearance, and for some time; they then desquamated slowly, throwing off a thin lamina of dried cuticle every now and then. Their color was a dull-red, sometimes inclined to purple, at other times to a coppery hue; and they ap- peared stationary, having been in existence, without any change, for several months, at the time of her visit to me. There was not a spot of any kind upon the rest of her body; she was a married woman, and having had no primary symptoms of syphilis, I inferred that the present eruption was occasioned by a secondary poison. Case 71.—While the preceding case was under treat- ment, a young lady of good family was brought to me, with an incomplete ring of tubercle situated on the 208 HEREDITARY SYPHILIS. cheek, near the lower eyelid. The line of tubercles curved upwards towards the temple, where they were met by a wheal-like tubercle nearly an inch in length. The color of the elevations was a dusky red, approach- ing to purple; they were perfectly smooth on the sur- face, and had occupied their present position for nearly two years. She had been treated with lotions and oint- ments of all kinds, and nitric acid had been proposed to her. The fear of a scar resulting from the use of the caustic, and the recent appearance of a similar tubercle on the nose, was the occasion of her visit to me. She had no other spot of any kind about her. The position in life of this young lady, the care with which she had been educated, and her age (nineteen), were such, that I felt the utter impossibility of her having been placed within the reach of the syphilitic poison; and yet the similarity of the eruption to that in cases 68 and 70 filled me with perplexity. The tuber- cles were not lupus; she had never evinced a symptom of scrofula; and I felt that if she had appeared among my poorer patients, I should not have hesitated to pronounce them to be syphilitic. As it was, and after mature re- flection, I came to the conclusion that the disease was a germ of the syphilitic poison derived from her parents, and now, for the first time, manifesting itself on her skin; in fact, that it was hereditary syphilis. I treated this young lady with the bichloride of mer- cury and sarsaparilla, and she gradually lost all trace of the eruption. It was not one of those cases of dis- organization of the skin above referred to, and therefore there was no cicatrix, not even a stain left behind. I have remarked upon the resemblance which these locally developed, isolated clusters of tubercles bear to lupus. Lupus itself consists of a cluster of locally developed tubercles, occurring for the most part on the HEREDITARY SYPHILIS. 209 nose or on the face. The tubercles are identical in point of size, color, configuration, even in their mode of ter- mination, with those of syphilis; and we take an interest in inquiring in what they differ. They differ in very little; they are more permanent; but we have seen a syphilitic eruption continue for many years (cases 68, 69); they are more destructive, but can any- thing be more destructive than the corroding and phage- denic ulcer of syphilis; they attack the nose, and so does syphilis. In making this comparison, I have taken the most marked examples of lupus; but between these and undoubted syphilitic tubercles tne incline is so gentle and the difference so slight, that the penalty of pursuing their investigation is the belief in their identity. Is lupus not syphilis? But lupus is generally regarded as owing its origin to scrofula—the obscure is called forth to illustrate the obscure. We are as much in the dark with regard to the cause of scrofula as we are with regard to that of lupus. Lupus is scrofula; and what, we might ask, is scrofula? Is scrofula syphilis? By a careful observation of the phenomena of syphi- lis, I have been led to the conclusion that many, if not all, of those cases of affection of the skin which have been denominated scrofula and lupus, take their origin in the syphilitic poison; and in the same category I feel inclined to place the squamous diseases, lepra and pso- riasis. The subject, however, is too large and too com- prehensive for precipitate judgment. I have expressed my belief; and I leave it to future years of observation and thought to mature my decision. It is unnecessary to discuss here the characters of lepra and psoriasis; they resemble syphilitic tubercles in many respects, indeed, the annulate form of syphilitic tubercle has heretofore been called syphilitic lepra and syphilitic psoriasis; they resemble lupus, and lupus, as 14 210 hereditary syphilis. I have just shown, is a twin with syphilis. I am not now speaking of a syphilitic eruption of any kind, but of ordinary lepra and psoriasis. It has always been a marvel to me what could be the source of this obstinate disease with two names. It is an hereditary disease; it is a life-long disease; it is unconnected with any general morbid affection of the economy; it is not scrofulous; it does not owe its origin, like some cutaneous diseases, to the uric-acid poison; nor does it proceed from any recognized or known poison. What, then, is its source ? May it not be a product of that widely-spread, that almost universal, animal poison, syphilis? I think it may, and is; but on this point the following case may prove interesting. Case 72.—A gentleman, forty-six years of age, married twenty years, and the father of a numerous family, consulted me for an eruption on the head, which had existed for fifteen or sixteen years, but within the last four months had been more than usually troublesome. On examining the scalp, I found the surface uneven, from the presence of a number of deep pits, and around the circumference of the cicatrized skin were several patches of dry scabs, surmounting a dull-red and thickened integument. The appearance of the skin corresponded perfectly with the ulcerated tubercular eruption of the scalp (case 35), but in a mitigated form. He was likewise nearly bald. He informed me that he suffered no pain from the eruption, and that his annoyance with regard to it pro- ceeded from its appearance, and the frequent formation of scabs. In the early periods of its existence, the attacks of eruption would last for a few weeks, and then go off; but within the last few years they had continued several months. The eruption usually commenced with a redness and slight degree of swelling of*some part of HEREDITARY SYPHILIS. 211 the scalp, or with the development of a group of tubercles; on this inflamed skin or on the tubercles a scab would form, but he had never observed ulceration. He had been more bald some years back than he is at present. He had occasionally been troubled with soreness of the sides of his tongue; he had also suffered from occasional pains in his arm and foot; and twenty years ago he had a crop of boils in the gluteal region. He does not remember that he ever had syphilis in any form. As a child, at the age of seven or eight, he had ringworm ? It broke out upon his head in the form of lumps, which passed into a state of ulceration. The ulcers were treated with caustics and have left behind them a deep and permanent cicatrix, quite distinct from the pits caused by the recent eruption. He took mer- cury for these sores to the extent of salivation; they lasted for a period of two years. ^ This gentleman has six living children, and lost Two in infancy at the respective ages of five and nine weeks. Of the six children, three are affected with lepra vulgaris, which began in them at five and six years of age. The other three are perfectly free from eruption of any kind. W To me, this case is one of peculiar interest, as embrac- ing in itself all the gradations of syphilis, which I believe that I have discovered and observed in different indivi- duals. Firstly. I believe this gentleman's case to have been originally one of hereditary syphilis, the eruption on the head, the so-called ringworm, having been in reality identical with the disease of the scalp described in the succeeding case (73). The eruption which brought him under my care, I believe to have been the continuation of the disease for which he was salivated in boyhood. Its chronic character is shown in the fact of its having 212 HEREDITARY SYPHILIS. lasted fifteen or sixteen years; and the endurance of the syphilitic poison in the further fact of the age of the patient (forty-six), and the disease still rife. Secondly. I believe the lepra vulgaris to have been the manifestation of the syphilitic poison in the third generation. The case to which I have just referred, as illustrating an hereditary syphilis of the scalp, is as follows :— Case 73.—A young gentleman, under twelve years of age, was brought to me with a cluster of syphilitic tubercles on the scalp; some of the tubercles were in a state of ulceration, and several large cicatrices showed where other ulcers had healed. He wras an unhealthy- looking boy, of short stature for his age, had large tonsils, and a tumid abdomen. His mother informed me_ that he had suffered from eruptions of the same nanire as that upon his scalp, ever since his birth. The age of this boy precluded the possibility of his having been in the way of the syphilitic poison; and yet no one who had ever seen a syphilitic tubercular eruption would have doubted for an instant as to the nature of #ie one under which he was suffering. I have seen several cases of a similar kind, which have been brought to me, under the idea of their being an obstinate form of ringworm. A young lady and her brother, the children of a college friend, not remarkable for his steadiness as a student, are now under my care for this disease, and are progressing rapidly under the use of the iodide of potassium. A common form of the hereditary syphilitic eruption is a roundish patch of a dull-red or purplish-red color, slightly raised above the level of the surrounding skin, indolent, sometimes spreading by the circumference, so as to form a ring, and healing imperfectly in the centre; HEREDITARY SYPHILIS. 213 sometimes spreading on one side only and healing on the rest; sometimes ulcerating deeply, in one or several points; in the latter case producing a worm-eaten appearance of the skin; sometimes ulcerating only superficially, and forming a dark irregular crust. The secretion of these patches is an unhealthy pus, or a mere watery ichor. This form of eruption is very commonly met with on the limbs and on the backs of the hands and feet; it exhibits a tendency to a peripheral situation, hence it may be developed also on the nose or on the ears. On the limbs and hands it would be recognized as a scro- fulous eruption; on the nose or ears, it would be called lupus. In a lad at present under my care, the patch of morbid skin occupies the dorsum of the thumb, and is perforated by several small openings, which exude a healthy-looking pus. In a young man of eighteen, it affects the dorsum of the feet; by peripheric growth the disease has been carried forward upon the toes, and outwards to the border of the foot, the central part having healed, and left a permanent cicatrix. The greater part of the ring has also healed, so that what remains is only a portion of the original disease. CASE 74.—A gentleman, aged twenty-seven, has se- veral patches of this kind on his right arm, the worst being on the dorsum of the hand. He has been several years under my care, paying me a visit from time to time. When he first came to me there were numerous holes in the skin, which was thickened and undermined; and the disease occupied the middle of the back of the hand. Now the part originally affected has healed, the disease has advanced upon the knuckles, there is no lon-er any deep ulceration, but the tubercular ridge which remains is covered by a thick dry crust, which 214 HEREDITARY SYPHILIS. brings into view an abraded surface when raised. The disease began as a tubercular blotch of small size, on the skin covering the carpo-metacarpal joint of the thumb. In his boyhood he suffered for a long time from chronic ophthalmia; a younger brother is affected with enlarge- ment of the lymphatic glands of the neck; but the rest of his brothers and sisters, older than himself, and five or six in number, are perfectly healthy, as are his parents. The following is another example of the same affec- tion :— Case 75.—A young lady, twenty years of age, was brought to me, in the year 1851, with an eruption on the dorsum of the right foot, which had troubled her since infancy. She was a person of lymphatic tempera- ment, but otherwise enjoyed good health, and she had no other disorder of the skin of any kind. The present eruption appeared on her foot as a patch of redness, when she was two months old, and continued in an indolent state; at four years, an abscess formed on the spot, and was succeeded by ulceration, which spread by degrees over the dorsum of the foot towards its outer border and the toes. The ulceration continued until within the last few months, but has now healed. As it moved onwards upon the skin, the parts behind healed and formed a large and permanent cicatrix. At the present time, the skin along the roots of the toes is thickened and uneven, of a purplish-red color, soft to the touch, fissured here and there by deep grooves, and in some parts incrusted by small adherent scabs. There is no ulceration, but when the scabs peel off, a little moisture oozes from the skin. The entire surface is red, and in a state of epidermal exfoliation. On the border of the foot, the erythema and epidermal exfolia- HEREDITARY SYPHILIS. 215 tion cease abruptly, and the broken and irregular edge of the thick cuticle of the sole of the foot forms the boundary of the disease. In her infancy she suffered from weak eyes. Her mother died of consumption when she was three years old; and two sisters, born one before and one after herself, died in infancy. She probably owes her own life to having oeen brought up away from home by a grandmother. Her father is a healthy man. I have already expressed my opinion, that scrofula is one of the results of syphilis, if not a form of heredi- tary manifestation of that disease; therefore, in this case, I see only the operation of the syphilitic poison. In another case—of identical nature, only that the tubercular blotches are more numerous, there being several on the arms, and one on the back of the hand— the subject was a young gentleman of delicate frame and much delicacy of constitution on his first visit to me five years back, but is now strong and robust, and the diseased skin healed. His father had been severely affected with syphilis. Passing away from the more obvious forms of cuta- neous disease depending on hereditary syphilitic poison to those which are more obscure, it has appeared to me that the latter might be classed under two heads, namely, such as might be recognized by ordinary observers as erythema; and such others as might be designated lupus. syphiloderma erythematosum h^reditarium. The hereditary erythematous syphiloderma occurs in three principal forms; namely, 1, in circular, cupped, and annulate blotches on the hands and feet; 2, in desquamating patches in the palms of the hands and soles of the feet; and, 3, in irregular patches on the nose, 216 hereditary syphilis. face, and head. These three forms of disease may occur separately, or they may all be present together in the same person. SYPHILODERMA ERYTHEMATOSUM DIGITORUM HiEREDITARIUM. The erythema in circular blotches on the fingers and hands I have hitherto seen only in young women. They occur in the form of circular spots, of a purplish- red color, and slightly raised above the level of the surrounding skin. In a short time, the blotch, which may vary in size from a split-pea to that of a shilling, becomes depressed in the centre; the cuticle in its centre assumes a whitish opaque appearance; it then gradually dries, and becomes yellowish and horny, and subse- quently peels off as a thin layer. This process is re- peated from time to time on the matured blotches; new spots make their appearance, and the disease is pro- longed for months and even years. A common situation of these blotches is the joints, and in the first instance, they are often mistaken for chilblains; their subsequent depression in the centre and annulate form, and their occurrence or persistence in the summer season as well as in the winter, however, soon serve to throw a doubt over the mind of the patient and her friends as to the correctness of their diagnosis. SYPHILODERMA ERYTHEMATOSUM PALMARE ET PLANTARE H^EREDITARIUM. Hereditary erythema syphiliticum palmare may be regarded as a blotch similar to those just described, but unattended with swelling, and occurring in the centre of the palm of the hand, or in one of its lines of motion, and thence extending over the entire palm, and HEREDITARY SYPHILIS. 217 sometimes as far as the ends of the fingers. Occa- sionally it is met with on the fingers, and is absent in the palms. This eruption corresponds exactly, indeed is identical, with the erythema palmare already de- scribed under the head of constitutional syphilis; and it differs from the latter only, in being found in persons who have incurred no risk of exposure to the syphilitic virus, in either its primary or secondary state, and could only have received it with their blood. The same form of eruption is also met with occasionally in the soles of the feet. SYPHILODERMA ERYTHEMATOSUM FACIEI ET CAPITIS, HiEREDI- TARIUM. Hereditary syphilitic erythema of the face (Plate 4, C,) is a more serious form of disease than either of the preceding, on account of the seat of its development. I have met with it as a separate disease, most frequently in women ; and I have also seen it in men, coupled with some other form of syphilitic eruption. Its distinctive features are, an erythematous redness of the skin, the redness being greater near the circumference than within the area; sometimes at the extreme edge the redness subsides by degrees into the tint of the surrounding skin; at other times, the patch is bounded by a slightly-raised wheal-like border. In recent cases, the wheal may have a delicate purple-red hue, the central area being whitish and opaque; in older cases, the redness of the area is more confirmed. The area of the patch is always depressed, apparently from exhausted nutrition; the skin looks dry and shrunken, as if its vitality were affected; the cuticle is j^ellow and horny; the sebife- rous pores are loaded with dry epithelial exuviae; the sebiparous glands appear to be in a state-of atrophy; 218 HEREDITARY SYPHILIS. and the term atrophied seems applicable to the whole of the affected skin; it looks as if a fire had passed over it, parched and seared. The patches of skin affected with this disease are manifestly thinner than natural, from interstitial absorp- tion ; if they occur among the hair, the hair-follicles are obliterated, and the hair is permanently lost; if they occur upon the nose, the bones and cartilages become unnaturally prominent, and, after a time, the skin has the appearance of a cicatrix. When the disease gets well, a permanent cicatrix is frequently left behind ; at other times, when treatment has been adopted early, I have seen the skin resume its normal thickness and appearance. Perhaps the most striking character of this disease is the destruction of the tissue of the skin by which it is accompanied. I have already pointed out that this is a common occurrence in cutaneous syphilis; and it is equally common in lupus. This peculiar character of the disease seems to have caught the attention of Caze- nave, for in some recent observations on the treatment of lupus, I find him making use of the term lupus ery- thematosus. He remarks that Biett distinguished this form of disease by the name of erythema centrifugum; and he goes on to describe it as an affection which appears on the faces of women, beginning by a small spot, spreading slowly, and bounded by a more or less raised edge. SYPHILODERMA ERYTHEMATOSUM, NASI, H^EREDITARIUM. I have at present under my care a young married lady, who has a patch of this disease as large as a six- pence on the tip of her nose. It began as a mere speck of redness about twelve months back, and has increased HEREDITARY SYPHILIS. 219 very slowly and gradually to its present dimensions. The skin at the centre of the patch is thin, transparent, and pale, allowing the borders of the cartilages of the tip of the nose to be distinctly seen; nearer the margin the skin is red, and studded with sebiferous pores, dis- tended with desiccated epithelium; farther outwards, the inflamed skin rises to the level of the surrounding healthy integument, and the redness ceases abruptly. In another case, fresh in my recollection, that of a young unmarried lady; the erythematous patch spread over the entire nose, and crept upwards to the angles of the eyelids. On looking closely into the skin, the numerous sebiferous ducts were distinguished by the vascularity of their follicular plexus; the derma seemed to have lost its papillary structure completely, and the surface was covered with a rough, dirty, dry coating, partly the result of alteration of the cuticle, and partly the altered product of the sebiparous glands. During a sudden attack of disordered health, the erythematous eruption in round patches, previously described, made its appearance on the fingers and hands of this young lady, showing the connection between these affections. The following case had for its subject a medical man: it is interesting, as showing the resistance of the com- plaint to the action of remedies. Case 76.—A gentleman had a circumscribed patch of erythematous eruption on the nose, near its tip, at the age of twenty-one. The patch resisted treatment for nearly two years, but yielded at length to arsenic and liquor potassae, getting well after a two-months course of these remedies. Six years later, a similar patch, but of larger size, made its appearance in the old place; its exciting cause being exposure to the heat of the sun; 220 HEREDITARY SYPHILIS. and the immediate symptoms, great redness, with a most violent and troublesome stinging and itching sensation. Since that period, the attacks of stinging and pricking have recurred every two or three Weeks, accompanied with desquamation of the thickened epiderma. He again had recourse to arsenic and potassae; but this time the remedy failed; he then took Donovan's solution, with equal want of success; and afterwards, iodide of potassium and Plummer's pills; but all in vain. Almost driven to despair, he consulted me; and finding his stomach much disordered and his powers weakened, I prescribed for him nitromuriatic acid and gentian, with a compound rhubarb pill at bedtime. He continued this plan for two months with benefit to his general health, but no improvement in the disease. I then gave him half a grain of the protioduret of mercury three times a day, and, having produced tenderness of the gums, kept him under the influence of the mercury for three weeks; the entire duration of the mercurial treat- ment being seven weeks. Still finding no relief, he commenced taking the cod-liver oil, which was followed by an immediate amendment in his symptoms and general feelings. He has now taken the oil four weeks; during this period he has had no scaling of the patch, and no pricking and stinging; the redness has subsided; the cuticle has returned to its normal appearance; the diseased skin, which before was depressed and sunken, has resumed its original thickness; and with the excep- tion of some shallow pits and a reddish stain, there is no trace of the disease. The dose of the cod-liver oil which he is taking is six drachms twice a day within an hour of meals. The most convenient vehicle for taking it he finds to be bitter beer. It rests, he says, very quietly upon his stomach. A poor woman lately under my treatment, presented HEREDITARY SYPHILIS. 221 an example of this disease in a more formidable form; the history of her case was as follows:— Case 77.—A woman, aged fifty-four, consulted me for an eruption which covered the greater part of her face and the sides of the head. On the face it presented a bluish-red color, was dry, and somewhat sunken below the level of the healthy skin. On the sides of the head there were some large cicatrices deprived of hair, and on the neck, near the margin of the hair, several copper- colored tubercles, and a stained state of skin. She said that she had always enjoyed good health un- til the age of thirty, when she had an attack of small- pox, and had never been well since. Her mother died of smallpox. Four months after the smallpox, an eruption broke out upon the back part of the head, and caused the bald places at present existing there. Of the eruption on the face she gave the following account. She stated that her menses had always been deficient in quantity and irregular since the attack of smallpox, and ceased at the age of forty-five. Three years afterwards, she met with an excessive fright, in consequence of seeing a woman who had cut her throat turned round so as to expose the gash. On this occasion she was observed to turn pale, she felt extremely faint, and became aware of a sudden discharge from the womb. This discharge was sanguineous, and she regarded it as a return of her menses; it continued for two hours, and has not reappeared since. Two months after this fright, the eruption on her face began as a pimple on the nose, and gradually extended to the cheeks, and from the cheeks to the ears and sides of the head. She com- plains of a great feeling of heat in the altered skin, of the " working and throbbing" sensation, and of a most troublesome degree of itching. 222 HEREDITARY SYPHILIS. She never had the venereal disease in any form. The following is a more severe, and, at the same time, a very remarkable, form of this singular disease. Case 78.—A poor woman, aged fifty, has the skin covered by a tubercular eruption of a dingy-red color; on the face it exists in the form of broad masses several inches in diameter. In the intervals of these patches, on the limbs and on the body, it occurs in the shape of small tubercles. She gives the following account of her medical history. She states, that eight years back, while menstruating, she received a severe fright, which caused a cessation of her menses for six weeks; that soon after this occurrence she suffered from flushing of the face and one arm, attended with a feeling of extreme heat. For a short period these flushings came and went, but after a few weeks they became permanent. The patches were prominent, rough, and covered by an altered epiderma; she compares them to the rough bark of a tree. The patch on the arm was as large as a half-crown, and had a centre of white. Twelve months later two other patches made their ap- pearance, one on the opposite arm and one on the neck. These patches were less raised than the preceding, and were attended with considerable itching; since their eruption the disease has gradually spread over the greater part of the face. Four years ago she put herself under medical treat- ment, and was mercurialized to the extent of salivation, but with no other result than to increase the eruption, which now came out in a new form, namely, as a crop of small round tubercles, which are distributed plenti- fully over all parts of her body, with the exception of the legs, below the knees. On the neck they are very HEREDITARY SYPHILIS. 223 abundant, indeed, are set as closely as possible; on the face, they occupy the spaces between the large patches. This renewed attack of eruption in the form of tuber- cles came on a month after her final monthly period, almost a year ago. With regard to ether points of her history, it appeared that she had never been married, and had never any affection of the organs of generation. She has not been subject to sore-throat, but has suffered from rheumatism during the last five or six years, and is liable to catarrhs. In other respects she is well. In another example of this affection, occurring in a delicate young woman, the disease in the skin of the face was accompanied with erythematous blotches on the hands and feet. The disease of the" face was asso- ciated with a more complete degree of atrophy than I had previously seen, and a patch was bounded by a slightly-elevated wheal. Case 79.—A young woman, of good character, con- sulted me in the early part of 1850, for an eruption on the face. The eruption consisted of a white and cica- trized patch situated on the forehead, and another patch on the nose, extending to the cheek on each side. The patch was bounded by a purplish-red rim, which pre- sented a map-like outline, and was very slightly raised. In the area of the rings the skin appeared to be in a state of atrophy; on the forehead it had shrunk to the bone, was bloodless, dry, and had lost its natural sensi- bility. The patches resembled very closely those chronic rings of the annulate variety of tubercular syphilis which are sometimes met with on the skin. She informed me that the eruption on her face com- menced seven years back; the patches began as white itchy spots, which appeared on the fingers as well as on 224 HEREDITARY SYPHILIS. the face. The spots soon became red, and then ex- panded into rings. Those on the hands went away by decrees, but those on the face have remained. There has never been any ulceration on the surface, and she herself erroneously attributes the cicatrices to the effect of blisters, which were applied to restore the healthy state of the skin. She is a delicate person ; has suffered long from leu- corrhoea, and occasionally from water-brash; she has certainly not been exposed to the syphilitic contagion. The present disease showed itself for the first time when she was twenty-one years of age. By the use of the iodide and bichloride of mercury, continued at intervals for twelve months, she is fast losing this eruption. The atrophied skin has regained some of its color, and has risen to the level of the adja- cent integument. In another example, the wheal was more elevated and positive; the destruction of the skin greater, and accom- panied by ulcerative action. Case 80.—A gentleman, aged sixty-two, consulted me for a disease of the skin of his nose (Plate 4, B), which had commenced five or six years before. At the time of my seeing it, there was a broad cicatrix which occupied nearly the whole extent of the bridge of the organ, and caused retraction of the right nostril. The cicatrix was very thin, and bound down to the bones and cartilages ; it was surrounded by a slightly elevated, reddish border, in which the principle of growth was still active; this border had approached very nearly to the angle of the eye, and had caused some swelling there; and a part of the border nearest the cheek was covered with a black scab, and was in a state of chronic ulcera- tion. The swollen skin near the angle of the eye had HEREDITARY SYPHILIS. 225 the reddish-yellow oedematous appearance of some forms of the syphilitic tubercle; and there existed along the ulcerating edge a plexus of small veins. With regard to his previous history, this gentleman informed me that he had been married forty years; and that he had never exposed himself to the contagion of syphilis either before or since his marriage. The dis- ease had never given him any other uneasiness than a trifling itching, which seemed to be occasioned by the collection of matter; for when he raised the edge of the scab with his finger-nail, a little fluid oozed out, and he was then easy. Sometimes the ulceration gave out a little blood. His father had been a strictly moral man, but had been troubled with a scaly eruption in the palms of the hands; probably syphiloderma erythematosum palmare. SYPHILODERMA LUPOIDES. I will now proceed to another form of disease, usually met with on the face, most frequently on the tip of the nose, and generally recognized as a form of lupus attended with hypertrophy (Plate 4, D, E). It is more common in women than in men, and may occur at any period of life. At the present time I have six ladies under my care, suffering from this form of complaint, and only one gentleman. One of the ladies, aged sixty, has suffered from the disease more than four years. It began with a feeling of dryness of the mucous membrane within the nose. A small pimple, which formed a scab on its summit, then appeared upon the ala nasi; it gave rise to no pain; but, from its inconvenient position, was frequently picked with the finger-nail. It has never exceeded a quarter of an inch in diameter, and appeared to be composed of a mass of imperfectly formed granu- 15 226 HEREDITARY SYPHILIS. lations. Latterly, it seemed to shift its situation, as though it were enlarging on one side and shrinking on the other; and on examining the part which it had left, it was found that it had imperceptibly eaten through the border of the nostril. The term, hypertrophous, must therefore be taken to refer only to the general appear- ance of these singular growths; they are destructive as well as hypertrophous, although to an infinitely less degree than the form of lupus which has been distin- guished by the name of " exedens." As I have already observed with regard to syphilitic tubercles, the hyper- trophy of this form of lupus seems to result from the conversion of the normal structure of the skin into its own substance, a material of an inferior type of organ- ization, which may be aptly compared to a vegetable fungus; and it follows, that, as soon as an absorbing action is set up either accidentally, or by the aid of medicine, the fungus tissue vanishes, and a deep hole is left in its place. Hence the disappearance of these growths is always followed by a cicatrix, and, as I have observed in the case of the lady just referred to, by a permanent loss of structure. This form of lupus offers some variety in point of color, a variety which seems to depend more upon the state of health or age of the patient than upon anything special in the morbid structure itself; and partty, perhaps, also on its situation. In a peripheral region like the end of the nose, the circulation is less active than in more central situations, diseases occurring upon it are liable to congestions, and the gradual conversion of arterial into venous blood gives them a purplish bloom, or a duskiness or lividity of hue. In passing away from the more obscure to the more generally known forms of lupus, we are leaving farther and farther behind us the original poison from which HEREDITARY SYPHILIS. 227 these diseases originated; the poison has very probably been filtered through the tissues of several generations, hence its relation to an original source must necessarily become more and more difficult to distinguish. The suspicion of any connection between these diseases and syphilis took root in my mind only after a long con- tinued and careful observation of their features, and has grown into a creed, by following out the successive gradations through which the more simple and obvious forms of the disease are converted into the more complex. It may be a stupendous undertaking to leap with one spring from the ground to the summit of a mountain, but how simple and easy the ascent becomes when one step follows leisurely and naturally that of its prede- cessor. The disease known as lupus non exedens (Plate 4r D) is a cluster of tubercles, having more or less of a circular disposition; they become incrusted on the summit with a thin scale; they rarely ulcerate (hence their name), but they subside, and leave behind them a deep cicatrix. How like the history of syphilitic tuber- cles. Let us mark the differences between them. Lupus non exedens is a life-long disease; its spontaneous cure is the exception and not the rule; the tubercles of syphilis, though very enduring, lasting, as some of the preceding cases testify, for many years, get well in time. The tubercles of lupus non exedens have a peculiar color, a reddish yellow, with a singular transparency, that enables us to see to their very base, and to perceive the small vessels meandering through their texture; I have described them as resembling a small collection of solid jelly, effused upon the skin. Syphilitic tubercles have not this peculiarity of color or texture, at first; but they also acquire it by degrees; that is, after the syphilitic virus has been long established in the blood. 228 HEREDITARY SYPHILIS. The difference between them, then, is only a difference when we compare the infancy of the one with the old age of the other, which, it must be admitted, is not a fair comparison. The old age of syphilitic tubercles seems to merge insensibly into the ordinary characters of lupus non exedens. In the irregular forms of lupus this is strikingly the case, as I shall endeavor to illustrate, by means of the following cases :— Case 81.—A young lady, aged fifteen years, consulted me for an oval patch of a yellowish red color and tubercular character, situated on the cheek, where it had existed for seven years. I was informed that the tuberculous patch had made its appearance immediately after an attack of scarlet fever; it was then not bigger than a split pea, and now, after seven years, was about the size of a shilling. It seemed to be composed of a small number of tubercles, blended together, and forming one slightly prominent mass. It gave rise to no in- convenience, beyond the occasional formation of a scab, from the desiccation of a small quantity of pus. This patient was one of a family of seven, and was alone the subject of cutaneous malady. A sister had suffered from an abscess in the hip, and her father had abscesses in the leg. Case 82. — A young woman of leuco-phlegmatic temperament, aged twenty-one, consulted me for a patch of eruption as large as the palm of the hand, situated on the body of the lower jaw, and extending for a short way beneath it. It was, in fact, a large cicatrix, crossed by white ridges, and bounded around the margin by a tubercular border of a reddish-yellow color. It began fourteen years before, as a small patch as large as a hereditary syphilis. 229 shilling, and remained in that state, until the age of puberty, when it began to enlarge slowly, and has gone on increasing until it has attained its present size. With the exception of this eruption her health is very good. In conclusion, I must repeat that I am deeply impressed with the belief that Lupus, Kelis, and Lepra and Psoriasis, are forms of cutaneous disease, all having their original source in syphilis, all maintaining a relationship in different degrees of remoteness with that disease, and all, therefore, falling into the category of hereditary syphilis. CHAPTER VIII. treatment of syphilis. We now come to that part of the subject which is, or should be, the end and aim of the practical surgeon, namely, cure. But before engaging with the question of cure, there is another, of equal importance, which first claims our attention, namely, prophylaxis, or prevention. prophylactic treatment. The first condition of " taking" the disease is the con- tact of morbid secretions with some part of the genital organs, either the mucous membrane or the skin: the time requisite for the continuance of the contact is pro- bably very short, particularly in the case of the mucous membrane; but time is necessary, and upon this circum- stance turns the most important of the rules of preven- tion, namely,careful ivashing with soap and water. This operation should be done well, and immediately after connection, and if it be done well, I think it impossible that absorption can take place, that is, in the male. The female is placed in a position of greater difficulty than the male; the poison in her case is conveyed to a situation where washing must necessarily be imperfect. Injection, so far as the vagina is concerned, is her only resource; but so far as affects the external organs, where primary disease most commonly manifests itself, 232 TREATMENT OF SYPHILIS. the powers of soap and water will be as potent for her, if properly used, as for the male. The best injection for the use of the female, in the case to which I am now referring, is weak vinegar and water. She should first wash with soap and water fully, perfectly, and abundantly, then inject the weak vinegar and water, and then bathe herself outwardly with the same fluid.1 The man should do the same, saving the injection, which is by no means necessary. In both, it is desirable to make water as soon after connection as may be, in order to wash the aperture of the urethra free from any secretion that may have settled there. The common situation of development of a venereal sore is among the folds of the prepuce, in the fossa coronae glandis, and particularly in the smaller and more occult folds of the fraenum. It may call for con- siderable care to expunge any morbid secretions from these situations, and the operation is not one that should be performed negligently or hastily. If a man have a venereal sore on the body of the penis, why, he richly deserves it, for nothing but gross neglect could have allowed the contact of the poisonous secretion for the length of time necessary for absorption, and particularly by the skin, which is not so apt at absorption as the mucous membrane. I have lately seen two instances, in which the sore was developed amongst the hair at the root of the penis. Here it is obvious that the washing had been imperfect, as not having reached that part, and probably the sufferers were not prepared for the develop- ment of a sore at so distant a point. This is only a reason for urging the application of the washing the most extensively possible. 1 Acids and alkalies possess the power of destroying the poisonous qualities of the syphilitic poison. PROPHYLACTIC TREATMENT. 233 After the washing has been thoroughly effected, the organ should be made perfectly dry, otherwise the moist- ure left by the ablution may only serve to effect the solution of some undisturbed atom1 of the poison, and facilitate its absorption. The power of oil of forming a kind of varnish to the skin, and preventing the contact of moisture for a time, might also be advantageously put in operation as a de- fence against the syphilitic poison, and as an antecedent, where careful washing is to follow as a subsequent. But it must not be relied upon as a sole defence; nothing should be permitted to interfere with the after action of the soap and water. Where a man is determined to rush into danger, the prepared caecum of the sheep may be advised as a pro- tection. It is one of great efficiency, and we are oc- casionally consulted under circumstances which render it necessary that we should be aware of the existence of such a remedy. The unexperienced may deride the suggestion, but the man of the world will appreciate its value. To woman, alas! we have no suggestion to offer, but that of inunction before, and soap and water and vinegar and water after, the act. There is a case in which the caecum of the sheep be- comes an all-important remedy, and where duty as well as security requires its use, namely, when a husband is suffering under chancre, and is anxious to conceal his misfortune. I need hardly say that ablution should not be confined to the hour; but should be performed daily, or at retiring 1 In reference to the reproductive powers of the poison, Mr. Acton observes : " To show the infinitesimal quantity of virus necessary for producing specific effects, one drop has been diluted with a pint of water, and the inoculated fluid has produced a pustule," (p. 353, second edition.) 234 TREATMENT OF SYPHILIS. at night, and at rising in the morning, until the time of danger is past. And then, we may be asked, what is that time ? For the mucous membrane it may be two, three, or more days; for the skin it may be as many weeks. In the instance (case 59) to which I have referred more than once, the venereal sore was four weeks before it made its appearance. Another question is frequently put to us: Is washing a certain preventive? The answer is simple: No; for ablution maybe imperfect; the poison may have become insinuated into some aperture of a follicle, some crevice, some undiscovered nook, where the soap and the water are incapable of reaching it; but this I regard as an ex- ceptional case. I have at this moment under my care a medical student with constitutional syphilis, who de- clares that he did wash, and immediately after the act. I can only not believe him, or rather that he could have performed the operation thoroughly; that he did not do so effectually is quite evident, unless we give him the benefit of an exception, which I must confess myself un- willing to grant without cogent reasons. In addition to efficient washing, certain astringent and stimulant lotions might be recommended; such as a solution of the super-sulphate of alumina, in the propor- tion of two drachms to the pint; a lotion of tannic acid, one drachm to the pint; port wine, diluted with six parts of water; eau de Cologne, diluted with ten or twelve parts of water, and so forth. But these appli- cations must all be considered as secondary to the saponaceous ablution. If the skin or mucous membrane be abraded or torn, so as to give rise to an excoriation, the stick of nitrate of silver should be passed over the abraded surface, and a piece of lint placed upon it, so as to prevent its contact CURATIVE TREATMENT. 235 with an opposing surface. If the excoriation evince any tendency to inflammation, the lint should be soaked in a solution of the watery extract of opium (one drachm to four ounces), and the part covered with water dress- ing. Any sluggishness of action on the part of the ex- coriation, or indisposition to heal, may be met by a mildly stimulating lotion, such as that of sulphate of copper or sulphate of zinc (two grains to the ounce), nitrate of silver, in the same proportion, the tannin lotion mentioned above, or the black wash and dry lint. In the case of any inflammatory disposition evince'd by the excoriation, it might also be desirable to administer some mild saline aperient, with tartarized antimony, in antiphlogistic doses. CURATIVE TREATMENT. We must now suppose that the effects of contagion have become evident on the organ, in the form of a papule, a pustule, or a small sore. What is now to be done? The abortive treatment must be immediately practised; that is, the pimple, pustule, or sore must be instantly touched with a caustic application, with the double view of destroying the morbid structure of which it consists, and of setting up a new and healthy action, in place of the poison generating one already in exist- ence or about to begin. If I were asked—Is there no alternative to such a practice as this ? I should say, none. I have heard of such an appearance as that to which I am now referring being made the subject of discussion or argument as to whether it were or were not a chancre. Such delay is a cruel injury to the patient. If it be not of a syphilitic nature, no harm can arise from the use of the caustic; 236 TREATMENT OF SYPHILIS. if it be syphilitic, the proper and only safe treatment has been put in force. If a patient have a simple excoriation, and that ex- coriation be the precursor of constitutional syphilis, it is a matter of infinitely small moment to him whether or not the sore had those particular scientific characters which would bring it into the classification of a simple venereal sore, a doubtful sore, or a genuine chancre. The fact is, that it is too much the custom to regard the primary affection as the disease, whereas, in truth, the primary affection is simply the indication of the inlet through which a poison capable of exciting a serious disease has been admitted to the blood. We have no evidence to prove how soon the poison passes into the blood, whether the poison pass immediately into that fluid, whether it be retained for a time by the tissues which primarily received it, and then enter the blood, or whether the original poison simply act as a ferment, and give rise to the production of a quantity of the poison in the part where the local disease mani- fests itself, and that from this source the supply is derived which contaminates the entire constitution. The question may be one of interest in a physiological point of view, but practically it is of little moment. The generally received belief is, that the poison remains for a time, perhaps a few days (the period must vary in different organizations), in the part where the primary disease is developed before it passes into the blood; hence the first duty of the surgeon is to destroy the tissues in which the poison is contained, with the rational hope that, with the destruction of the infected tissues, the poison may be annihilated. In the selection of the caustic, the surgeon will have to consider the respective merits of nitrate of silver, nitric acid, actual cautery, chloride of zinc, potassa cum ABORTIVE TREATMENT. 237 calce, or potassa fusa.1 I have long since given a pre- ference to potassa fusa; with it the destruction of the tissues is effected totally, and the extent of destruction may be regulated with the utmost nicety. The potassa cum calce (Vienna paste) comes next in the list of pre- ference; then chloride of zinc, which is objectionable on account of the pain to which it gives rise; then follow nitrate of silver, nitric acid, and actual cautery, all of which I consider to be perfectly useless. If a patient were to tell me that his surgeon had cauterized the primary affection within an hour of its first appearance with the nitrate of silver, I should consider him as certain to have constitutional syphilis as if the sore had been left to itself. The morbid tissues are not confined to the actual surface, they extend probably to the depth of a line, and the nitrate of silver effects the surface only. It forms a hard, leathery layer at first, which is soon followed by a still harder crust, and both effectually conceal from the eye of the surgeon what is passing beneath them. As a destructive agent it is a most unsurgeon-like remedy. With a pointed stick of potassa fusa, on the other hand, the surgeon possesses the almost magical power of converting all he touches into a transparent jelly; and with a sponge he wipes away the disease as though it were laid mechanically on the surface, and, above all, with little pain to the patient; and he dismisses his patient absolutely cured; that is, if the patient present himself before the surgeon on the earliest appearance of the local disease. I must here remind my junior readers, that the potassa 1 Mr. Acton remarks that alkalies and acids destroy " the property which inoculation has invested the sore with, of producing an analogous secretion, provided they be employed at an early stage," (p. 353, second edition.) 238 TREATMENT OF SYPHILIS. fusa is a remedy that requires to be employed with caution; it is, perhaps, the most powerful destroyer of animal tissues known; and although, in the hands of the experienced, it is as safe as the most harmless expedient of surgery, in the hands of the uninitiated it might be productive of the most serious injury. It always leaves behind it a deep and permanent cicatrix, and therefore it becomes necessary to limit the extent of such a cicatrix as much as possible. It may be useful to remember, also, that, as soon as so much as is required of the caustic has been effected, a little vinegar and water will immediately neutralize the excess of the alkali, and its further corrosive action. The solution of continuity occasioned by the potassa fusa is to be treated upon ordinary surgical principles; —a piece of lint moistened in a solution of the watery extract of opium, in the proportion of one drachm to four ounces, should be laid on the sore; and the organ enveloped in another piece of lint soaked in tepid water, and covered with oiled silk;—the common water-dressing. The patient should be recommended to remain at rest as much as possible, to keep the penis elevated, and to repeat the opium-dressing to the wound and the water- dressing to the organ night and morning. If swelling ensue, we should be prepared for the occurrence of phimosis, and take means to prevent it by enjoining the horizontal position, keeping the patient in bed, supporting the penis, and seeing that the water-dressing is properly adjusted. If phimosis take place, we must, failing other means, liberate the stricture by incision. However well in health a person may be at the time of syphilitic infection, the action of the poison on his tissues is a pathological condition, independently of which a man in civilized life is rarely so well that some function or other is not more or less the subject of PRIMARY SYPHILIS. 239 derangement; hence the opportunity is not to be allowed to slip of prescribing some gentle remedy for regulating the digestive functions, and with a view to anticipate any disposition to congestive action existing in his system. The following simple medicine, taken night and morning, is well suited for the purpose, and may be preceded, if the bowels are confined, or the skin yellow, with eight grains of the compound colocynth pill, and two of blue pill. R. Magnesiae sulphatis £j ; Antimonii potassio-tartratis gr. £ ; Aquae nienthse viridis 3xj. M. Fiat haustus. Now, supposing the abortive treatment to have been carried out in the manner and to the extent above described, there is no longer any poison; there is there- fore no necessity for treatment by mercury. It very rarely happens, however, that the patient comes to the surgeon at the first appearance of the disease; he is willing to deceive himself with some hope that what he sees is a mere pimple, which will subside; or perchance, by a strange neglect, some days transpire before he perceives the rising malady; or. very possibly, he had gathered certain ideas from the medical theories of the time, and doubts its being a chancre—in a word, he loses time; and the sore is several days old before the surgeon is called upon to treat it. The treatment is still the same; the only difference being, that the chance of arresting the poison in its transit to the blood is dimi- nished. The chance still exists; it is simply rendered less; but as there is a hope, however small, and the object is so important, the same procedure should be adopted. We receive a practical hint in illustration of this principle of treatment from the venereal sore itself, in 240 TREATMENT OF SYPHILIS. the various forms which, in different constitutions, it is apt to assume. In the cold and slow indurated chancre, the chances of transmission of the poison to the blood are the greatest, its actions are those of growth and assimilation; in the more active, superficially ulcerating sore, the chances are less; while in the sloughing and phagedaenic sores, they are least of all; and for the obvious reason that the great surgeon, Nature, has been at work with her potassa fusa, and destroyed together the poison and its fomes. Or let us turn for instruction to the inoculation of an animal poison, as in vaccination; it will then appear that excess of action in the inoculated spot is obstructive of its intended results; and that, if we wish the process to be perfectly successful, we must maintain a state of calm and rest. But, as in the syphilitic inoculation our object is exactly the reverse of this, we may find our best aid in that destructive action which removes the contaminated tissues, or an inflammation, which eon- verts the poison-generating action into one of formation of simple inflammatory products. The sloughing, or the phagedaenic venereal sore, expending its power upon the tissues which it involves, is a mere trifle in com- parison with the simple excoriation, the harmless-looking pimple, or the insignificant ulcer, which serve as the mere inlets of a dangerous, a repulsive, and life-lasting poison. A poultice, some doses of opium, and a few drops of nitric acid, command the one, but the best>directed medical treatment, persevered in steadfastly for years, may do little towards the subjugation of the other. In the case where the primary disease is attacked at the onset by local means, I have observed that general treatment is unnecessary; but if the functions of the body were obviously deranged, it would be desirable to restore them by the ordinary remedies. In the case of PRIMARY SYPHILIS. 241 the venereal sore of a few days' standing, on the other hand, constitutional treatment is most necessary and most important. Let us consider why. A poison has been admitted into the tissues; there is every reason to fear that it may be received into the blood; our judgment is therefore called into exercise, not to prevent its admission into the blood, because, if the endosmotic action be once set up, that is impossible, and even if it were not, we are powerless as to means ; but, to prevent the increase of the poisonous ferment in the blood, firstly; and secondly, to insure its being car- ried away by the natural emunctories of the system, as rapidly as it is formed. These, then, are two simple and obvious indications, to the fulfilment of which our treatment should be directed. 1. To prevent the increase of the poisonous ferment in the blood, the blood should be put in as healthy a condi- tion as possible; and to this end, the diet should be regular and unstimulating; alcoholic stimulants and smoking should be carefully shunned; the mind should be kept at rest; a proper amount of exercise should be maintained; a tepid or cold bath taken daily; cold and fatigue avoided; and the secretions of the bowels and kidneys properly regulated. We might fairly hope, in effecting this state of the animal functions, to preserve the blood in a healthy condition, in one favorable to the resistance of a morbid process, like that of the genera- tion of a noxious ferment. 2. The next indication, namely, to cause the removal by the natural emunctories of the body of the noxious poison as rapidly as it may be formed, would require, in addition to the faithful carrying out of the requisitions of the preceding indication, the use of medicines which are known to possess the property of exciting the emunc- tories to increased action. At the same time, it must be 16 242 TREATMENT OF SYPHILIS. remembered that this kind of excitement is not to be carried too far, or be too long continued, otherwise it becomes a disease, and lays the foundation of more serious evils. It would be better far to do nothing than to do too much. The great emunctories of the body are the bowels, the kidneys, the liver, the skin, and the entire extent of the mucous membrane. The bowels require, to increase their activity, the use of gentle aperients; the liver, mercurials; the kidneys, aqueous fluids, and alkaline salts; the skin, antimony; and the mucous membrane, in general, ipecacuan. Nearly the whole of these remedies, separately, form the basis of the various modes of treatment which have been adopted from time to time for the treatment of sy- philis; but it is clear that, if our purpose be to excite the emunctories, we require not one alone, but all together, or at least an equivalent. Of all the known remedies for syphilis, mercury is that which has for the greatest length of time maintained its character and warranted the confidence of medical men; and for the simple reason that mercury alone possesses the power of acting upon all the emunctories of the body; it excites action in the bowels, the liver, the kidneys, the mucous membrane, and even in the skin; mercury, then, deserves to be considered the great anti- dote of syphilis. But while mercury is the remedy for syphilis, there is no medicine which requires greater judgment in its use; there is no medicine more safe, if properly employed, or more dangerous and destructive, if abused. And then, we are not to rely upon mercury alone; mercury, un- assisted, is a remedy of very trifling value, when com- pared with mercury supported by the other adjuvantia with which our materia medica abounds. All other PRIMARY SYPHILIS. 243 remedies by the side of mercury are feeble and inefficient; they may be safer in inexperienced hands, but they are m nowise safer than mercury in the hands of the master of medicine. It is use or abuse which makes mercury a blessing or a curse. But to return : To fulfil the second indication in the treatment of primary syphilis, the patient must take mer- cury; the form in which it shall be exhibited being left to the judgment of the surgeon. I prefer the blue pill where it can be procured perfectly pure; Mr. Acton, an eminent authority, gives a preference to mercury with chalk; others choose the chloride, or the iodides; but the truth is, that the form in which the remedy is exhibited is a totally secondary consideration; the manner, the extent, and the purpose, are the primary objects. A good workman will produce good work with bad tools; a bad workman will fail with the best tools. The dose of the mercury is from two to five grains of the blue pill, three to five of the hydrargyrum cum creta, two or three of the chloride, one grain of the iodide, and a quarter of a grain of the biniodide, to be taken for the first five or six days at night only, and afterwards night and morning. Then the mercury should be combined with a sedative, such as opium, conium, lettuce, or hyoscyamus; a quarter of a grain of opium, or three or four grains of extract of conium, lettuce, or henbane; and for two reasons, firstly, to prevent the occurrence of excess of action of the bowels; and secondly, to subdue the irritability of system which an irritant purge might occasion. For the same reason, in the regulation of diet, acids should be eschewed, as tending to occasion the purgative action of mercurials. This effect may sometimes be controlled by combining the mercurial with three grains of Dover's powder, or with catechu, or kino; and if the purgative 244 TREATMENT OF SYPHILIS. action continue, the form of mercury may be changed. The protioduret has appeared to me to have the greatest tendency to produce relaxation of the bowels, the mer- cury with chalk and blue pill the least. For ordinary cases this treatment is all that may be considered necessary, and it possesses the great advan- tage over every other of ^permitting the patient to pursue his usual habits of avocation and exercise. It evinces also the great powers of mercury, and the grand results which we expect from its use. No other medicine exhibits the same amount of pretension, and none war- rants the confidence which we repose in it. By its aid a man is enabled to move about, to think and to act as in a state of health, and all this while under the influ- ence of a medicine which controls the actions of a poison in his blood, and directs it in a current stream out of his system. I have said, in reference to the first indication for the cure of syphilis, that the patient should take an abund- ance of diluent drinks. The purpose of these is to dilute and dissolve the poison, and to supply a vehicle by which it may be conveyed away from the body, through the gastro-pulmonary mucous membrane, and particularly through the kidneys and skin. In the summer-time, the heat of the weather becomes a valu- able remedy as promoting the transpiration of the in- gested fluids through the skin. This action may be advantageously promoted by exercise, and sometimes, particularly in the winter season, by the addition of an eighth of a grain of tartarized antimony to the pill above prescribed. In cases where it is found necessary to confine the patient to his room or to his bed, the emunctory action of the mucous membranes, the kidneys, and the skin, may be further stimulated by sudorific drinks, such as / PRIMARY SYPHILIS. 245 infusion of elder-flowers, compound decoction of sarsa- parilla, decoction of the woods, decoction of saponaria, &c. In a word, the treatment of primary syphilis consists in limiting supply and encouraging waste. But the supplies are to be limited, not restricted; the waste is to be economized, and not encouraged to run to profusion; and herein lies the real difficulty of treating syphilis—a difficulty which can only be overcome by judgment, discretion, and patience. And now, having dilated so fully upon the purpose to be gained in the administration of mercury, it should be unnecessary to remark, that the medicine must not be carried to the extent of producing any of the well-known morbid effects of that remedy. Among the first of these morbid effects is that increase in the quantity of the saliva, attended with soreness of the mouth and tume- faction of the mucous membrane and salivary glands, termed salivation. These effects begin to be apparent at about the fifth day of taking the mercury, hence we proceed with great caution up to and beyond that period. We administer mild doses, at first at night only, after the fifth day we venture upon a morning dose on alter- nate mornings, in addition to that taken at night, and soon we reach the efficient frequency of a dose night and morning. This caution is the more necessary from the uncertainty of the effects of the remedy upon an untried constitution; some persons possess an idiosyn- crasy favorable for salivation, while others resist the action of mercury almost indefinitely. I once saw a man salivated by stopping his tooth with a mineral amalgam containing mercury; and many cases are recorded of a high degree of sensitiveness to this med- icine. As it is our purpose carefully to avoid salivation as 246 TREATMENT OF SYPHILIS. injurious both to the objects of our treatment and to our patient, we diminish the dose of the mercury as soon as the first symptoms of salivation are perceptible, or sus- pend it entirely until these threatening symptoms sub- side. If a patient present himself to us during a course of mercury, we have no difficulty in detecting the fact by the odor of the breath, the congested state of the mucous membrane, or the presence of a red line parallel with and near the free margin of the gum; and if we be desirous of keeping up the effects of mercury on the system, these are the signs by which we know it to be acting according to our wishes. When salivation has taken place, our treatment must be directed to its relief and removal, for in the inflamed condition of the mouth and salivary glands which accompanies that state we can do nothing towards the cure of the original disease. The remedies suited for the relief of salivation are, gentle aperients and astrin- gent gargles. Among the best of the latter are a solu- tion of the chlorinated soda (one part to twelve of water), or barley-water acidulated with muriatic acid and sweetened with honey. When abrasions or ulcera- tions of the mucous membrane occur, they are to be touched daily with a solution of nitrate of silver (four or five grains to the ounce), or, as recommended by Mr. Acton, writh strong muriatic acid, the mouth being well washed out afterwards with tepid water. Internal remedies which have obtained repute in salivation are, the phosphoric acid, the chlorate of potash in drachm doses, and sulphur in half-drachm doses, with lemonade for drink. To these succeed acidulated bitter infusions; and as salivation is generally followed by more or less anaemia, ferruginous preparations become necessary, such as the potassio-tartrate of iron, vinum ferri, or per- haps, best of all, the citrate of iron and quinine. PRIMARY SYPHILIS. 247 We may now inquire how long the mercurial treat- ment should be continued ? The answer must be deter- mined by the state of the sore. It should not be stopped for a week after the sore is healed; but, in the case of the indurated sore, must be continued as long as any induration remains. The common superficial sore and the other common forms of venereal sore are mere local diseases, the constitutional treatment being of use to them rather as a preventive of absorption than as a cure. They heal as soon as the local action ceases, and their progress is hastened by the reparative vigor given to the entire system by the course of mercurial treat- ment. The indurated sore, on the other hand, is a local disease, plus a constitutional disease, it is a secondary action superadded to a primary disease, and evinces that the blood has been already fully saturated with the poison. The indurated sore, therefore, requires the course of treatment for secondary disease to be added on to that for the primary disease; it requires longer time and often additional means. I have heard it said that the mercurial treatment involves so many inconveniences and dangers, that it should not be practised excepting under extreme cir- cumstances. What may be the meaning of this remark I am unable to comprehend. Is there any danger in the fullest course of mercury, conducted upon the prin- ciples which I have just been laying down? Surely, none whatsoever. But there is great danger in permit- ting a poison to creep into the tissues and revel in the blood undisturbed. Is there anything in this treat- ment that should prevent us from using it in any case of chronic disease that might require an alterative treat- ment? Certainly none. And why should we hesitate to employ it in syphilis ? Without a thorough acquaint- ance with the laws and phenomena of syphilis, 1 grant 248 TREATMENT OF SYPHILIS. that a man is not entitled to treat it. But the objection to mercury rests upon a groundless prejudice—a preju- dice which dates back to a period when mercury was "thrown in" with a want of judgment frightful to con- template ; when a common expression in one of the public services was, to " heave a fellow down" with mercury. But we live in different times now, and have a better knowledge of the powers and uses of reme- dies. It is a question, about which some difference of opinion may be supposed to exist, whether mercury is needful in the simple superficial venereal sore; but there can be none with regard to its inapplicability to the inflamma- tory and phagedaenic sores. These latter must be treated according to the common principles of surgical medicine. The inflammatory chancre, or simple venereal sore, complicated by inflammation, has a tendency to run on to gangrene and sloughing; and this disposition must be checked by the maintenance of the recumbent posture, by aperients and salines internally, and locally by the application of the solution of opium, previously mention- ed, and warm water-dressing. These means will not fail to control the inflammatory action and bring the sore into a healing state. Should phimosis occur, and produce strangulation of the glans, it may be necessary to divide the stricture with a bistoury. The phagedenic chancre indicates an irritable state of the system which calls for the use of sedative and tonic remedies internally, and the adoption of means to check the destructive action going on in the part. Pure nitric acid has long enjoyed a reputation for checking the local mischief; it should be applied by means of a piece of lint fastened to the end of a stick, and after being allowed to remain in contact with the ulcerated surface for a few PRIMARY SYPHILIS. 249 seconds, must then be washed away by means of a stream of tepid water. It is desirable, before making this application, to calm the patient's nervous system by the exhibition of a full dose (forty minims) of laudanum. After the excess of nitric acid is washed away by the water, the sore should be treated with the solution of opium and water-dressing. Sometimes so great a degree of irritability appears to be present that caustic applica- tions are contraindicated, in which case we must be satisfied with the opiate solution, or we may prefer to employ some other caustic than the nitric acid; for example, the potassa cum calce, nitrate of silver, acid nitrate of mercury, or sulphuric acid. If the healing of the sore be tardy in its progress, it may be stimulated by the sulphate of copper, a solution of nitrate of silver (ten grains to the ounce), or a lotion of tincture of iodine, one or two drachms to the half pint. The phagedaenic chancre is frequently accompanied by an anaemic state of constitution, in which the ferru- ginous preparations are indicated. Ricord recommends the potassio-tartrate of iron in large doses in phagedaenic ulcerations. I must not pass over in this place a common accompa- niment and consequence of venereal infection, namely, enlargement of the inguinal glands, or bubo. The bubo of indurated chancre partakes of the properties of the parent sore; it is slow, chronic, affects both groins, and frequently several glands, and gives rise to little in- convenience or pain. The bubo of the other forms of chancre is more acute, painful, and involves only one gland. There are, besides, buboes resulting from irri- table or unhealthy states of the constitution, which are to be distinguished from the preceding. When the bubo is unattended with pain it may be treated by compression, or simply by the application of 250 TREATMENT OF SYPHILIS. a piece of ammoniaco-mercurial plaster ; or if it threaten to pass beyond its chronic stage, by the application of nitrate of silver as a stimulant discutient. If there be tenderness and signs of active inflammation about the glands, the patient must be kept at rest, and the enlargement treated by cold and compression; and even in this stage cauterization of the surface is often of value. Should the inflammation run on to suppuration, the abscess must be opened by the potassa fusa, or potassa cum calce. When opened, the resulting sore is to be treated writh the solution of opium and water- dressing ; with the addition of a solution of nitrate of silver, or sulphate of copper, should a stimulant appear desirable. When the bubo is inflamed and painful, but indisposed to suppuration, the application of a belladonna plaster is often productive of relief. After the inflammatory action has subsided, and the glands still remain enlarged and indurated, compression comes again into action, assisted by mercurial frictions, and the use of the iodide of potass with chalybeates in- ternally. Where the enlargement is peculiarly indolent, or irritable, a blister is often a useful remedy. TREATMENT OF CONSTITUTIONAL SYPHILIS. In constitutional syphilis, we have no longer to deal with a possibility of absorption of the poison; the fact is placed out of the reach of doubt; the poison is in the blood, and makes its presence known by certain signs. Our treatment, therefore, must be directed to the removal of the poison; and for this reason, every power which we possess must be made to bear upon the natural emunc- tories of the system; the bowels, the liver, the kidneys, and the skin. It rarely happens that the syphilitic fever rises so CONSTITUTIONAL SYPHILIS. 251 high as to require the abstraction of blood; but such cases nevertheless occur; and if the patient be full and strong, no inconvenience can arise from the practice. Local congestions are relieved by the bleeding; the nervous system oppressed by the weight of the poison is lightened; and the blood which remains is impressed with a different action to that of generating a morbid ferment; namely, one of repairing its own loss. On the other hand, it must be borne in mind, that upon the general powers of the system must fall the labor of eliminating the poison, and resisting its morbid effects; hence the constitution must not be lowered too much, and particularly so in cities and large towns. Indeed, the power which we possess of relieving the blood through the natural emunctories is so great, that venesection is only likely to be required in very severe cases of local congestion, as of the brain or lungs; and even in such cases, the quantity requiring to be removed is very small. The general inflammatory excitement attendant on an outburst of the syphilitic fever is there- fore to be combated by active purges, diuretics, and dia- phoretics. A dose of calomel and colocynth, followed by a draught of senna and Epsom salts, will effect the first of these objects; and tartarized antimony, with abundance of diluent drinks, the rest. Opium is also a necessary element of the treatment, its purpose being to calm irritability and restlessness; with this object, and for the purpose of aiding the action of the mucous mem- branes and skin, ten grains of Dover's powder, at bed- time, will be found of much service. As soon as the inflammatory excitement is allayed, it is time to begin the mercurial treatment. I am not aware that any particular form of mercurial preparation is superior to another for this purpose. I select usually the biniodide, which I prescribe in doses of a third of a 252 TREATMENT OF SYPHILIS. grain in combination with extract of lettuce, or conium, three times a day. This medicine agrees with the stomach usually very well; but if it produce nausea or uneasiness, then I either exhibit the pills less frequently, or have recourse to some other form of mercurial pre- paration. Where the alimentary canal evinces a decided repug- nance to the presence of mercury, we may obtain its effects by means of inunction. For this purpose a drachm of the strong mercurial ointment should be gently rubbed into the inner side of the thigh and leg every night at bedtime, changing the leg each night to avoid too much irritation of the skin. In a case where it was of conse- quence that the inunction should not attract the atten- tion of the patient's family, I limited the frictions to the soles and inner sides of the feet with perfect success. Indeed, the inunction may be made on any part of the body that shall be most convenient to the patient. In pursuing the mercurial treatment, it is of the utmost importance to pay attention to the rules with regard to hygienic conditions and diet, already laid down for the treatment of the primary disease. Stimu- lants of all kinds, either in food or drink, are to be carefully avoided, as is also exposure to cold and fatigue. And the intention of the treatment should never be lost sight of, namely, to increase the natural functions of the depurating or einunctory organs, the bowels, the liver, the kidneys, and the skin. The action of the mercury, and especially the func- tions of the kidneys and skin, are very much aided by the use of the compound decoction of sarsaparilla; the compound decoction of guaiacum; the decoction of sapo- naria, or the infusion of elder-flowers. I have no belief in the specific powers of sarsaparilla; but I cannot con- ceive a remedy better suited for the purpose of soothing CONSTITUTIONAL SYPHILIS. 253 the alimentary canal, and at the same time of acting on the depurating organs, than the compound decoction of that root. For this purpose it must be taken largely; a pint and a half or a quart in the course of the day. We have now the plan of treatment of constitutional or secondary syphilis before us; namely, 1. The careful avoidance of all stimulants, either mental or physical; the patient to keep his bed or his room; and to defend himself particularly from the risk of being chilled." 2. Medicinally; if the inflammatory symptoms run high, and the powers of the system be equal to the loss, ab- straction of a few ounces of blood; leeches or mustard cataplasms for local congestions; a calomel and colocynth purge, followed by a black draught, together with liquor ammonioe citratis and tartarized antimony; or efferves- cent salines, with antimony; and a Dover's powder at bedtime, until the inflammatory stage is subdued. 3. Mercury in small doses, with the compound decoction of sarsaparilla; attention to the bowels, and an opiate at bedtime. Besides the above, which may be regarded as embrac- ing the more essential points in the treatment of con- stitutional syphilis, there are several appliances which may be added to the general treatment, or be made to occupy a prominent position, according to the views of the surgeon or the convenience of the patient; for ex- ample, the warm bath and vapor bath. The former of these is soothing and agreeable, and may be used daily, or even twice a day. The latter might also be used daily; it is a powerful and important remedy, and establishes an active drain, which doubtless carries off a large share of the syphilitic poison in its stream. The vapor bath, of late years, has acquired additional importance, from its having been made the chief agent of treatment of constitutional syphilis by Langston 254 TREATMENT OF SYPHILIS. Parker. Mr. Parker raises the vapor of the water by means of a lamp, and he also introduces beneath the cloak which surrounds the patient, an oxide of mercury, furnished with a separate lamp, for the purpose of vapor- izing it; hence, he observes, the patient is " exposed to the influence of three agents—heated air, common steam, and the vapor of mercury." Here, it will be seen, the treatment is made to turn upon the general emunctory property of mercury, and the special emunctory action of the skin. In Germany, in addition to several curative processes, which turn upon the limitation of supplies, one method of treatment, which may be briefly defined as a triple compound of starving, purging, and sweating, enjoys especial favor. I mean the treatment by Zittmann's decoction. This treatment is as follows :— On the first day the patient takes a full dose of calo- mel and the resinous extract of jalap. During the next four days he drinks daily two quarts of Zittmann's decoc- tion ; one quart of the strong decoction, taken warm in the morning, and one quart of the weak, cold, at mid-day. On the sixth day he repeats his calomel and jalap pills; and during the four succeeding days, continues the decoc- tion, as before. On the eleventh day, if the patient be strong, he takes another dose of the purgative pills; if not, this is dispensed with. During the above treatment, the patient's diet is care- fully regulated; on the days when he takes the purga- tive medicine he has three meals of broth ; on the decoc- tion days he is allowed two ounces of roast-meat and two ounces of bread. He keeps his bed during the entire treatment, and at its conclusion is not permitted to quit his room for some time longer, maintaining a low diet, and drinking the decoction of the woods. If the patient be suffering under syphilitic ulcers, these CONSTITUTIONAL SYPHILIS. 255 are dressed simply, with lint soaked in water; and if he be weakly, he takes of Zittmann's decoction only one bottle a day instead of two, with a view to prolong the treatment. If he be not well at the conclusion of the treatment, it is to be repeated a second time, or until he is well. This treatment has the sanction of a sound practical surgeon, whose practice I had the advantage of following for some time—Chelius, of Heidelberg. The decoction keeps up a constant state of perspira- tion from the skin, increases the quantity of urine, and produces five or six watery evacuations in the course of the day. Its mode of preparation is as follows :— Decoctum fortior. R Sarsaparilke radicis concisas ^iv; Aquae fontanae Oxxiv. Coque per quartam horse partem, et adde Aluminis, Sacchari albi, aa 3vj ; Hydrargyri chloridi giv; Antimonii oxysulphureti gj. In nodulo ligato. Sub fine coctionis admisce Sennae foliorum 5jiij ; Glycyrrhizce radicis ^iss; Anisi seminum, Foeniculi seminum, aa §ss. Decoque ad octaria xvj, et cola. Decoctum tenue. R Decocti fortioris residui, Sarsaparillae radicis |vj ; Aquae fontanae Oxxiv. Coque, et sub fine coctionis adde Pulveris corticis citronum, Pulveris cinnamomi, Pulveris cardamomum, aa ^iij > Glycyrrhizae radicis 3vj. Decoque ad octaria xvj, et cola. After the symptoms of constitutional syphilis have fairly subsided under the influence of the mercurial treatment, the nitric acid may be exhibited for two or 256 TREATMENT OF SYPHILIS. three weeks longer, to give tone to the mucous mem- brane, and remove any remains of the poison which may still linger in the blood or in the tissues. The dose of the dilute nitric acid is twenty drops twice or three times a day, in sweetened barley-water; or it may be combined with the fluid extract of sarsaparilla, as a vehicle; or, should there be any appearance of anaemia, we must restore the healthy condition of the blood by means of ferruginous remedies. We may now suppose the first attack of constitutional fever, or secondary sj^mptoms, to have passed away; but it does not therefore follow that the syphilitic poison is entirely banished from the blood; on the contrary, the probability is, that after the lapse of a few months a second attack will occur, and after that we have a third, a fourth, and even more; the attacks at last becoming irregular, and putting on a new shape and new characters. We have therefore to consider what modification of treatment may be most suitable for these successive attacks; what change of remedies the chronic character of the syphilitic disease may require. It is a curious fact, that as the attacks of constitutional syphilis become further removed from the original conta- gion, that is, as the poison becomes more and more assimilated, mercury seems to lose its influence, and other remedies acquire the control of the poison which it previously possessed. That may not be the case with regard to the second, or even the third, outbreak of the syphilitic fever; the time varies in different constitutions, but we must be prepared for the manifestation of the peculiarity sooner or later. In the second attack of constitutional disease, the biniodide of mercury will possibly be found to retain all its power; in the third, the bichloride may be more efficient; in the fourth and successive attacks, the iodide CONSTITUTIONAL SYPHILIS. 257 of potassium. It is difficult to explain this peculiarity otherwise than by supposing that the tissues lose their susceptibility of being excited by the mercury after a number of repetitions. In the chronic forms of syphilis, those forms which belong to the " tertiary" period of Ricord, mercury is not only inadequate to the removal and cure of the disease, but is actually injurious, inducing irritability of system, producing new and more violent attacks of eruption, and forcing a simple tubercular eruption into a state of refractory ulceration. It is at this period that iodide of potassium takes the lead as an antisyphilitic remedy, and its use is attended with the most satisfactory results. Sometimes it effects a cure in a short period; at others it seems to flag in its effects, and requires to be increased in dose; and it may be beneficially assisted by bitters, or, in case of an anaemic state of the constitution, by the preparations of iron. I have before remarked that a useful and effective dose of the iodide of potassium in the beginning of treatment is three grains; this we may increase, if need be, to five, eight, or ten grains, or even more, three times in the day; and indeed, without such increase, we are liable, in cases rendered unusually rebellious by mal-treatment, and especially by the abuse of mercury, to fail altogether, and attribute to the remedy what is properly due to our own mismanagement. The iodide of potassium is the remedy best suited to those chronic forms of tuberculous eruption which I have distinguished as tubercula circumscripta (cases 22 to 25), and it is especially indicated in the ulcerating tubercles (cases 30 to 37), and those deeply-seated dis- organizations of the skin and sub-cutaneous tissues which have received the name of "gummata," (case 67.) Experience has taught us that there are certain symp- toms, frequently of great severity, which sometimes 17 258 TREATMENT OF SYPHILIS. exist as complications of constitutional syphilis, which may be advantageously treated by particular remedies; this is the case with regard to Syphilitic Neuralgia and Syphilitic Rheumatism. The remedy for these affections is the iodide of potassium, under which they yield rapidly and completely. In severe cases, the dose of the iodide should be five grains, with one drachm of the compound tincture of gentian, or in the compound decoction of guaiacum or sarsaparilla, three times a day; in less severe cases, three grains may be enough. It is surprising how rapidly the most dreadful neuralgic pains yield before this medicine. It is curious also to note that the iodide sometimes occasions pains similar to those which it has the property of removing. I am not aware that this could take place in persons who had never suffered from syphilitic neuralgia; for it is to persons of the latter class that I now allude. A gentleman, who had suffered from severe syphilitic neuralgia in the head, without being aware of its nature, consulted me eighteen months after, for some slight eruption, which I recog- nized as chronic syphilis. I prescribed for him the iodide of potassium in three-grain doses, three times a day, with a Plummer's pill at bedtime. After he had taken the iodide for little more than a week, he experienced a sudden and violent return of the old pain in his head; he had only that one attack of pain, which was not repeated, although he continued to take the medicine. The gentleman, whose medical history forms the subject of case 72, reported that a few nights after having commenced taking the iodide of potassium, which I had prescribed for him, he had violent neuralgic pains; they went away in the morning, and he has had no repetition of them since. The pains in these cases I should be inclined to refer to some remains of the syphilitic poison CONSTITUTIONAL SYPHILIS. 259 lingering in the nerves, disturbed, and probably dis- placed, by the medicine. I have already observed that in those chronic cases of constitutional syphilis (tertiary syphilis) where mercury ceases to exert a beneficial influence; where mercury is not merely negative in its effects, but obviously and plainly excites an irritable and destructive action both on the system at large and upon the local disease; our great remedial agent is iodide of potassium, and this medicine frequently acts as a charm in such instances. I have in my mind at this moment the case of a gentle- man, who one morning staggered feebly into my con- sulting-room, accompanied by his physician, and ordi- nary medical attendant. He introduced himself as a lost and hopeless man; and he certainly presented a vivid picture of exhaustion and decay. He showed me several large, deep, and foul ulcers upon his legs, and he said that the surgeons of eminence whom he had con- sulted, even a few days before his visit to me, would insist upon his taking mercury, which he knew was destroying him. I prescribed for him the iodide of potassium; and in less than three months he called upon me, having just returned from the country, de- claring that he had never felt stronger or better in his life. I should be very sorry to have mentioned this case, if I thought it could, by any possibility, be used as an argument against mercury. Mercury, as I have before observed, is an invaluable medicine, but one re- quiring to be used with judgment; to be watched in its effects, and to be regulated according to those effects rather than upon any scheme of theoretical results; indeed, mercury, like iodide of potassium, and every other medicine, must be exactly graduated in dose, combination, and period of administration, to the special case of the patient. Each patient as he varies in phy- 260 TREATMENT OF SYPHILIS. siognomy from his foregoers, varies also in constitution, in the characters of his disease, and in his susceptibility to the influence of medicine. Neuralgia, and chronic enlargement of the testicle, one of the morbid effects of chronic syphilis, and occu- pying, according to Ricord, a transition position between secondary and tertiary syphilis, requires iodide of potas- sium for its treatment. The enlargement of the testis, mentioned in case 4, was quickly and effectually removed by this medicine, and the pains in the organ subsided at the same time with those in the joints. Affections of a later period of chronic syphilis, and all those coming under the category of the "tertiary" syphilis of Ricord, namely, such as are developed at a long period after the occurrence of the primary disease, and affect the deeper structures of the body; for example, the fibrous tissue of the penis, the periosteum, and bones, giving rise to periosteal inflammation, nodes, and exostoses—are also to be treated with the iodide of potassium. Locally, affections of the bones and periosteum, if they do not immediately yield to the iodide of potassium, re- quire the addition of local applications, such as a few leeches; followed by poultices, fomentations, and seda- tives, if the*pain be acute; or a blister followed by seda- tives, if the pain be chronic or obstinate; sometimes a repetition of blisters is necessary; and if there be a purulent formation, the matter must be let out by inci- sion. The chronic thickening which sometimes succeeds to nodes must be treated by frictions of iodine or mer- cury, or the application of the ammoniaco-mercurial plaster. The iodide of potassium seems to act, generally, upon all the tissues of the body, in a remarkably short space of time, and especially on the kidneys. Its combination CONSTITUTIONAL SYPHILIS. 261 wTith the compound decoction of sarsaparilla facilitates its action, notably increasing its diuretic properties, and supplying a convenient vehicle, by which the poison may be excreted by the mucous membranes and by the skin. After it has been taken for a time, it begins to excite an over-action in the various tissues of the body; firstly, in the mucous membrane ; then, in the nervous system and brain; and these actions may be regarded as evincing the poisonous properties of the medicine. I have said that the symptoms now referred to are first perceived in the mucous membranes, and especially in that of the fauces, the nose, and the eyes. All that is necessary, therefore, is to watch for these symptoms, and if it be thought desirable, as soon as they occur, the use of the remedy should be suspended, or the dose reduced. In this way we are enabled to put an immediate stop to the continuation of the morbid effects. When iodine begins to act as an irritant to the system, there is a feeling of stiffness and dryness in the throat; more or less coryza, and an uncomfortable feeling with increased secretion from the nose ; sometimes tenderness of the salivary glands and salivation. By degrees the congestion extends to the trachea and bronchial tubes, adding bronchitis to the other symptoms. These indications of irritation of the mucous membrane gene- rally precede those of disturbance of the nervous system, and give sufficient warning of a necessity for putting a stop to the use of the medicine. When the iodine has been carried further, the patients complain of dimness of sight, giddiness, and pain in the head; and in one patient I saw severe palpitations of the heart. But although I have used the medicine extensively, I have seen very little of its morbid effects, probably from having exhibited it in small doses. 262 TREATMENT OF SYPHILIS. Iritis, another particular affection sometimes attend- ant on constitutional syphilis, requires the administra- tion of mercury until the mouth is made tender. For this purpose calomel and opium, in doses of two grains of the former combined with a quarter of a grain of the latter, and exhibited every four, six, or eight hours, in order to influence the system as speedily as possible, is the most valued treatment. The inflammation is usually of the chronic kind, and yields very favorably before the mercurial action. Bleeding is unnecessary, and the severe pains which sometimes accompany the iritis, being of a neuralgic kind, are speedily removed by the iodide of potassium. In chronic syphilitic affections of an obstinate kind, a method of treatment is pursued on the continent, which has for its basis the bichloride of mercury. I am in- duced to refer to this plan, because it has been mentioned to me with praise by several physicians of northern Europe; but I must confess myself so little impressed in its favor, that I have not even ventured to give it a trial. The method is that of Dzondi, and is as follows:— He begins by exhibiting to his patient one-fifth of a grain of the bichloride of mercury, which he continues for twenty-seven days, augmenting the dose by one-tenth of a grain every third day, so that on the last day of treatment the dose has become raised to one grain and a half; and the patient will have taken in the course of twenty-seven days, twenty-two grains of the mercurial salt. During this course, the patient is to be kept warm, to live abstemiously, and to drink decoction of sarsaparilla, or of the woods. If salivation should threaten, the treatment is to be suspended until the danger is past, and then continued as before. SYPHILODERMA. 263 LOCAL TREATMENT OF THE SYPHILODERMATA. Syphilitic eruptions of the skin, when general, require no other treatment than the occasional use of the tepid soap-bath. When local, and particularly when situated on the face, the diluted citrine ointment, or the nitric- oxide of mercury ointment, applied with gentle friction, are good remedies, and tend to hasten the absorption of the pimples and tubercles, and the removal of the stains which they leave behind them. When tubercles pass into a state of ulceration, these ointments are still of much service, as gentle stimulants. But when a more soothing remedy is required, or when we merely desire to protect the ulcer from the influence of the atmosphere, we may have recourse to the oxide of zinc ointment, either by itself or in combination with a few grains of camphor, or a few drops of liquor plumbi diacetatis. For sloughing sores, an opiate lotion and water-dress- ing answer the purpose well, and if the ulcers be indis- posed to heal, the black wash and yellow wash, either with or without opium. In these cases, and particularly in phagedaenic sores, Phave found a lotion of chloride of zinc of excellent service ; a medium strength is one drachm to the half pint, but this can be increased or diminished, according to its effects, and particularly in reference to the degree of pain which it may occasion. Of course, the local treatment is quite secondary to that of the general system; but I have succeeded beyond my expectation, in several instances, in causing the removal of local tubercular masses in a state of ulcera- tion, by frictions with the mercurial ointment. 264 TREATMENT OF SYPHILIS. TREATMENT OF SYPHILITIC ALOPECIA. It is remarkable how soon the fall of the hair, which accompanies syphilis, is checked by means of the reme- dies employed for the relief of the other sj^mptoms ; the mercurial preparations or the compounds of mercury with iodine. The plan of treatment is therefore simple and obvious. Occasionally, however, alopecia is the only evident symptom of the presence of the syphilitic poison in the blood, in which case we should hardly be warranted in subjecting our patient to a mercurial course. Under such circumstances, I have found the iodide of potassium, in three-grain doses, three times a day, or five grains twice a day, answer every purpose ; continuing the treatment for a medium period of six weeks, unless symptoms of iodic irritation arise. For local application the best remedy is a pomatum, consisting of one part of the nitric-oxide of mercury ointment to three of scented pomatum. This should be well rubbed into the roots of the hair at bedtime each night, and a proper degree of action maintained in the scalp, by means of plentiful friction with the hair-brush. As an aid to the stimulant excitation of the skin, the following wash, introduced among the roots of the hair by means of a sponge, may be used in the morning before brushing:— R Olei amygdalarum dulcium, Liquoris ammonias aa §j ; Aquae mellis ^ij ; Spiritus rosmarini, |;iv. M. Fiat lotio. This hair-wash, besides aiding in the excitation of the skin, assists in removing the scurf which is apt to form upon the sordid skin of persons affected with constitu- AFFECTIONS OF THE HANDS AND FEET. 265 tional syphilis, and affords great comfort to the patient. By these means I have never failed in checking the fall of the hair, and causing its reproduction where it had already fallen. TREATMENT OF SYPHILITIC AFFECTIONS OF THE HANDS AND FEET. The chronic affections of the nails, attended with dryness and imperfect formation, come into the same category with erythematous affections of the palms of the hands and soles of the feet, and their treatment is mercurial; either the biniodide or the bichloride. It is quite remarkable how rapidly chronic erythemata of the hands and feet, attended with desiccation, cracking, and exfoliation of the cuticle, and depending on syphilis, give way to the action of either of the above prepara- tions, in-alterative doses. In three weeks the misery of years may frequently be entirely cured, after every other remedy and mode of treatment had been tried in vain. Medical men suffering from this complaint have been startled at my audacity, when I have promised them a cure, in three weeks, of that which has baffled themselves for months, and more frequently for years; but my promise has rarely failed to be accomplished. I must mention, however, that these erythematous disorders are apt to return from time to time; but the remedy may be repeated as often as they appear, and in the end will prove triumphant. I do not believe that any good results from continuing the medicine for many days beyond the period of cure : I order it to be left off at the end of a week after the skin is healed; and prefer, in case of any return, to resume the remedy as before. For the local treatment of these erythemata, the camphor cerate is the best application, or the oxide of 266 TREATMENT OF SYPHILIS. zinc ointment with honey or the spirit of camphor. In either case, the proportion is a drachm to the ounce. If glycerine can be procured free from odor, an ointment containing a drachm of that fluid to the ounce of simple cerate is a good application; or a lotion, containing one part of glycerine to three of camphor mixture, or rose- water. The purpose of these local remedies is simply to keep the skin moist; and great comfort is sometimes obtained by sleeping with a water-dressing on the parts; the cure is to be looked for from the internal remedies alone. Onychia and the painful granulating sores which sometimes form under and around the nails, also derive their cure from the constitutional treatment; but they at the same time require some local management. When in an inflamed state, -water-dressing, or a solution of opium in place of simple wrater; when less painful, a weak solution of chloride of zinc, or acetate of lead, are the proper remedies. Sometimes the zinc ointment, or simple cerate with camphor, or an ointment of Peruvian balsam, answer better than the lotions; and in two or three instances I have obtained the best results from covering the granulations with powder of charcoal. TREATMENT OF CONDYLOMA. Condyloma, like other forms of syphilitic tubercle, obeys the will of the internal remedies employed against the manifestation of the syphilitic poison on the skin. It would get well without any external application; but sometimes we may be required to treat it locally, when the nitrate of silver, the oxide of zinc ointment, or a lotion of chloride of zinc, or alum, or the black or yellow wash, will be found the best suited to our purpose. AFFECTIONS OF THE MOUTH AND THROAT. 267 After drying the tubercles wTell, it has been recom- mended to powder them with calomel. TREATMENT OF AFFECTIONS OF THE MUCOUS MEMBRANE OF THE MOUTH AND THROAT. What I have said with regard to all the other syphi- litic affections which have been passed in review before us, must be repeated with regard to those of the mucous membrane of the mouth and throat. The disease is not in the mucous membrane, but in the blood; and therefore the general constitutional treatment directed towards the removal of the poison from the blood must be looked to for relief to the local affections, which are mere manifestations of the existence of the poison, and probably outlets for its escape. The ulcerations of the tonsils, the mucous membrane of the pharynx and fauces, and of the tongue, will heal under the. use of the general treatment of constitutional syphilis; but their progress may be assisted, or local indications may be fulfilled, by the application of nitrate of silver, or the use of antiseptic and gently stimulating gargles, such as that of alum in compound infusion of roses; hydro- chloric acid in simple infusion of roses; the bichloride of mercury in a weak solution of hydrochloric acid; the nitric-acid lotion; a weak solution of tannin; an in- fusion of green tea (^ij ad Oj); or a lotion of chloride of soda. Where the ulceration is extensive, advantage may be attained by the use of mercurial fumigations; or by touching the sores with the bichloride of mercury in honey, in the proportion of from five to ten grains to the ounce. If the affection of the throat belong to the latter period of the secondary disease, our chief reliance must be placed in the iodide of potassium. 268 TREATMENT OF SYPHILIS. TREATMENT OF CONGENITAL SYPHILIS. In the instance of the infant affected with syphilis, the treatment must consist of mercury; and the best remedies, in every respect, according to my experience, are, the bichloride or the hydrargyrum cum creta, which may be administered either to mother or child, or both, according to the judgment of the surgeon. If the mother evince symptoms of constitutional syphilis, it may be sufficient to exhibit the mercury to her only, the infant drawing its nourishment from her breast being regarded as part of herself. If the proportion of mer- cury thus conveyed to the infant be deemed insufficient, there can be no objection to give it independently to the latter. And in several instances I have satisfied myself with giving it to the infant only. I have not, in this case, for an instant imagined that the mother was free from the poison; but only that her tissues were so far accustomed to its presence, that it was incapable of setting up any morbid action, at least so long as she continued to suckle, and the milk performed the office of an emunctory current; and I was quite prepared, should any retardation in the cure of the infant occur, to exhibit the remedy to the mother also. In a word, I consider the safest practice in these cases to be, to give mercury to the mother as well as to the infant; taking care to moderate the dose to such a degree as not to check or injure the secretion of milk. I have heard it suggested, that the infant may be affected with syphilis in the womb of its mother, without the latter being contaminated; and that contamination of the mother may subsequently occur in consequence of the transmission of the poison of the diseased child to the tissues of the parent. Such a theory I consider CONGENITAL SYPHILIS. 269 to be most unphilosophical: it is easy to comprehend that, in the instance of syphilitic contagion, the child may be the seat of manifestation of the disease, just as in a male, the disease may fix upon one spot or one organ of the entire body; indeed, not merely because the foetus under such circumstances is a part of the whole, but because it is also a part of more recent forma- tion, a new organ, and made up of new tissues, which we may conceive to be more susceptible of receiving, and more easily influenced by, a morbid poison. It is also perfectly consistent with physiological laws, that the foetus having become the focus of excessive accumulation of the poison, the latter may react upon the parent with such force as to cause a manifestation of the presence of the poison in her tissues as well. The problem, therefore, resolves itself simply into one of latency and development. The dose of the bichloride to the mother, under the above circumstances, should be one-sixteenth of a grain in combination with syrup of poppies and tincture of bark, or the compound fluid extract of sarsaparilla, three times a day; and to the infant, one twenty-fourth of a grain in syrup of poppies and dill-wTater. The local treatment for excoriations around the nose and mouth of the infant is the oxide of zinc ointment, or an ointment composed of a drachm of the unguentum hydrargyri nitratis to the ounce of ceratum cetacei. The latter is especially applicable to excoriations in the neighborhood of the eyelids. For cracks upon the hands and feet, and for excoriations around the puden- dum and anus, the oxide of zinc ointment is also the proper application; and secretions in these parts may be absorbed by the oxide of zinc powder. For discharges from the meatuses of the ears, soap and water is the best remedy. 270 TREATMENT OF SYPHILIS. TREATMENT OF HEREDITARY SYPHILIS. After the age of infancy, congenital syphilis gradually merges into what may be termed hereditary syphilis. The infantile syphilis gets well, but several months or years afterwards, it breaks out again. Sometimes, how- ever, the patient has been free from any indications of syphilis in his infantile age, the first manifestations of its presence in the system being delayed to the period of advanced childhood, puberty, or even adult life. This more properly constitutes hereditary syphilis. The kind of syphilitic disease now under consideration, in its more recent forms yields without much difficulty to the bichloride of mercury; when more advanced, the iodide of potassium is a useful auxiliary; and in a more distant remove, the combinations of iodine, mer- cury, and arsenic, and cod-liver oil, become valuable remedies. I have had little experience of the hydro- chloride of gold, but I should apprehend that it is to the present form of syphilis that it would be especially applicable. Some of the forms of hereditary syphilis are remarkable for their extreme obstinacy, refusing the slightest obedi- ence to medical agents, and maintaining their course unimpeded. These cases are only to be managed by opposing obstinacy to obstinacy, by following them up with appropriate remedies, that is, by remedies directed upon a proper principle, when even the most enduring will be found to yield at last. In pursuing this course, it is evident that we must seek to obtain a gentle and continuous influence over the system, such as that by which Nature conducts her operations; we give expres- sion to our meaning by the term " alterative," our process should be essentially alterative; large doses of medicine HEREDITARY SYPHILIS. 271 and heroic action are only calculated to exhaust the powers and do mischief. In making these observations I have now in my memory several persevering " incura- bles," who, by a steady continuance of remedies for periods varying between one year and four, are fast approaching cure. And in another point of view, these observations are not without their value: the patient frequently tires, the surgeon despairs; in both instances, because an unwarrantable expectation has been created; but if from the first the difficulty be appreciated, both move onward with more comfort, and with less prospect of disappointment. The surgeon is no longer incited to make a bold effort, which cannot but end unhappily, and the patient takes no step to urge him to such an attempt by impatient suggestions. The young gentleman whose history is recorded in case 73 got perfectly well in the course of a few weeks, under the use of three grains of iodide of potassium three times a day, and a grain of calomel each night. In addition to the removal of the disease from the scalp, he improved in general health, the tumefaction of his abdomen sub- sided, and the tonsils became reduced. For hereditary syphiloderma palmare et plantare, I depend, as in the case of its occurrence as a form of chronic syphilis, on the bichloride of mercury. Cases 76 to 79 are all examples of the same form of disease, but presenting different degrees of severity. In them the triple compound of mercury, iodine, and arsenic, is the remedy upon which we must rely; and in case of failure with it I have recourse to the cod-liver oil. I need hardly say that any general indications which in the mean time present themselves, must be met by gene- ral means. It is also of importance to remember that when the remedies disagree with the patient, or seem to cease to exert a beneficial action, they should be im- 272 TREATMENT OF SYPHILIS. mediately suspended, and resumed after such an interval of time as may seem good in the judgment of the sur- geon. Like food and hygienic conditions, medicines, which are very beneficial at one moment lose their power after a time, and then require to be changed or modified, either in form or quantity, until the appetite for them returns. This is a very important rule to be borne in mind in the management of so obstinate a class of diseases as those of the skin. Cases 77 and 79, two most unpromising examples of disease of the skin, were both cured by Donovan's solu- tion. The dose which I am in the habit of giving is ten drops three times a day, with meals. Donovan recom- mended, when the medicine was first introduced to the profession, half-drachm doses; but for some years I have adhered to the smaller dose above mentioned, and, as I believe, with advantage. It is less likely to disagree with the stomach, or cause salivation, and it may be persevered in for a longer time. In chronic diseases, Nature demands chronic remedies. Finding the arsenic of the above solution frequently objectionable, I have sometimes had recourse to the tonic properties of quinine as an adjunct to the iodide of mercur}7, and with a very satisfactory result. The fol- lowing formula is an excellent substitute for Donovan's solution, agreeing well with the stomach, and possessing the advantage of being in a more condensed and con- venient shape for deglutition:— R Hydrargyri biniodidi gr. \ ; Quinse iodidi gr. j ; Micae panis gr. j ; Mucilaginis q. s. M. The dose of these pills is one three times a day. The cod-liver oil may be taken either at the same time with the Donovan's solution or the above pills, or, better still, after a course of the former. Case 76 is very HEREDITARY SYPHILIS. 273 instructive in this respect, and illustrates the changes which the constitution undergoes, and the consequent necessity of a change of means. In a first attack of the disease of the skin the patient cured himself by a two- months course of arsenic and liquor potassae. On a se- cond occasion, the liquor arsenicalis and liquor potassae failed, as did Donovan's solution, and iodide of potassium with Plummer's pills, as did the protioduret of mercury carried to the extent of producing and keeping up a tender state of the gums for some weeks; but the cod- liver oil succeeded instantly; in a day there was manifest relief, and in a month he was almost well. Now, I think that any medical man will be ready to acknowledge the value of the cod-liver oil in this case; but he will also feel that the remedy was adopted at the happy moment when the system was prepared to take advantage of its presence, and that that state of preparation was effected by the alterative treatment which had gone before. I have seen a similar result under similar circumstances, and I have seen cod-liver oil fail altogether, both when taken independently of any previous treatrftnt, and after a preparatory course of mercurial alteratives. Nevertheless, it is by adopting the latter course that I should hope to effect a cure. I do not think that much good is to be attained by the use of local remedies in these cases. If any are cal- culated to be of service, they are the nitric oxide of mer- cury ointment or the unguentum hydrargyri nitratis. All caustics and strongly stimulating remedies are ob- jectionable. TREATMENT OF ESTHIOMENOUS AFFECTIONS. We now come to the consideration of the Esthiomenous affections of the skin, which, as I have already said, I 18 274 TREATMENT OF SYPHILIS. believe to be due to the syphilitic poison in a distant remove from its original source. Cases 81 and 82 are of this nature. These are cases for which the common and received treatment is destruction by caustic remedies, that is, when they occupy a small space; when they embrace a larger extent of surface, caustics are, of course, inappli- cable, excepting upon a principle of gradual encroachment. But the exclusive treatment by caustics is decidedly bad. When the morbid alteration in the skin has been burnt away, it is apt to return in the cicatrix, and then we are in a much worse position than before the treatment was commenced. Cases 81 and 82 both got well under the steady use of the biniodide of mercury, combined with the iodide of quinine; and several similar cases have yielded to the same remedy, without the adoption of any local treatment whatever. After the constitutional treatment has been continued for one or two weeks, or more, then a stimulant application is sometimes of great service; it co-operates with the internal medicine, and often piwuces a rapid change for the better. The ap- plication to which I give the preference is the chloride of zinc. When the Esthiomenous syphiloderma attacks the nose, it is to be treated in a similar manner. I have two cases now under my care, and fast approaching cure, which presented the following characters. The subjects, the one a gentleman, the other a lady, had a large trembling tongue coated with yellowish-white mucus, and indented by the teeth. They were miserably out of spirits, and desponding; the skin of the face was of a muddy-yellow hue, moistened with a greasy secretion, the conjunctivae yellow and muddy, and upon the tip of the nose was a prominent granular-looking mass, of a dirty-red color, and partly covered by a thin black crust, ESTHIOMENOUS AFFECTIONS. 275 which on being raised permitted the escape of a sero- purulent fluid. It was obvious that these persons were too much out of health for the immediate adoption of any specific treatment. One was having the disease fed by high living and stimulants, the other had been half poisoned with empirical treatment, of which arsenic formed the base. In both instances I prescribed the citrate of quinine and iron, a gentle purgative, a mode- rate diet, and avoidance of stimulants. A few weeks after this, my patients were so much improved in appearance and health, that I felt justified in commenc- ing the specific treatment. I gave, then, the iodide of mercury and quinine pill three times a day, and touched the diseased growth, twice in one case, and once in the other, with the chloride of zinc, and both have got well. Several cases now under treatment, one a medical man, promise to get well in a similar manner; their present progress is most favorable. I have hinted, in a previous page of this work, at the discovery of a principle of treatment which I conceive to be the correct one for the cure of these diseases. The principle to which I then referred is that which I have just been endeavoring to illustrate—the treatment by alterative doses of mercury. I have also expressed my belief, that these diseases owe their origin to the syphi- litic poison. I would not for an instant be supposed to say, that because they are to be cured by mercury they are therefore syphilitic; such a declaration would be most unphilosophical; but I am not ashamed to avow, that it was my belief in their syphilitic nature that first suggested to my mind their treatment by the well-known specific of syphilis—mercury; and this treatment, in my hands, has been most encouraging and most successful. They have yielded before the antisyphilitic treatment, as if " syphilis" were stamped upon them in printed 276 TREATMENT OF SYPHILIS. characters; and they certainly belong to that category of diseases, which treated by syphilitic remedies are to be relieved and cured; but which treated in any other way are not only incurable, but often destructive of life. All other methods of treatment tend to the aggravation of the disease. It must be recollected that the class of diseases to which I am now referring is essentially refractory. They are diseases for which the treatment, as admitted by the whole profession, is empirical. The language of medi- cine, in reference to them, merges in the verb " try;" we try this, and we try that, with the hope of such and such remedies being of service, but we have no principle of action. We catch at foreign suggestions, the farther from home the better; the best practitioners in the world, the British, catch at any trial which may be sug- gested by the worst practitioners in the world, if it only come to them in the mysterious envelop of a foreign garb. It matters little how absurd the suggestion may be when weighed in the balance of sound judgment and philosophy; it is foreign; in other words, it is unknown, it is therefore good, and a trial is made. If we sought for an explanation of this peculiarity of British practi- tioners, it might be found in the fact, which is in the highest degree creditable to them, of their being the most practical people under the sun. They want the inventive genius of the man who invents and lies, and they see only that which, in the want of confidence in other means, they are willing to receive as an established fact. To correct such illusions as these, our real want is a principle of action, a theory, an hypothesis, even, a something which we may regard as the standard, by which we may test the suggestions which every now and then pass before us, and from which, and towards which, all our aberrations, explorative or tentative, ESTHIOMENOUS AFFECTIONS. 277 may take their departure or find their centre. That standard I am now seeking to establish, that principle I now announce. These obscure diseases take their origin in syphilis ; they are to be cured by the judicious use of antisyphilitic remedies—mercury, iodine, cod-liver oil, nitric acid, &c. Let the remedies that have been suggested during the last century, as at all successful in these diseases, be examined ; they will all be found to come under the head of antisyphilitic remedies, means already in our hands, and none the worse, if properly used, for being old. New suggestions generally turn upon the exclusive use of one or other of these means, nothing more; which is a positive offence to our judg- ment. All are useful, and even necessary, in different stages of disease, in different constitutions, in different climates. We have our speculators in physic, as the world has its speculators in railroads ; a trunk line for the cure of lupus, cod-liver oil poured down the throat until it sweats out pure through every pore of the skin; loop lines of specifics by hundreds. To place Medicine in its proper niche in the temple of Science we wrant philosophers, and not empirics. We possess all the means that empirics can give to us; we want the learning, the judgment, and the candor, to employ them rightly, and to acknowledge the services of those who labor in our behoof. In speaking of the esthiomenous diseases, I do not include the forms known as lupus exedens and lupus vorax: I have had but little experience of them; but from what I have seen, I am inclined to place them in the category of syphilodermata, aggravated by hygienic conditions, or by improper treatment. The following is an instance of a very mild form of disease putting on the most serious characters, under the influence of mal- treatment. 18* 278 TREATMENT OF SYPHILIS. Case 83.—In the spring of 1850, in the course of my morning reception, a man about forty years of age, placed himself on a chair before me, and projected his face, without saying a word. He was right; his face was a written page, and there was no need of speech. Taking him in his humor, the following colloquy took place between us :— " You have been treated for lupus ?" " Yes." " If your case were one of lupus,1 I should, in its present state, hold out very little hope to you; but it is not one of lupus, and you shall be cured in a few weeks." The man started to his feet, and, with tears in his eyes, exclaimed: "You do not know for how many months I have suffered from this dreadful disease, and that I have tried everything in vain ?" He then told me, that in consequence of this infliction he had been obliged to give up an appointment which he had held in the city, and with his wife and family, and slender means, was about to retire into Devonshire; that, in a word, his prospects were destroyed—he was ruined; his only remaining hope being a residence in the country, and trust in the curative powers of Nature; that before taking this final step he had been advised to consult me. To an unpractised eye his appearance was most unpromising; his nose was swollen and inflamed, the swelling and redness extending upwards to the eyes, and on the right side involving the inner canthus and upper lid, outwards upon the cheeks, and downwards to the middle of the upper lip. The mucous membrane was equally swollen, and caused a partial obstruction of the 1 I alluded to lupus exedens. ESTHldMENOUS AFFECTIONS. 279 nostrils. Around the base of the nose was an extensive superficial ulceration, coated by a thick scab, and on the right cheek were several tubercular risings, having the characteristic color of syphilitic tubercles. On the 25th of April I put him on the following treatment, which he promised me faithfully to carry out; and he fulfilled his promise. He was to take one- sixteenth of a grain of the bichloride of mercury in tincture of bark, three times a day; half a drachm of compound jalap powder at bedtime each night; and not less than two quarts of infusion of elder-flowers in the course of the twenty-four hours. For diet, he was to have, at 8 A. M., bread and butter and cocoa; 2 P. M., good broth, either of beef or mutton, bread and biscuit, but no solid meat; 5 P. M., bread and butter and tea; 9 P. M., if he suffered from hunger, he was to have either broth, as for his dinner, or bread and butter. In three weeks after beginning this treatment, the change in his appearance was so remarkable that he could hardly be recognized as the same person.1 The nose had recovered its natural dimensions, the ulceration was healed, the crusts all gone, and nothing remained of the disease but the discoloration and a patch of small tubercles situated in the angle formed by the nose and left cheek. A month after the beginning of the treatment, he reported to me that he had followed my instructions rigidly; that he had taken no solid meat and no alco- holic drink whatever; that he felt strong, and had increased in weight. He had taken daily, five pints of elder-flower tea, which kept up a gentle perspiration 1 I had a drawing of him made before beginning the treatment, and on the nineteenth day, which I shall be happy to show to any member of the profession who may be interested in the subject. 280 TREATMENT OF SYPHILIS. on the skin, and caused a copious excretion of urine, four or five times a day. The jalap-powder produced three, four, and five motions of a light color, before one o'clock in the day. He was content to go on with the treatment, but petitioned for bread and milk in addition to his other diet. I gave him permission, and allowed him besides, a mutton chop and half a pint of bitter beer for his dinner. Soon after this the jalap-powder was changed for sul- phate of magnesia, and on the completion of the sixth week I gave him three grains of the iodide of potassium, in a decoction of sarsaparilla, twice a day, in place of the bichloride of mercury. He was to take the iodide of potassium for another fortnight. He then wrent to the sea-side, promising to be careful in his diet; to take little meat and stimulus; and to keep his bowels regu- lar. He returned perfectly well, a happy and vigorous man; and my promise was redeemed. APPENDIX. I subjoin in this place two cases which have been accidentally omitted from the body of the work. They both serve to illustrate points of interest in connection with the manifestations of the syphilitic poison, as will be shown in their recital. The first of the two cases is one of indurated chancre, treated with mercury; followed after three months by secondary syphilis, also treated with mercury; and thirteen years later, by tertiary syphilis in a mild form, namely, as an annulate tubercular eruption on the face. Case 84.—A gentleman, aged thirty-five, consulted me (October, 1851) for a syphilitic tubercular ring situated on the nose, and neighboring part of one cheek. The eruption had commenced twelve months back, by a small tubercular patch on the side of the nose, and had gradually enlarged until it had inclosed the whole of the organ within its area. He had likewise some erythematous and slightly raised spots in the axillae, and others upon the thighs. His syphilitic history was as follows: Fifteen years since he had a small indurated chancre on the prepuce, accompanied by a bubo, which passed into a state of suppuration. A year later he had another sore, which he describes as having been as large as a horse-bean. 282 APPENDIX. This latter gave rise to enlarged glands in both groins, but the enlargement subsided without suppuration. He took mercury for both attacks. About three months after the last primary disease, he was attacked with sore-throat and feverish symptoms; but had no pains or eruption on the skin. He was again treated with mercury, this time continuing its use for four months, and has remained well, and without a symptom of syphilis, until the appearance of the present eruption (tertiary) twelve months since. The eruption, although of twelve months' duration, immediately yielded to the iodide of potassium, five grains, three times a day. The next case exhibits the effects of the syphilitic poison on an irritable constitution, and the empirical use and abuse of remedies. The original disease appears to have been a simple venereal sore, treated with mer- cury; six weeks afterwards, secondary syphilis set in, and continued for ten months. The points of interest in the case are, the injudicious use of mercury for the primary disease, and its further abuse in the secondary affection; the syphilitic disease having been aggravated and rendered permanent by the reckless administration of that medicine. Case 85. — A gentleman, aged 29, consulted me (October, 1851) for an eruption of roseola papulata, which had existed on his skin for ten months. During the last six weeks a fresh outbreak had taken place, and the eruption was more extensive than it had before been. He had, besides, a trifling degree of headache; but no sore-throat, no enlarged lymphatic glands, and, indeed, with the exception of a muddy skin and conjunctiva, no other symptom of syphilis. The origin of the present disease dated back to the APPENDIX. 283 end of September of the preceding year, when, for the first time, he had a venereal sore. The sore was situated in the fossa glandis, on the dorsal aspect of the penis; it was of small size, and healed in the course of ten or twelve days. He had no bubo, and there is no remain- ing induration at the seat of the sore. He was treated for this attack with mercury, which he continued for a fortnight. He took altogether about thirty pills, but without any effect upon his mouth, and was obliged to desist from their use in consequence of too great action upon his bowels. In the beginning of November—namely, about six weeks after the appearance of the primary disease—he experienced its constitutional effects in the shape of febrile symptoms, pains in the back of the neck, along the spine, and in the shoulders. The pains were most severe at night, and accompanied with profuse perspi- rations. He had, also, a few spots of eruption on the abdomen. From this period until the present he has had a suc- cession of fresh eruptions on the skin, without decline of those which preceded, until the trunk of the body is nearly covered. With regard to treatment: I have remarked, that for the primary disease he took thirty mercurial pills, which produced purging, but no specific effects. For the first attack of constitutional symptoms, in November, he fol- lowed a simple antiphlogistic plan. For a second attack in December, he took mercury for ten days, when his mouth became tender. In February, for a third appear- ance of the symptoms he again took mercury, but not to the extent of affecting his mouth. Not so, however, in June, when the mercury was repeated for the fourth time, and continued for a fortnight, producing a severe degree of salivation, the eruption after the mer- 284 APPENDIX. curialization being, as he observed, wTorse than before he began. 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The rapid extension of mail facili- ties, will now place the numbers before subscribers with a certainty and dispatch not heretofore attainable; while by the system now proposed, every subscriber throughout the Union is placed upon an equal footing, at the very reasonable price of Five Dollars for two periodicals, without further expense. Those subscribers who do not pay in advance will bear in mind that, their subscription of Five Dollars will entitle them to the Journal only, without the News, and that they will be at the expense of their own postage on the receipt of each number. The advantage of a remittance when order- ing the Journal will thus be apparent. As the Medical News and Library is in no case sent without advance payment, its subscriber* Will always receive it free of postage. 3 ' «-"wc» It should also be borne in ramd that the publishers will now take the risk of remittances by mail on y requiring, in cases of loss, a certificate from the subscriber's Postmaster, that the money was duly mailed and forwarded. ' l^3 Funds at par at the subscriber's place of residence received in payment of subscriptions. Address, BLANCHARD Monthly Journal of Medical Science. BLANCHARD & LEA'S MEDICAL BEALE (LIONEL JOHN), M. R. C.S., &c. THE LAWS OF HEALTH IN RELATION TO MIND AND BODY. A Series of Letters from an old Practitioner to a Patient. In one handsome volume, royal 12mo., extra cloth. BILLING (ARCHIBALD), M. D. TIIE PRINCIPLES OF MEDICINE. Second American, from the Fifth and Improved London edition. In one handsome octavo volume, extra cloth, 250 pages. BLAKISTON (PEYTON), M. D., F. R. S., &c. PRACTICAL OBSERVATIONS ON CERTAIN DISEASES OF THE CHEST, and on the Principles of Auscultation. In one volume. 8vo., pp. 384. BURROWS (GEORGE), M.D. ON DISORDERS OF THE CEREBRAL CIRCULATION, and on the Con- neclion between the Affections of the Brain and Diseases of the Heart. In one 8vo. vol., with eolored plates, pp. 21t>. BUDD (GEORGE), M. D., F. R. S., Professor of Medicine, in King's College, London. ON DISEASES OF THE LIVER. Second American, from the second and enlarged London edition. In one very handsome octavo volume, with four beautifully colored plates, and numerous wood-cuts. pp. 468. New edition. (Just Issued.) The reputation which this work has obtained as a full and practical treatise on an important class of diseases will not be diminished by this improved and enlarged edition. It has been carefully and thoroughly revised by the author; the number of plates has been increased, and the style of its me- chanical execution will be found materially improved. work roust be the authority of the great mass of The full digest we have given of the new matter introduced into the present volume, is evidence of (he value we place on it. The f:ict that the profes- sion has required a second edition of a monograph such as that before us, bears honorable testimony to its usefulness. For many years, Dr. Budd's British practitioners on the hepatic diseases ; and it is satisfactory that the subject has been taken up by so able and experienced a physician.—British and Foreign Medico-Chirurgical Review. BUCKLER (T. H.), M. D., Formerly Physician to the Baltimore Almshouse Infirmary, &c. ON THE ETIOLOGY, PATHOLOGY, AND TREATMENT OF FIBRO- BRONCHITIS AND RHEUMATIC PNEUMONIA. In one handsome octavo volume, extra cloth. (Now Ready.) , The concluding chapter on Treatment is full of sound practical suggestions, which make this emi- nently a book to be prized by the '■ working doctor" rather than the mere closet student.—N. J. Medical Reporter, March, 1854. BLOOD AND URINE (MANUALS ON). BY JOHN WILLIAM GRIFFITH, G. OWEN REESE, AND ALFRED MARKWICK. One thick volume, royal 12mo., extra cloth, with plates, pp. 460. BRODIE (SIR BENJAMIN C), M. D., &c. CLINICAL LECTURES ON SURGERY. 1 vol. 8vo., cloth. 350 pp. BY THE SAME AUTHOR. SELECT SURGICAL WORKS, 1 vol. 8vo. leather, containing Clinical Lectures on Surgery, Diseases of the Joints, and Diseases of the Urinary Organs. BIRD (GOLDING), A. M., M. D.. &c. URINARY DEPOSITS: THEIR DIAGNOSIS, PATHOLOGY AND THERAPEUTICAL INDICATIONS. A new and enlarged American, from the last improved London edition. With over sixty illustrations. In one royal 12mo. volume, extra cloth. suits of those microscopical and chemical researches regarding the physiology and pathology of the uri- nary secretion, which have contributed so much to the increase of our diagnostic powers, and to the extension and satisfactory employment of our thera- peutic resources. In the preparation of this new edition of his work, it is obvious that Dr. Golding Bird has spared no pains to render it a faithful repre- sentation of the present state of scientific knowledge on the subject it embraces.- The British and Foreign Medico-Chirurgical Review. The new edition of Dr. Bird's work, though not increased in size, has been greatly modified, and much of it rewritten. It now presents, in a com- pendious form, the gist of ull that is known and re- liable in this department. From its terse style and convenient size, it is particularly applicable to the student, to whom we cordially commend it.—The Medical Examiner. - It can scarcely be necessary for us to say anything of the merits of this well-known Treatise, which so admirably brings into practical application the re- BY THE SAME AUTHOE. ELEMENTS OF NATURAL PHILOSOPHY; being an Experimental Intro- duction to the Physical Sciences. Illustrated with nearly four hundred wood-cuts. From the third London edition. In one neat volume, royal 12ino. pp. 402. ajnjj ouir-NTIFIC PUBLICATIONS. 5 BARTLETT (ELISHA), M. D., Professor of Materia Medica and Medical Jurisprudence in the College of Physicians and Surgeons, New York. THE HISTORY, DIAGNOSIS, AND TREATMENT OF THE FEVERS OF THE UNITED STATES. Third edition, revised and improved. In one octavo volume, of six hundred pages, beautifully printed, and strongly bound. In preparing a new edition of this standard work, the author has availed himself of such obser- vations and investigations as have appeared since the publication of his last revision, and he has endeavored in every way to render it worthy of a continuance of the very marked favor with which it has been hitherto received. The masterly and elegant treatise, by Dr. Bartlett is invaluable to the American student and practi- tioner.—Dr. Hohnes's Report to the Nat. Med. Asso- ciation. We regard it, from the examination we have made of it, the best work on fevers extant in our language, and as such cordially recommend it to the medical public.—St. Louis Medical and Surgical Journal. Take it altogether, it is the m»st complete history of our fevers which has yet been published, and every practitioner should avail himself of its con- tents.— The Western Lancet. Of the value and importance of such a work, it is needless here to speak ; the profession of the United States owe much to the author for the very able volume which he has presented to them, and lor the careful and judicious manner in which he has exe- cuted his task. No one volume with which we are acquainted contains so complete a history of our fevers as this. To ITr. Bartlett we owe our best thanks for the very able volume he has given us, as embodying certainly the most complete, methodical, and satisfactory ;iceount of our fevers anywhere to be met with.— The Charleston Med. Journal and Review. BOWMAN (JOHN E.), M.D. PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. In one neat volume, royal 12mo., with numerous illustrations, pp. 288. BY THE SAME AUTHOR. INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANA- LYSIS. With numerous illustrations. In one neat volume, royal 12mo. pp. 350. BARLOW (GEORGE H.), M.D. A MANUAL OF THE PRINCIPLES AND PRACTICE OF MEDICINE. In one octavo volume. (Preparing.) CYCLOP/EDIA OF PRACTICAL MEDICINE. Edited by Dunglison, Forbes, Tweedie, and Conolly, in four large octavo volumes, strongly bound, fi®* See Dunglison. COLOMBAT DE L'ISERE. A TREATISE ON THE DISEASES OF FEMALES, and on the Special Hygiene of their Sex. Translated, with many Notes and Additions, by C. D. Meigs, M. D. Second edition, revised and improved. In one large volume, octavo, with numerous wood-cuts. pp. 720. The treatise of MP Colombat is a learned and la- i MP Colombat De LTsere has not consecrated ten borious commentary on these diseases, indicating years of studious toil and research to the frailer sex very considerable research, great accuracy of judg-, in vain; and although we regret to hear it is at the ment, and no inconsiderable personal experience, expense of health, he has imposeda debtof gratitude With the copious notes and additions of its experi- i as well upon the profession, as upon the mothers and enced and very erudite translator and editor, Dr. ! daughters of beautiful France, which that gallant Meigs, it presents, probably, one of the most coin- I nation knows best how to acknowledge.—New Or- plete and comprehensive works on the subject we i leans Medical Journal. possess.—American Med. Journal. \ COPLAND (JAMES), M. D., F. R. S., &c. OF THE CAUSES, NATURE, AND TREATMENT OF PALSY AND APOPLEXY, and of the Forms, Seats, Complications, and Morbid Relations of Paralytic and Apoplectic Diseases. In one volume, royal 12mo., extra cloth, pp. 326. CHAPMAN (PROFESSOR N.), M. D., Sic. LECTURES ON FEVERS, DROPSY, GOUT, RHEUMATISM, &c. &c. In one neat 8vo. volume, pp. 450. CLYMER (MEREDITH), M. D., Sec. FEVERS; THEIR DIAGNOSIS, PATHOLOGY, AND TREATMENT. Prepared and Edited, with large Additions, from the Essays on Fever in Tweedie's Library oi Practical Medicine. In one octavo volume, of 600 pages. CARSON (JOSEPH), M. D., Professor of Materia Medica and Pharmacy in the University of Pennsylvania. SYNOPSIS OF THE COURSE OF LECTURES ON MATERIA MEDICA AND PHARMACY, delivered in the University of Pennsylvania. la one very neat octavo volume, of 208 pages. BLANCHARD & LEA'S JfiRi CARPENTER (WILLIAM B.), M. D., F. R. S., tc, Examiner in Physiology and Comparative Anatomy in the University of London. PRINCIPLES OF HUMAN PHYSIOLOGY; with their chief applications to Psychology, Pathology, Therapeutics, Hygiene, and Forensic Medicine. Fifth American, from the fourth and enlarged London edition. With three hundred and fourteen illustrations. Edited, with additions, by Francis Gurney Smith, M. D., Professor of the Institutes of Medicine in the Pennsylvania Medical College, &c. In one very large and beautiful octavo volume, of about 1100 large pages, handsomely printed and strongly bound in leather, with raised bands. New edition. (Lately Issued.) This edition has been printed from sheets prepared for the purpose by the author, who has introduced nearly one hundred illustrations not in the London edition; while it has also enjoyed the advantage of a careful superintendence on the part of the editor, who has added notices of such more recent investigations as had escaped the author's attention. Neither care nor expense has been spared in the mechanical execution of the work to render it superior to former editions, and_U is confidently presented as in every way one of the handsomest volumes as yet placed before the medical profession in this country. The most complete work on the science in our i The best text-book in the language on this ex- language.— Am. Mid. Journal. tensive subject.—London Med. Times. .. ... f„u„„;„i„„„ ,„>„„>, A complete cyclopaedia of this branch of science. The most complete exposition of physiology which i y v . > v any language can at present give.—Brit, and For. j ;" ' , ' .t . ., - . . Med -Chirurs. Review. The standard of authority on physiological sub- jects. * * * In the present edition, to particularize We have thus adverted to some of the leading | the alterations and additions which have been made, additions and alterations," which have been in- would require a review of the whole work, since scarcely a subject has not been revised and altered, added to, or entirely remodelled to adapt it to the present state of the science.—Charleston Med. Journ. Any reader who desires a treatise on physiology may feel himself entirely safe in ordering this.— Western Med. and Surg. Journal. From this hasty and imperfect allusion it will be seen by our readers that the alterations and addi- tions to this edition render it almost a new work— and we can assure our readers that it is one of the best summaries of the existing facts of physiological science within the reach of the English student and physician.—N. Y. Journal of Medicine. The profession of this country, and perhaps also of Europe, have anxiously and for some time awaited the announcement of this new edition of Carpenter's Human Physiology. His former editions have for many years been almost the only text-book on Phy- troduced by the author into this edition of his phy Biology. These will be found, however, very far to exceed the ordinary limits of a new edition, " the old materials having been incorporated with the new, rather than the new with the old."_ It now certainly presents the most complete treatise on the nubject within the reach of the American reader; and while, for availability as a text-book, we may perhaps regret its growth in bulk, we are sure that r.be student of physiology will feel the impossibility of presenting a thorough digest of the facts of the science within a more limited compass.—Medical Examiner. The greatest, the most reliable, and the best book on the subject which we know of in the English language.—Stethoscope. The most complete work now extant in our lan- guage.— N. O. Med. Register. B ° siology in all our medical schools, and its circula- The changes are too numerous to admit of an ex- tion among the profession has been unsurpassed by tended notice in this place. At every point where ] any work in any department of medical science. the recent diligent labors of organic chemists and I It is quite unnecessary for us to speak of this micrographers have furnished interesting and valu- ! work as its merits would justify. The mere an- able facts, they have been appropriated, and no pains | nouncement of its appearance will afford the highest have been spared, in so incorporating and arranging | pleasure to every student of Physiology, while its them that the work may constitute one harmonious j perusal will be of infinite service in advancing system.—Southern Med. and Surg. Journal. '■ physiological science.—Ohio Med. and Surg. Journ. BY THE SAME author. (Now Ready.) PRINCIPLES OF COMPARATIVE PHYSIOLOGY. New American, from the Fourth and Revised London edition. In one large and handsome octavo volume, with over three hundred beautiful illustrations. The delay which has existed in the appearance of this work has been caused by the very thorough revision and remodelling which it has undergone at the hands of the author, and the large number of new illustrations which have been prepared for it. It will, therefore, be found almost a new work, and fully up to the day in every department of the subject, rendering it a reliable text-book for all students engaged in this branch of science. Every effort has been made to render its typo- graphical finish and mechanical execution worthy of its exalted reputation, and creditable to the mechanical arts of this country. A few notices of the last edition are appended. Without pretending to it, it is an Encyclopedia of the subject, accurate and complete in all respects— a truthful reflection of the advanced state at which the science has now arrived.—Dublin Quarterly Journal of Medical Science. A truly magnificent work—in itself a perfect phy- siological study.—Ranking's Abstract. This work stands without its fellow. It is one few men in Europe could have undertaken; it isone no man, we believe, could have brought to so suc- cessful an issue as Dr. Carpenter. It required for its production a physiologist at once deeply read in the labors of others, capable of taking a general, critical, and unprejudiced view of those labors, and of combining the varied, heterogeneous materials at his disposal, so as to form an harmonious whole. We feel that this abstract can give the reader a very imperfect idea of the fulness of this work, and no idea of its unity, of the admirable manner in which material has been brought, from the most various sources, to conduce to its completeness, of the lucid- ity of the reasoning it contains, or of the clearness of language in which the whole is clothed. Not the profession only, but the scientific world at large, must feel deeply indebted to Dr. Carpenter for this great work. It must, indeed, add largely even to his high reputation.—Medical Times. by the same author. (Preparing.) THE MICROSCOPE AND ITS REVELATIONS. In one handsome volume, beautifully illustrated with plates and wood-cuts. AND SCIENTIFIC PUBLICATIONS. 7 CARPENTER (WILLIAM B-), M. D., F. R. S., Examiner in Physiology and Comparative Anatomy in the University of London. ELEMENTS (OR MANUAL) OF PHYSIOLOGY, INCLUDING PHYSIO- LOGICAL ANATOMY. Second American, from a new and revised London edition. With one hundred and ninety illustrations. In one very handsome octavo volume. In publishing the first edition of this work, its title was altered from that of the London volume, by the substitution of the word "Elements" for that of " Manual," and with the author's sanction the title of " Elements" is still retained as being more expressive of the scope of the treatise. A comparison of the present edition with the former one will show a material improvement, the author having revised it thoroughly, with a view of rendering it completely on a level with the most advanced state of the science. By condensing the less important portions, these numerous additions have been introduced without materially increasing the bulk of the volume, and while numerous illustrations have been added, and the general execution of the work improved, it has been kept at its former very moderate price. To say that it is the best manual of Physiology now before the public, would not do sufficient justice to the author.—Buffalo Medical Journal. In his former works it would seem that he had exhausted the subject of Physiology. In the present, he gives the essence, as it were, of the whole.—N. Y. Journal of Medicine. Those who have occasion for an elementary trea- tise on Physiology, cannot do better than to possess themselves of the manual of Dr. Carpenter.—Medical Examiner. We do not hesitate to pronounce it the best and most comprehensive system of modern surgery with which we are acquainted.—Medico-Chirurgical Re- view. The fullest and ablest digest extant of all that re- lates to the present advanced state of surgical pa- thology.—American Medical Journal. As complete as any system of Surgery can well be.—Southern Medical and Surgical Journal. It is not needful that we should compare it with the other pharmacopoeias extant, which enjoy and merit the confidence of the profession : it is enough to say that it appears to us as perfect as a Dispensa- tory, in the present state of pharmaceutical science, could be made. If it omits any details pertaining tp this branch of knowledge which the student has a right to expect in such a work, we confess the omis- sion has escaped our scrutiny. We cordially recom- mend this work to such of our readers as are in need of a Dispensatory. They cannot make choice of a better.—Western Journ. of Medicine and Surgery. The best and most complete expose" of modern Physiology, in one volume, extant in the English language.—St. Louis Medical Journal. With such an aid in his hand, there is no excuse for the ignorance often displayed respecting the sub- jects of which it treats. From it's unpretending di- mensions, it may not be so esteemed by those anxious to make a parade of their erudition; but whoever masters its contents will have reason to be proud of his physiological acquirements. The illustrations are well selected and finely executed.—Dublin Med. Press. The most learned and complete systematic treatise now extant.—Edinburgh Medical Journal. A complete encyclopaedia of surgical science—a very complete surgical library—by far the most complete and scientific system of surgery in the English language.—N. Y. Journal of Medicine. The most extensive and comprehensive account of the art and science of Surgery in our language.— Lancet. There is not in any language a more complete and perfect Treatise.—N. Y. Annalist. In conclusion, we need scarcely say that we strongly recommend this work to all classes of our readers. As a Dispensatory and commentary on the Pharmacopoeias, it is unrivalled in the English or any other language.—The Dublin Quarterly Journal. We earnestly recommend Dr. Christison's Dis- pensatory to all our readers, as an indispensable companion, not in theStudy only, but in the Surgery also.—British and Foreign Medical Review. BY THE SAME AUTHOR. A PRIZE ESSAY ON THE USE OF ALCOHOLIC LIQUORS IN HEALTH AND DISEASE. New edition, with a Preface by D. F. Condie, M. D., and explanations of scientific words. In one neat 12mo. volume. (Now Ready.) This new edition has been prepared with a view to an extended circulation of this important little work, which is ijniversally recognized as the best exponent of the laws of physiology and pathology applied to the subject of intoxicating liquors, in a form suited both for the profession and the public. To secure a wider dissemination of its doctrines the publishers have done up copies in flexible cloth, suitable for mailing, which will be forwarded through the post-office, free, on receipt of fifty cents. Societies and others supplied in quantities for distribution at a liberal deduction. CHELIUS (J. M.), M. D., Professor of Surgery in the University of Heidelberg, &c. A SYSTEM OF SURGERY. Translated from the German, and accompanied with additional Notes and References, by John F. South. Complete in three very large octavo volumes, of nearly 2200 pages, strongly bound, with raised bands and double titles. CHRISTISON (ROBERT), M. D., V. P. R. S. E., Sec. A DISPENSATORY; or. Commentary on the Pharmacopoeias of Great Britain and the United States; comprising the Natural History, Description, Chemistry, Pharmacy, Ac- tions, Uses, and Doses of the Articles of the Materia Medica. Second edition, revised and im- proved, with a Supplement containing the most important New Remedies. With copious Addi- tions, and two hundred and thirteen large wood-engravings. By R. Eglesfeld Griffith, M. D. In one very large and handsome octavo volume, of over 1000 pages. 8 BLANCHARD & LEA'S MEDICAL CONDIE (D. F.), M. D., Sec. A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Fourth edition, revised and augmented. In one large volume, 8vo., of nearly 750 pages. (Just Issued.) From the Author's Preface. ^ The demand for another edition has afforded the author an opportunity of again subjecting the entire treatise to a careful revision, and of incorporating in it every important observation recorded since jjie appearance of the last edition, in reference to the pathology and therapeutics of the several diseases of which it treats. In the preparation of the present edition, as in those which have preceded, while the author has appropriated to his use every important fact that he has found recorded in the works of others, having a direct bearing upon either of the subjects of which he treats, and the numerous valuable observations—pathological as well as practical—dispersed throughout the pages of the medical journals of Europe and America, he has, nevertheless, relied chiefly upon his own observations and experience, acquired during a long and somewhat extensive practice, and under circumstances pe- culiarly well adapted for the clinical study of the diseases of early life. Every species of hypothetical reasoning has, as much as possible, been avoided. The author has endeavored throughout the work to confine himself to a simple statement of well-ascertained patho- logical facts, and plain therapeutical directions—his chief desire being to render it what its title imports it to be, a practical treatise on the diseases of children. Dr. Condie's scholarship, acumen, industry, and practical sense are manifested in this, as in all his numerous contributions to science.—Dr. Holmes's Report to the American Medical Association. Taken as a whole, in our judgment, Dr. Condie's Treatise is the one from the perusal of which the practitioner in this country will rise with the great- est satisfaction —Western Journal of Medicine and Surgery. One of the best works upon the Diseases of Chil- dren in the English language.—Western Lancet. Perhaps the most full and complete work now be- fore the profession of the United States; indeed, we may say in the English language. It is vastly supe- rior to most of its predecessors.—Transylvania Med. Journal. We feel assured from actual experience that no physician's library can be complete without a copy of this work.—N. Y. Journal of Medicine. A veritable paediatric encyclopedia, and an honor to American medical literature.—Ohio Medical and Surgical Journal. We feel persuaded that the American medical pro- fession will soon regard it not only as a very good, but as the very best " Practical Treatise on the Diseases of Children."—American Medical Journal. We pronounced the first edition to be the best work on the diseases of children in the English language, and, notwithstanding all that has l)een published, we still regard it in that light.—Medical Examiner. COOPER (BRANSBY B.), F. R. S., Senior Surgeon to Guy's Hospital, &c. LECTURES ON THE PRINCIPLES AND PRACTICE OF SURGERY. In one very large octavo volume, of 750 pages. (Lately Issued). For twenty-five years Mr. Bransby Cooper has been surgeon to Guy's Hospital; and the volume before us may be said to consist of an account of the results of his surgical experience during that long period. We cordially recommend Mr. Bransby Cooper's Lectures as a most valuable addition to our surgical literature, and one which cannot fail to be of service both to students and to those who are actively engaged in the practice of their profes- sion.—The Lancet. COOPER (SIR ASTLEY P.), F. R. S., Sec. A TREATISE ON DISLOCATIONS AND FRACTURES OF THE JOINTS Edited by Bransby B. Cooper, F. R. S., &c. With additional Observations bv Prof J C Son woodDeW Ame"Can edi,i0n- In one handsome octavo volume, with numerous il'lustra- BY THE SAME AUTHOR. ON THE ANATOMY AND TREATMENT OF ABDOMINAL HERNIA One large volume, imperial 8vo., with over 130 lithographic figures. BY THE SAME AUTHOR. 0?heT?Iym^sRg1CaZREo AN?- DIS®ASES OF THE TESTIS, AND ON THE THYMUS GLAND. One vol. imperial 8vo., with 177 figures, on 29 plates. BY THE SAME AUTHOR. ON THE ANATOMY AND DISEASES OF THE BREAST, with twenty- STptateT "* gl° PerS' °De laPge V°lume> hafetM 8vo" with 252 fi&ures> °» These last three volumes complete the surgical writings of Sir Astley Cooper. They are very Sc^ssss^^sir*'ot li,hographic p,ates'executed itt the »*styfe'ana« ft»i) SCIENTIFIC PUBLICATIONS. 9 CHURCHILL (FLEETWOOD), M. D., M. R. I. A. ON THE THEORY AND PRACTICE OF MIDWIFERY. A new American, from the last and improved English edition. Edited, with Notes and Additions, by D. Francis7 Condie, M. D., author of a "Practical Treatise on the Diseases of Children," &c With 139 illustrations. In one very handsome octavo volume, pp. 510. (Lately Issued.) To bestow praise on a book that has received such marked approbation would be superfluous. We need only say, therefore, that if the first edition was thought worthy of a favorable reception by the medical public, we can confidently affirm that this will be found much more so. The lecturer, the practitioner, and the student, may all have recourse to its pages, and derive from their perusal much in- terest and instruction in everything relating to theo- retical and practical midwifery.—Dublin Quarterly Journal of Medical Science. A work of very great merit, and such as we can confidently recommend to the study of every obste- tric practitioner.—London Medical Gazette. This is certainly the most perfect system extant. It is the best adapted for the purposes of a text- book, and that which he whose necessities confine him to one book, should select in preference to all others.—Southern Medical and Surgical Journal. The most popular work on midwifery ever issued from the American press.—Charleston Med. Journal. Were we reduced to the necessity of having but one work on midwifery, and permitted to choose, we would unhesitatingly take Churchill.—Western Med. and Surg. Journal. It is impossible to conceive a more useful and elegant manual than Dr. Churchill's Practice of Midwifery.—Provincial Medical Journal. Certainly, in our opinion, the very best work on the subject which exists.—N. Y. Annalist. To these papers Dr. Churchill has appended notes, embodying whatever information has been laid be- fore the profession since their authors'time. He has also prefixed to the Essays on Puerperal Fever, which occupy the larger portion of the volume, an interesting historical sketch of the principal epf- No work holds a higher position, or is more de- serving of being placed in the hands of the tyro, the advanced student, or the practitioner.—Medical Examiner. Previous editions, under the editorial supervision of Prof R. M. Huston, have been received with marked favor, and they deserved it; but this, re- printed from a very late Dublin edition, carefully revised and brought up by the author to the present time, does present an unusually accurate and able exposition of every important particular embraced in the department of midwifery. * * The clearness, directness, and precision of its teachings, together with the great artlount of statistical research which its text exhibits, have served to place it already in the foremost rank of works in this department of re- medial science.—N. O. Med. and Surg. Journal. In our opinion, it forms one of the best if not the very best text-book and epitome of obstetric science which we at present possess in the English lan- guage.— Monthly Journal of Medical Science. The clearness and precision of style in which it is written, and the great amount of statistical research which it contains, have served to place it in the first rank of works in this departmentof medical science. — N. Y. Journal of Medicine. Few treatises will be found better adapted as a text-book for the student, or as a manual for the frequent consultation of the young practitioner.— ' American Medical Joltrnal. demies of that disease. The whole forms a very valuable collection of papers, by professional writers of eminence, on some of the most importantaccidents to which the puerperal female is liable.—American Journal of Medical Sciences. BY THE SAME AUTHOR. ON THE DISEASES OF INFANTS AND CHILDREN. handsome volume of over 600 pages. In one large and We regard this volume as possessing more claims to completeness than any other of the kind with which we are acquainted. Most cordially and earn- estly, therefore, do wc commend it to our profession- al brethren, and we feel assured that the stamp of their approbation will in due time be impressed upon it. After an attentive perusal of its contents, we hesitate not to say, that it is one of the most com- prehensive ever written upon the diseases of chil- dren, and that, for copiousness of reference, extent of reseaTt-h, and perspicuity of detail, it is scarcely to be equalled, and not to be excelled, in any lan- guage.—Dublin Quarterly Journal. After this meagre, and we know, very imperfect notice of Dr. Churchill's ■work, we shail conclude by saying, that it is one that cannot fail from its co- piousness, extensi ve research, and general accuracy, to exalt still higher the reputation of the author in this country. The American reader will be particu- larly pleased to find that Dr. Churchill has done full justice throughout his work to the various American authors on this subject. The names of Dewees, Eberle, Condie, and Stewart, occur on nearly every page, and these authors are constantly referred toby the author in terms of the highest praise, and with the most liberal courtesy.—The Medical Examiner. The present volume will sustain the reputation acquired by the author from his previous works. The reader will find in it full and judicious direc- tions for the management of infants at birth, and a compendious, but clear account of the diseases to which children are liable, and the most successful mode of treating them. We must not close this no- tice without calling attention to the author's style, which is perspicuous and polished to a degree, w« regret to say, not generally characteristic of medical works. We recommend the work of Dr. Churchill most cordially, both to students and practitioners, as a valuable and reliable guide in the treatment of the diseases of children.—Am. Journ. of the Med. Sciences. We know of no work on this department of Prac- tical Medicine which presents so candid and unpre- judiced a statement or posting up of our actual knowledge as this.—N. Y. Journal of Medicine. Its claims to merit both as a scientific and practi- cal work, are of the highest order. Whilst we would not elevate it above every other treatise on the same subject, we certainly believe that very few are equal to it, and none superior.—Southern Med. and Surgical Journal. BY THE SAME AUTHOR. ESSAYS ON THE PUERPERAL FEVER, AND OTHER DISEASES PE- CULIAR TO WOMEN. Selected from the writings of British Authors previous to the close of the Eighteenth Century. In one neat octavo volume, of about four hundred and fifty pages. 10 BLANCHARD & LEA'S MEDICAL CHURCHILL (FLEETWOOD), M. D., M. R. I. A., Sec. ON THE DISEASES OF WOMEN; including those of Pregnancy and Child- bed. A new American edition, revised by the Author. With Notes and Additions, by D Fran- cis Condie, M. D., author of "A Practical Treatise on the Diseases of Children." In one large and handsome octavo volume, with wood-cuts, pp. 684. (Just Issued.) From the Author's Preface. In reviewing this edition, at the request of my American publishers, I have inserted several new sections and chapters, and I have added, I believe, all the information we have derived from recent researches; in addition to which the publishers have been fortunate enough to secure the services of an able and highly esteemed editor in Dr. Condie. We now regretfully take leave of Dr. Churchill's book. Had our typographical limits permitted, we should gladly have borrowed more from its richly stored pages. In conclusion, wc heartily recom- mend it to the profession, and would at the same time express our firm conviction that it will not only add to the reputation of its author, but will prove a work of great and extensive utility to obstetric practitioners.—Dublin Medical Press. Former editions of this work have been noticed in previous numbers of the Journal. The sentiments of high commendation expressed in those notices, have only to be repeated in this; not from the fact that the profession at large are not aware of the high merits which this work really possesses, but from a desire to see the principles and doctrines therein contained more generally recognized, and more uni- versally carried out in practice.—N. Y. Journal of Medicine. We know of no author who deserves that appro- bation, on "the diseases of females," to the same extent that Dr. Churchill does. His, indeed, is the only thorough treatise we know of on the subject; and it may be commended to practitioners and stu- dents as a masterpiece in its particular department. The former editions of this work have been com- mended strongly in this journal, and they have won their way to an extended, and a well-deserved popu- larity. This fifth edition, before us, is well calcu- lated to maintain Dr. Churchill's high reputation. It was revised and enlarged by the author, for his American publishers, and it seems to us that there is scarcely any species of desirable information on its subjects that may not be found in this work.—The Western Journal of Medicine and Surgery. We are gratified to announce a new and revised edition of Dr. Churchill's valuable work on the dis- eases of females We have ever regarded it as one of the very best works on the subjects embraced within its scope, in the English language; and the present edition, enlarged and revised by the author, renders it still more entitled to the confidence of the profession. The valuable notes of Prof Huston have been retained, and contribute, in no small de- gree, to enhance the value of the work. It is a source of congratulation that the publishers have permitted the author to be, in this instance, his own editor, thus securing all the revision which an author alone is capable of making.—The Western Lancet. Asa comprehensive manual for students, or a work of reference for practitioners, we only speak with common justice when we say that it surpasses any other that has ever issued on the same sub- ject from the British press.—The Dublin Quarterly Journal. DEWEES (W. P.), M.D., Sec. A COMPREHENSIVE SYSTEM OF MIDWIFERY. Illustrated by occa- sional Cases and many Engravings. Twelfth edition, with the Author's last Improvements and Corrections. In one octavo volume, of 600 pages. (Just Issued.) BY THE SAME AUTHOR. A TREATISE ON THE PHYSICAL AND MEDICAL TREATMENT OF CHILDPtEN. Tenth edition. In (One volume, octavo, 548 pages. (Just Issued.) BY THE SAME AUTHOR. A TREATISE ON THE DISEASES OF FEMALES. one volume, octavo, 532 pages, with plates. (Just Issued.) Tenth edition. In DICKSON (PROFESSOR S. H.), M.D. ESSAYS ON LIFE, SLEEP, PAIN, INTELLECTION, HYGIENE, AND DEATH. In one very handsome volume, royal 12mo. DANA (JAMES D). ZOOPHYTES AND CORALS. In one volume, imperial quarto, extra cloth, with wood-cuts. ' ' ALSO, AN ATLAS TO THE ABOVE, one volume, imperial folio, with sixty-one mae- nificent plates, colored after nature. Bound in half morocco. ALSO, ON THE STRUCTURE AND CLASSIFICATION OF ZOOPHYTES Sold separate, one vol., cloth. DE LA BECHE (SIR HENRY T.), F. R. S., Sec THE GEOLOGICAL OBSERVER. In one very large and handsome octavo volume, of 700 pages. With over three hundred wood-cuts. (Lately Issued.) AND SCIENTIFIC PUBLICATIONS. 11 DRUITT (ROBERT), M. R. C. S.f Sec. THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. A new American, from the improved London edition. Edited by F. W. Sargent, M. D., author of " Minor Surgery," &c. Illustrated with one hundred and ninety-three wood-engravings. In one very handsomely printed octavo volume, of 576 large pages. Dr. Druitt's researches into the literature of his subject have been not only extensive, but well di- rected ; the most discordant authors are fairly and impartially quoted, and, while due credit is given to each, their respective merits are weighed with an unprejudiced hand. The grain of wheat is pre- served, and the chaff is unmercifully stripped off. The arrangement is simple and philosophical, and the style, though clear and interesting, is so precise, that the book contains-more information condensed into a few words than any other surgical work with which tre are acquainted.—London Medical Times and Gazette, February 18, 1854. No work, in our opinion, equals it in presenting bo much valuable surgical matter in so small a compass.—St. Louis Med. and Surgical Journal. Druitt's Surgery is too well known to the Ameri- can medical profession to require its announcement anywhere. Probably no work of the kind has ever been more cordially received and extensively circu- lated than this. The fact that it comprehends in a comparatively small compass, all the essential ele- ments of theoretical and practical Surgery—that it is found to contain reliable and authentic informa- tion on the nature and treatment of nearly all surgi- eal affections—is a sufficient reason for the liberal patronage it has obtained. The editor, Dr. F. W. Sargent, has contributed much to enhance the value of the work, by such American improvements as are calculated more perfectly to adapt it to our own views and practice in this country. It abounds everywhere with spirited and life-like illustrations, which to the young surgeon, especially, are of no minor consideration. Every medical man frequently needs just such a work as this, for immediate refe- rence in moments of sudden emergency, when he has not time to consult more elaborate treatises.—The Ohio Medical and Surgical Journal. The author has evidently ransacked every stand- ard treatise of ancient and modern times, and all that is really practically useful at the bedside will be found in a form at once clear, distinct, and interest- ing.—Edinburgh Monthly Medical Journal. Druitt's work, condensed, systematic, lucid, and practical as it is, beyond most works on Surgery accessible to the American student, has had much currency in this country, and under its present au- spices promises to rise to yet higher favor.—The Western Journal of Medicine and Surgery. The most accurate and ample resume of the pre- sent state of Surgery that we are acquainted with.— Dublin Medical Journal. A better book on the principles and practice of Surgery as now understood in England and America, has not been given to the profession.—Boston Medi- cal and Surgical Journal. An unsurpassable compendium, not only of Sur- gical, but ■of Medical Practice.—London Medical Gazette. This work merits our warmest commendations, and we strongly recommend it to young surgeons as an admirable digest of the principles and practice of modern Surgery.—Medical Gazette. It may be said with truth that the work of Mr. Druitt affords a complete, though brief and con- densed view, of the entire field of modern surgery. We know of no work on the same subject having the appearance of a manual, which includes1 so many topics of interest to the surgeon ; and the terse man- ner in which each has been treated evinces a most enviable quality of mind on the part of the author, ' who seems to have an innate power of searching out and grasping the leading facts and features of the most elaborate productions of the pen. It is a useful handbook for the practitioner, and we should deem a teacher of surgery unpardonable who did not recommend it to his pupils. In our own opinion, it is admirably adapted to the wants of the student.— Provincial Medical and Surgical Journal. DUNGLISON, FORBES, TWEEDIE, AND CONOLLY. THE CYCLOPAEDIA OF PRACTICAL MEDICINE: comprising Treatises on the Nature and Treatment of Diseases, Materia Medica, and Therapeutics, Diseases of Women and Children, Medical Jurisprudence, &c. &c. In four large super royal octavo volumes, of 3254 double-columned pages, strongly and handsomely bound. #£* This work contains no less than four hundred and eighteen distinct treatises, contributed by sixty-eight distinguished physicians. The most complete work on Practical Medicine extant: or, at least, in our language.— Buffalo Medical and Surgical Journal. For reference, it is above all price to every prac- titioner.—Western Lancet. One of the most valuable medical publications of the day—as a work of reference it is invaluable.— Western Journal of Medicine and Surgery. It has been to us, both as learner and teacher, a work for ready and frequent reference, one in which modern English medicine is exhibited in the most advantageous light.—Medical Examiner. We rejoice that this work is to be placed within the reach of the profession in this country, it being unquestionably one of very great value to the prac- titioner. This estimate of it has not been formed from a hasty examination, but after an intimate ac- quaintance derived from frequent consultation of it during the past nine or ten years. The editors are practitioners of established reputation, and the list of contributors embraces many of the most eminent professors and teachers of London, Edinburgh, Dub- lin, and Glasgow. It is, indeed, the great merit of this work that the principal articles have been fur- nished by practitioners who have not only devoted especial attention to the diseases about which they have written, but have also enjoyed opportunities for an extensive practical acquaintance with them, and whose reputation carries the assurance of their competency justly to appreciate the opinions of others, while it stamps their own doctrines with high and just authority.—American Medical Journ. DUNGLISON (ROBLEY), M.D., Professor of the Institutes of Medicine, in the Jefferson Medical C ollege, Philadelphia. HUMAN HEALTH j or, the Influence of Atmosphere and Locality, Change of Air and Climate, Seasons, Food, Clothing, Bathing, Exercise, Sleep, &c. &c, on Healthy Man; constituting Elements of Hygiene, Second edition, with many modifications and additions. In one octavo volume, of 464 pages. 12 BLANCHARD & LEA'S MEDICAL DUNGLISON (ROBLEY), M.D., Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. MEDICAL LEXICON; a Dictionary of Medical Science, containing a concise Explanation of the various Subjects and Terms of Physiology, Pathology, Hygiene, Therapeutics, Pharmacology, Obstetrics, Medical Jurisprudence, &c. With the French and other Synonymes; Notices of Climate and of celebrated Mineral Waters; Formulae for various Officinal, "Empirical, and Dietetic Preparations, etc. Eleventh edition, revised. In one very thick octavo volume, ol over nine hundred large double-columned pages, strongly bound in leather, with raised bands. (Just Issued.) Every successive edition of this work bears the marks of the industry of the author, and of hi.-* determination to keep it fully on a level with the m.ost advanced state of medical science. Thus nearly fifteen thousand words have been added to it within the last few years. As a complete Medical Dictionary, therefore, embracing over FIFTY THOUSAND DEFINITIONS, in all the branches of the science, it is presented as meriting a continuance of the great favor and popularity which have carried it, within no very long space of time, to an eleventh edition. Every precaution has been taken in the preparation of the present volume, to render its mecha- nical execution and typographical accuracy worthy of its extended reputation and universal use. The very extensiv.e additions have been accommodated, without materially increasing the bulk of the volume by the employment of a small but exceedingly clear type, cast for this purpose. The press has been watched with great care, and every effort used to insure the verbal accuracy so ne- cessary to a work of this nature. The whole is printed on fine white paper; and, while thus exhi- biting in every respect so great an improvement over former issues, it is presented at the original exceedingly low price. We welcome it cordially; it isnn admirable work, and indispensable to all literary medical men. The labor which has been bestowed upon it is something prodigious. The work, however, has now been done, and we are happy in the thought that no hu- man being will have again to undertake the same gigantic task. Revised and corrected from time to time, Dr. Dunglison's '• Medical Lexicon" will last for centuries.—British and Foreign Med. Chirurg. Review, July, 1853. The fact that this excellent and learned work has passed through eight editions, and that a ninth is rendered necessary by the demands of the public, affords a sufficient evidence of the general apprecia- tion of Dr. Dunglison's labors by the medical pro- fession in England and America. It is a book which will be of great service to the student, in teaching him the meaning of all the technical terms used in medicine, and will be of no less use to the practi- tioner who desires to keep himself on a level with the advance of medical science.—London Medical Times and Gazette. valuable work, we directed the attention of our readers to its peculiar merits; and we need do little more than state, in reference to the present reissue, that, notwithstanding the large additions previously made to it, no fewer than four thou- sand terms, not to be found in the preceding edi- tion, are contained m the volume b fore us.— Whilst it is a wonderful monument of its author's erudition and industry, it is also a work of great practical utility, «s we can testify from our own experience; for we keep it constantly within our reach, and m;ike very frequent reference to it, nearly always finding in it the information we seek. —British and Foreign Med.-Chirurg. Review. It has the rare merit that it certainly has no rival in the English language for accuracy and extent of references. The terms generally include short physiological and pathological descriptions, so that, as the author justly observes, the reader does not possess in this work a mere dictionary, but a book, which, while it instructs him in medical etymo- logy, furnishes him with a large amount of useful information. The author's labors have been pro- perly appreciated by his own countrymen ; and we can only confirm their judgment, by recommending this most useful volume to the notice of our cisat- lantic readers. No medical library will be complete without it.—London Med. Gazette. It is certainly moTe complete and comprehensive than any with which we are acquainted in the English language. Few, in fact, could be found belter qualified than Dr. Dunglison for the produc- tion of such a work. Learned, industrious, per- severing, and accurate, he brings to the task all the peculiar talents necessary for its successful performance; while, at the same time, his fami- liarity with the writings of the ancient and modern therefore almostas indispensable to the other learned ! '" musters of our ajV' renders him skilful to note professions as to our own. In fact, to all who may , eiact u?n&e of ,.^e several terms of science, haveoccasion to ascertain the meaning of any word ■ , the various modifications which medicnl term- belonging to the many branches of medicine. From I "•lolo^.t"S underP°ne with the change of theo- a careful examination ofthe present edition, we can I "eS °r .- ProSr,'8.s °.f .improvement. — American In taking leave of our author, we feel compelled to confess that his work bears evidence of almost incredible labor having been bestowed upon its com- position.— Edinburgh Journal of Med. Sciences, Sept. 1&53. A miracle of labor and industry in one who has written able and voluminous works on nearly every branch of medical science. There could be no more t useful book to the student or practitioner, in the present advancing age, than one in which would be found, in addition to the ordinary meaning and deri- vation of medical terms—so many of which are of modern introduction—concise descriptions of their explanation and employment; and all this and much more is contained in the volume before us. It i vouch for its accuracy, and for its being brought quite up to the date of publication ; the author states in his preface that hehasadded to it about four thou- sand terms, which are not to be found in the prece- ding one. — Dublin Quarterly Journal of Medical Sciences. Journal ofthe Medical Sciences. One of the most complete and copious known to the cultivators of medical science.—Boston Med. Journal. The most comprehensive and best English Dic- tionary of medical terms extant.—Buffalo Medical On the appearance of the last edition of this Journal. ' BY THE SAME AUTHOR. THE PRACTICE OF MEDICINE. A Treatise on Special Pathology and The- rapeutics. Third Edition. In two large octavo volumes, of fifteen hundred pages? Upon every topic embraced in the work the latest information will be found carefully posted up.— Medical Examiner.' The student of medicine will find, in these two ferings of the race—Boston Medical and Surgical Journal. It is certainly the most complete trentise of which we haveany knowledge.— Western Journal ofMedi- elegant volumes, a mine of facts, a' gathering of L^fJ^"J17 n precepts and advice from the world of experience, euu and Surgery that will nerve him with courage, and faithfully One of the most elaborate treatises of the kind direct him m his efforts to relieve the physical suf- we have— Southern Med. and Surg. Journal. i'ETm'TIFIC PUBLICATIONS. 13 DUNGLISON (ROBLEY), M.D., Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. HUMAN PHYSIOLOGY. Seventh edition. Thoroughly revised and exten- sively modified and enlarged, with nearly five hundred illustrations. In two large and hand- somely printed octavo volumes, containing nearly 1450 pages. It has long since taken rank as one of the medi eal classics of our language. To say that it is by tar the best text-book of physiology ever published in this country, is but echoing the general testi- mony of the profession .—N. Y. Journal of Medicine. There is no single book we would recommend to the student or physician, with greater confidence than the present, because in it will be found a mir- ror of almost every standard physiological work of the day. We most cordially recommend the work to every member of the profession, and no student should be without it. It is the completest work on Physiology in the English language, and is highly creditable to the author and publishers.—Canadian Medical Journal. The most complete find satisfactory system of Physiology in the English language.—Amer. Med. Journal. The best work of the kind in. the English lan- guage.—Silliman's Journal. The most full and complete system of Physiology in our language.—Western Lancet. BY THE SAME AUTHOR. *(Just Issued.) > GENERAL THERAPEUTICS AND MATERIA MEDICA; adapted for a Medical Text-book. Fifth edition, much improved. With one hundred and eighty-seven illus- trations. In two large and handsomely printed octavo vols., of about 1100 pages. The new editions ofthe United States Pharmacopoeia and those of London and Dublin, have ren- dered necessary a thorough revision of this work. In accomplishing this the author has spared no pains in rendering it a complete exponent of all that is new and reliable, both in the departments of Therapeutics and Materia Medica. The book has thus been somewhat enlarged, and a like im provemeut will be found in every department of its mechanical execution. As a convenient text- book for the student, therefore, containing within a moderate compass a satisfactory resume of its important subject, it is again presented as even more worthy than heretofore of the very great favor which it has received. In this work of Dr. Dunglison, we recognize the1 As a text-book for students, for whom it is par- ticularly designed, we know of none superior to it.—St. Louis Medical and Surgical Journal. same untiring industry in the collection and em- bodying of facts on the several subjects of which he treats, that has heretofore distinguished him, and we cheerfully point to these volumes, as two of the most interesting that we know of. In noticing the additions to this, the fourth edition, there is very little in the periodical or annual literature of the profession, published in the interval which has elapsed since the issue of the first, that has escaped i the careful search of the author. As a book for ' an increase of patronage over any of its former -Charleston Med. Jour- ones> on account of its increased merit. — N. Y. It purports to be a new edition, but it is rather a new book, so greatly has it been improved, both in the amount and quality of the matter which it contains.—N. O. Medical and Surgical Journal. We bespeak for this edition, from the profession, reference, it is invaluable.' nal and Review. Journal of Medicine. It may be said to be the work now upon the sub- j We consider this work unequalled.—Boston Med. jects upon which it treats.— Western Lancet. ; and Surg. Journal. BY THE SAME AUTHOR. NEW REMEDIES, WITH FORMULAE FOR THEIR ADMINISTRATION. Sixth edition, with extensive Additions. In one very large octavo volume, of over 750 pages. One of the most useful of the author's works.— Southern Medical and Surgical Journal. This well-known and standard book has now reached its sixth edition, and has been enlarged and improved by the introduction of all the recent gifts to therapeutics which the last few years have so richly produced, including the anresthetic agents, &c. This elaborate and useful .volume should be found in every medical library, for as a book of re- ference, for physicians, it is unsurpassed by any other work in existence, and the double index for diseases and for remedies, will be found greatly to enhance its value.—New York Med. Gazette. The great learning of the author, and his remark- able industry in pushing his researches into every source whence information is derivable, has enabled him to throw, together an extensive mass of facts and statements, accompanied by full reference to authorities; which lust feature renders the work practically valuable to investigators who desire to examine the original papers.—The American Journal of Pharmacy. DURLACHER (LEWIS). A TREATISE ON CORNS, BUNIONS, THE DISEASES OF NAILS, AND THE GENERAL MANAGEMENT OF THE FEET. In one 12mo. volume, cloth. pp. 134. DE JONGH (L. J.), M. D., Sec. THE THREE KINDS OF COD-LIVER OIL, comparatively considered, with their Chemical and Therapeutic Properties. Translated, with an Appendix and Cases, by Edward Carky, M. D. To which is added an article on the subject from "Dunglison on New Remedies." In one small 12mo. volume, extra cloth. DAY (GEORGE E.), M. D. A PRACTICAL TREATISE OX THE DOMESTIC MANAGEMENT AND MORE IMPORTANT DISEASES OF ADVANCED LIFE. With an Appendix on a new and successful mode of treating Lumbago and other forms of ChTonic Rheumatism. One volume, octavo, 2v!6 pages. 14 BLANCHARD & LEA'S MEDICAL ELLIS (BENJAMIN;, M.D. THE MEDICAL FORMULARY: being a Collection of Prescriptions, derived from the writings and practice of many of the most eminent physicians of America and Europe. Together with the usual Dietetic Preparations and Antidotes for Poisons. To which is added an Appendix, on the Endermic use of Medicines, and on the use of Ether and Chloroform. The whole accompanied with a few brief Pharmaceutic and Medical Observations. Tenth edition, revised and much extended by Robert P. Thomas, M. D., Professor of Materia Medica in the Philadelphia College of Pharmacy. In one neat octavo volume, of two hundred and ninety-six pages. (Now Ready. Revised and enlarged to 1851.) This work has received a very complete revision at the hands ofthe editor, who has made what- ever alterations and additions the progress of medical and pharmaceutical science has rendered ad- visable, introducing fully the new remedial agents, and revising the whole by the latest improvements ofthe Pharmacopoeia. To accommodate these additions, the size of the page has been increased, and the volume itself considerably enlarged, while every effort has been made to secure the typo- graphical accuracy which has so long merited the confidence of the profession It will prove particularly useful to students and young practitioners, as the most important prescrip- tions employed in modern practice, which lie scat- tered through our medical literature, are here col- lected and conveniently arranged for reference.— Charleston Med. Journal and Review. After an examination of the new matter and the alterations, we believe the reputation of the work built up by the author, and the late distinguished editor, will continue to flourish under the auspices of the present editor, who has the industry and accu- racy, and, we would say, conscientiousness requi- site for the responsible task.—American Journal of Pharmacy, March, 1854. ERICHSEN (JOHN)., Professor of Surgery in University College, London, &c. THE SCIENCE AND ART OF SURGERY; being a Treatise on Surgical Injuries, Diseases, and Operations. With Notes and Additions by the American Editor. Il- lustrated with over three hundred engravings on wood. In one large and handsome octavo volume, of nearly nine hundred closely printed pages. (NowReady.) This is a new work, brought up to May, 1854. This work, which is designed as a text-book for the student and practitioner, will be found a very complete treatise on the principles and practice of surgery. Embracing both these branches ofthe subject simultaneously, and elucidating the one by the other, it enables the reader to take a compre- hensive view of the objects of his study, and presents the subjects discussed in a clear and con- nected manner. The author's style will be found easy and flowing, and the illustrations having been drawn under his especial supervision, are with few exceptions new, and admirably adapted to elucidate the text to which they refer. In every point of mechanical execution, it will be found one of the handsomest works issued from the American press. The aim of Mr. Erichsen appears to be to improve I which he is Professor, and we can cordinlly recom- upon the plan of Samuel Cooper; and by connecting i mend it as a work of reference, both to students and in one volume the science and art of Surgery, to i practitioners.—Medical Times and Gazette. supply the student with a text-book and the practi- . tinner with a work of reference, in which scientific I We surprised by a stately crop which may bear feel perfectly safe in recommending it to our read- I C() ' ri!|on with any of (ta former rivals. The ers as a monograph unequalled in interest anu , u'mlB of our high appreciation of the work will practical value by any other on the subject in our . gg obviong as we proceed; and we doubt not that language.—Western Journal of Med. and burg. | {he present facilities for obtaining American books It has remained for an American writer to wipe • wi[i induce many of our readers to verify our re- away this reproach ; and so completely has the task commendation by their own perusal of it.—Brtttsh been fulfilled, that we venture to predict for Br. j awi Foreign Medico-Chirurgical Review. Gross's treatise a ?™™?$™\£ £rt work.™ j Whoever will peruse the vast amount of valuable ofsurgery, worthy o rank with.the ^^ ™d I practical information it contains, and which we hu'tS.eee" i .Tup of If volume is moscrldrtabl^ nave been un:,ble even to notice will we.think but the getting up oi tae vi mine • here nQ work m ,.he English monstrate that America is making rapid advances in BY the same author. (Nearly Ready.) A PRACTICAL TREATISE ON FOREIGN BODIES IN TIIE AIR-PAS- SAGES. In one handsome octavo volume, with illustrations. by the same author. (Preparing.) A SYSTEM OF SURGERY; Diagnostic, Pathological, Therapeutic, and Opera- tive. With very numerous engravings on wood. 16 BLANCHARD & LEA'S MEDICAL GLUGE (GOTTLIEB), M. D., Professor of Physiology and Pathological Anatomy in the University of Brussels, &c. AN ATLAS OF PATHOLOGICAL HISTOLOGY. Translated, with Notes and Additions, by Joseph Leidy, M. D., Professor of Anatomy in the University of Pennsylva- nia. In one volume, very large imperial quarto, with three hundred and twenty figures, plain and colored, on twelve copperplates. This being, as far as we know, the only work in the unconnected observations of a great number of which pathological histology is separately treated authors. The development of the morbid tissues, of in a comprehensive manner, it will, we think, for and the formation of abnormal products, may now this reason, be of infinite service to those who desire be followed and studied with the same ease and to investigate the subject systematically, and who satisfaction as the best arranged system of phy- nave felt the difficulty of arranging in their mind siology.—American Med. Journal. GRIFFITH (ROBERT E.), M. D., Sec. A UNIVERSAL FORMULARY, containing the methods of Preparing and Ad- ministering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceu- tists. Second Edition, thoroughly revised, with numerous additions, by Robert P. Thomas, M. D., Professor of Materia Medica in the Philadelphia College of Pharmacy. In one large and handsome octavo volume, of over six hundred pages, double columns. (Just Ready.) The speedy exhaustion of a large edition, and the demand for a second, sufficiently show the posi- tion which this work has so rapidly attained as an authoritative and convenient work of reference for the physician and pharmaceutist. The opportunity thus afforded for its improvement has not been neglected. In its revision, Professor Thomas (to whom this task has been confided in consequence ofthe death ofthe author), has spared no labor, in the hope of rendering it the most complete and correct work on the subject as yet presented to the profession All, the newly introduced articles ofthe Materia Medica have been inserted, such formulae as had escaped the attention of the author have been added, and the whole has been most carefully read and examined, to insure the absolute correctness, so indispensable in a work of this nature. The amount of these additions may be esti- mated from the fact that not only has the page been considerably enlarged, but the volume has also been increased by about fifty pages, while the arrangement of the formulae and the general typo- graphical execution will be found to have undergone great improvement. To the practitioner, its copious collection of all the forms and combinations of the articles of the Pharmacopoeia render it an invaluable book of reference, while its very complete embodiment of officinal preparations of ail kinds, derived from all sources, American, English, and Continental, make it an indispensable assis- tant to the apothecary. Dr. Griffith's Formulafy is worthy of recommen- dation, not only on account of the care which has been bestowed on it by its estimable author, but for its general accuracy, and the richness of its details. —Medical Examiner. Most cordially we recommend this Universal Formulary, not forgetting its adaptation to drug- gists and apothecaries, who would find themselves vastly improved by a familiar acquaintance with this every-day book of medicine.—The Boston Med. and Surg. Journal. A very useful work, and a most complete compen- dium on the subject of materia medica. We know of no work in our. language, or any other, so com- prehensive in all its details.—London Lancet. Pre-eminent among the best and most useful com- pilations of the present day will be found the work before us, which can have been produced only at » very great cost of thought and labor. A short de- scription will suffice to Bhow that we do not put too high an estimate on this work. We are not cog- nizant ofthe existence of a parallel work. Its value will be apparent to our readers from the sketch of its contents above given. We strongly recommend it to all who are engaged either in pructics.1 medi- cine, or more exclusively with its literature.—Land. Med. Gazette. A valuable acquisition to the medical practitioner, and a useful book of reference to the apothecary on numerous occasions.—Amer. Journal of Pharmacy. BY THE SAME AUTHOR. MEDICAL BOTANY; or, a Description of all the more important Plants used m Medicine, and of their Properties, Uses, and Modes of Administration. In one large octavo volume, ol 704 pages, handsomely printed, with nearly 350 illustrations on wood. One of the greatest acquisitions to American medi- cal literature. It should by all means be introduced, at the very earliest period, into our medical schools, and occupy a place in the library of every physician in the land.—South-western Medical Advocate. Admirably calculated for the physician and stu- dent — we have seen no work which promises greater advantages to the profession.—N. O. Med and Surg. Journal. One of the few books which supply a positive de- ficiency in our medical literature.—Western Lancet. We hope the day is not distant when this work will not only be a text-book in every medical school and college in the Union, but find a place in the li- brary of every private practitioner.—A'. Y. Journal of Medicine. GREGORY (WILLIAM), F. R. S. E., Professor of Chemistry in the University of Edinburgh, &c. LETTERS TO A CANDID INQUIRER ON ANIMAL Description and Analysis of the Phenomena. Details of Facts and Cases royal l2aio., extra cloth. MAGNETISM. In one neat volume, GARDNER (D. PEREIRA), M. D. MMD^AnbC^EMISTilY'ifortlieuseof Sfcudents and th* Profession: being a AJND SCIENTIFIC PUBLICATIONS. 17 HASSE (C. E.), M. D. AN ANATOMICAL DESCRIPTION OF THE DISEASES OF RESPIRA- TION AND CIRCULATION. Translated and Edited by Swaine. In one volume, octavo. HARRISON (JOHN), M.D. AN ESSAY TOWARDS A CORRECT THEORY OF THE NERVOUS SYSTEM. In one octavo volume, 292 pages. HUNTER (JOHN). TREATISE ON THE VENEREAL DISEASE. With copious Additions, by Da. Ph. Ricord, Surgeon to the Venereal Hospital of Paris. Edited, with additional Notes, by F. J. Bumstead, M. D. In one octavo volume, with plates (Now Ready.) I3P See Ricord. Also, HUNTER'S COMPLETE WORKS, with Memoir, Notes, &c. &c. In four neat octavo volumes, with plates. HUGHES (H. M.), M. D., Assistant Physician to Guy's Hospital, &c. A CLINICAL INTRODUCTION TO THE PRACTICE OF AUSCULTA- TION, and other Modes of Physical Diagnosis, in Diseases of the Lungs and Heart. Second American from the Second and Improved London Edition. In one royal ]2mo. vol. (Just Ready.) It has been carefully revised throughout. Some small portions have been erased; much has been, I trust, amended; and a great deal of new matter has been added; so that, though funda- mentally it is the same book, it is in many respects a new work.—Preface. HORNER (WILLIAM E.), M. D., Professor of Anatomy in the University of Pennsylvania. SPECIAL ANATOMY AND HISTOLOGY. Eighth edition. Extensively revised and modified. In two large octavo volumes, of more than one thousand pages, hand- somely printed, with over three hundred illustrations. This work has enjoyed a thorough and laborious revision on the part of the author, with the view of bringing it fully up to the existing state of knowledge on the subject of general and special anatomy. To adapt it more perfectly to the wants ofthe student, he has. introduced a large number of additional wood-engravings, illustrative of the objects described, while the publishers have en- deavored to render the mechanical execution ofthe work worthy of the extended reputation which it has acquired. The demand which has carried it to an EIGHTH EDITION is a sufficient evi- dence of the value of the work, and of its adaptation to the wants of the student and professional reader. HOBLYN (RICHARD D.), A. M. A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE COLLATERAL SCIENCES. Second and Improved American Edition. Revised, with nu- merous Additions, from the second London edition, by Isaac Hays, M. D., &c. In one large royal 12mo. volume, of over four hundred pages, double columns. (Nearly Ready.) In passing this work a second time through the press, the editor has subjected it to a very tho- rough revision, making such additions as the progress of science has rendered desirable, and sup- plying any omissions that may have previously existed. As a concise and convenient Dictionary of Medical Terms, at an exceedingly low price, it will therefore be found of great value to the stu- dent and practitioner. _________________ HOPE (J.), M. D., F. R. S., 8ec. A TREATISE ON THE DISEASES OF THE HEART AND GREAT VESSELS. Edited by Pennock. In one volume, octavo, with plates, 572 pages. HERSCHEL (SIR JOHN F. W.), F. R. S., Sec. OUTLINES OF ASTRONOMY. New American, from the third London edition. In one neat volume, crown octavo, with six plates and numerous wood-cuts. (Just Issued.) HUMBOLDT (ALEXANDER). ASPECTS OF NATURE IN DIFFERENT LANDS AND DIFFERENT CLIMATES. Second American edition, one vol. royal 12mo., extra cloth. JONES (T. WHARTON), F. R. S., Sec. THE PRINCIPLES AND PRACTICE OF OPHTHALMIC MEDICINE AND SURGERY. Edited by Isaac Hays, M. D., &c. In one very neat volume, large royal 12mo., of 529 pages, with four plates, plain or colored, and ninety-eight wood-cuts. The work amply sustains, in every point the al- might become, a manual for daily reference and ready high reputation of the author as an ophthalmic consultation by the student and the general practi- sur-eon as well as a physiologist and pathologist tioner. The work is marked by that correctness Thfbook is evidently the result of much labor and* clearness, and precision of style which distinguish research and has been written with the greatest all the productions of the learned author .-British care and' attention. We entertain little doubt that and Foreign Medical Review. this book will become what its author hoped it 18 BLANCHARD & LEA'S MEDICAL JONES (C. HANDFIELD), F. R. S., Se EDWARD H. SIEVEKING, M. D. A MANUAL OF PATHOLOGICAL ANATOMY. With numerous engravings on wood. In one handsome volume. (In Press.) KIRKES (WILLIAM SENHOUSE), M. D., Demonstrator of Morbid Anatomy at St. Bartholomew's Hospital, &c; and JAMES PAGET, F..R. S., Lecturer on General Anatomy and Physiology in St. Bartholomew's Hospital. A MANUAL OF PHYSIOLOGY. Second American, from the second and improved London edition. With one hundred and sixty-five illustrations. In one large and handsome royal 12mo. volume, pp. 550. (Just Issued.) that it is important to know, without special details, which are read with interest only by those who would make a specialty, or desire to possess a criti- cal knowledge of the subject.—Charleston Medical Journal. One of the best treatises that can be put into the hands ofthe student.—London Medical Gazette. The general favor with which the first edition of this work was received, and its adoption as a favor- ite text-book by many of our colleges, will insure a large circulation to this improved edition. It will fully meet the wants of the student. — Southern Med. and Surg. Journal. Particularly adapted to those who desire to pos- sess a concise digest of the facts of Human Physi- ology.—British and Foreign Med.-Chirurg. Reviexo. We conscientiously recommend it as an admira- ble " Handbook of Physiology."—London Journal of Medicine, In the present edition, the Manual of Physiology has been brought up to the actual condition of the science, and fully sustains the reputation which it has already so deservedly attained. We consider the work of MAI. Kirkes and Paget to constitute one of the very best handbooks of Physiology we possess —presenting just such an outline of the science, com- prising an account of its leading facts and generally admitted principles, as the student requires during his attendance upon a course of lectures, or for re- ference whilst preparing for examination. The text is fully and ably illustrated bv a series of very supe- rior wnod-engravings, by which a comprehension of some of the more intricate of the subjects treated of is greatly facilitated.—Am. Medical Journal. We need only say, that, without entering into dis- cussions of unsettled questions, it contains all the recent improvements in this department of medical science. For the student beginning this study, and the practitioner who has but leisure to refresh his memory, this book is invaluable, as it contains all KNAPP (F.), PH. D., Sec. TECHNOLOGY; or, Chemistry applied to the Arts and to Manufactures. Edited, with numerous Notes and Additions, by Dr. Edmund Ronalds and Dr. Thomas Richardson. First American edition, with Notes and Additions, by Prof. Walter R. Johnson. In two hand- 'some octavo volumes, printed and illustrated in the highest style of art, with about five hundred wood-engravi ngs. LEHMANN. PHYSIOLOGICAL CHEMISTRY. Translated by George E. Day, M. D. (Preparing.) LEE (ROBERT), M. D., F. R. S., Sec. CLINICAL MIDWIFERY; comprising the Histories of Five Hundred and Forty-five Cases of Difficult, Preternatural, and Complicated Labor, with Commentaries. From the second London edition. In one royal 12mo. volume, extra cloth, of 238 pages. LA ROCHE (R.), M. D., Sec. PNEUMONIA; its Supposed Connection, Pathological and Etiological, with Au- tumnal Fevers, including an Inquiry into the Existence and Morbid Agency of Malaria. In one handsome octavo volume, extra cloth, of 500 pages. A more simple, clear, and forcible exposition of the groundless nature and dangerous tendency of certain pathological and etiological heresies, has seldom been presented to our notice.—N. Y. Journal of Medicine and Collateral Science, March, 1854. This work should be carefully studied by Southern physicians, embodying as it does the reflections of an original thinker and close observer on a subject peculiarly their own.—Virginia Med. and Surgical Journal. The author had prepared us to expect a treatise from him, by his brief papers on kindred topics in the periodical press, and yet in the work before us he has exhibited an amount of industry and learning, research and ability, beyond what we are accustomed to discover'in modern medical writers; while his own extensive opportunities for observation and experience have been improved by the most laudable Qiligence, and display a familiarity with the whole subject in every aspect, which commands both our respect and confidence. As a corrective of prevalent and mischievous error, sought to be propagated by novices and innovators, we could wish that Dr. La Roche's book could be widely read.—N. Y. Medical Gazette. LONGET (F. A.) TREATISE ON PHYSIOLOGY. With numerous Illustrations. Translated Mc D" Pr°feS£0r °f InStitUteS °f Medicine iQ the Pennsylvania AND SCIENTIFIC PUBLICATIONS. 19 LAWRENCE (W.), F. R. S., Sec. A TREATISE ON DISEASES OF TIIE EYE. A new edition, edited, with numerous additions, and 243 illustrations, by Isaac Hats, M. D., Surgeon to Wills Hospi- tal, &c. In one very large and handsome octavo volume, of 950 pages, strongly bound in leather With raised bands. (Now Ready.) This work is thoroughly revised and brought up to 1854. This work is so universally recognized as the standard authority on the subject, that the pub- lishers in presenting this new edition have only to remark that in its preparation the editor has carefully revised every portion, introducing additions and illustrations wherever the advance of science has rendered them necessary or desirable. In this manner it will be found to con- tain over one hundred pages more than the last edition, while the list of wood-engravings has been increased by sixty-seven figures, besides numerous improved illustrations substituted for such as were deemed imperfect or unsatisfactory. The various important contributions to ophthalmological science, recently made by Dalrymple, Jacob, Walton, Wilde, Cooper, &c, both in the form of separate treatises and contributions to periodicals, have been carefully examined by the editor, and, combined with the results of his own experience, have been freely introduced throughout the volume, rendering it a complete and thorough exponent of the most advanced state ofthe subject. Among the most important additions may he mentioned a full account of the recent microscopical investigations into the structure and pathology ofthe eye; the description of several affections not treated of in the original; an account of the catoptric investigation of the eye, and of its employment as a means of diagnosis ; a description of recently invented instruments for illuminating the retina, and of some new methods for examin- ing the interior structures of the eye. Very great improvements will likewise be found in the typographical and mechanical execution of the work. In a future number we shall notice more at length octavo pnges—has enabled both author and editor to this admirable treatise-the safest guide and most : do justice to all the details of this subject, and con- comprehensive work of reference, which is within j dense in this single volume the present state of our the reach of all classes of the profession:—Stetho- I knowledge of the whole science in this department, scope, March, 1851. ! whereby its practical value cannot be excelled. We ! heartily commend it, especially as a book of refe- This standard text-book on the department of j rence, indispensable in every medical library. The which it treats, has not been superseded, by any or i additions of the American editor very greatly en- all of the numerous publications on the subject i nance the value of the work, exhibiting the learning heretofore issued. Nor with the multiplied improve- j and experience of Dr. Hays, in the light in which he ments of Dr. Hays, the American editor, is it at all ' ought to be held, as a standard authority on all sub- likely that this great work will cease to merit the j jects appertaining to this specialty, to which he has confidence and preference of students or practition- j rendered so many valuable contributions.—N. Y. ers. Its ample extent—nearly one thousand large j Medical Gazette. i BY THE SAME AUTHOR. A TREATISE ON RUPTURES; from the fifth London edition. In one octavo volume, sheep, 480 pages. LISTON (ROBERT), F. R. S., Sec. LECTURES ON THE'OPERATIONS OF SURGERY, and on Diseases and Accidents requiring Operations. Edited, with numerous Additions and Alterations, by T. D. Mutter, M. D. In one large and handsome octavo volume, of 566 pages, with 216 wood-cuts. LALLEMAND (M.). THE CAUSES, SYMPTOMS, AND TREATMENT OF SPERMATOR- RHOEA. Translated and edited by Henry J. McDougal. In one volume, octavo, 320 pages. Second American edition. (Now Ready.) LARDNER (DIONYSIUS), D. C. L., Sec. HANDBOOKS OF NATURAL PHILOSOPHY AND ASTRONOMY. Revised, with numerous Additions, by the American editor. First Course, containing Mecha- nics, Hydrostatics, Hydraulics, Pneumatics, Sound, and Optics. In one large royal 12mo. volume, of 750 pages, with 424 wood-cuts. Second Course, containing Heat, Electricity, Mag- netism, and Galvanism, one volume, large royal 12mo., of 450 pages, with 250 illustrations. Third Course ( now ready), containing Meteorology and Astronomy, in one large volume, royal 12mo. of nearly eight hundred pages, with thirty-seven plates and two hundred wood-cuts. The whole complete in three volumes, of about two thousand large pages, with over one thousand figures on steel and wood. The various sciences treated in this work will be found brought thoroughly up to the latest period. The work furnishes a very clear and satisfactory account of our knowledge in the important depart- ment of science of which it treats. Although the medical schools of this country do not include the study of physics in their course of instruction, yet no student or practitioner should be ignorant of its laws. Besides being of constant application in prac- i Their laws are elucidated in a manner both pleasing tice, such knowledge is of inestimable utility in fa- cilitating the study of other branches of science. To Btudents, then, and to those who, having already en- tered upon the active pursuits of business, are desir- ous to sustain and improve their knowledge of the general truths of natural philosophy, we can recom- mend this work as supplying in a clear and satis factory manner the information they desire.—The Virginia Med. and Surg. Journal. The present treatise is a most complete digest of all that has been developed in relation to the great forces of nature, Heat, Magnetism, and Electricity. Their laws are elucidated in a manner both pleasing and familiar, and at the same time perfectly intelli- gible to the student. The illustrations are suffi- ciently numerous and appropriate, and altogether we can cordially recommend the work as well-de- serving the notice both of the practising physician and the student of medicine.—The Med. Examiner. 20 BLANCHARD & LEA'S MEDICAL MEIGS (CHARLES D.), M. D., Professor of Obstetrics, &c, in the Jefferson Medical College, Philadelphia. WOMAN: HER DISEASES AND THEIR REMEDIES. A Series of Lee- tures to his Class. Third and Improved edition. In one large and beautifully printed octavo volume. (Just Ready. Revised and enlarged to 1854.) The gratifying appreciation of his labors, as evinced by the exhaustion of two large impressions of this work" within a few years, has not been lost upon the author, who has endeavored in every way to render it worthy of the favor with which it has been received. The opportunity thus afforded for a second revision has been improved, and the^'ork is now presented as in everyway superior to its predecessors, additions and alterations having been made whenever the advance oi science has rendered them desirable. The typographical execution of the work will also be found to have undergone a similar improvement and .the work is now confidently presenled as in every way worthy the position it has acquired as the standard American text-book on the Diseases-of Females. It contains a vast amount of practical knowledge, by one who has accurately observed and retained the experience of ninny years, and who tells the re- sult in a free, familiar, and pleasant manner.—Dub- lin Quarterly Journal. There is an off-hand fervor, a glow, and a warm- heartedness infecting the effort of Dr. Meigs, which is entirely captivating, and which absolutely hur- ries the reader through from beginning to end. Be- sides, the book teems with solid instruction, and it shows the very highest evidence of ability, viz., the clearness with which the information is pre- sented. We know of no better test of one's under- standing a subject than the evidence of the power of lucidly explaining it. The most elementary, as well as the obscurest subjects, under the pencil of Prof. Meigs, are isolated and made to stand out in such bold relief, as to produce distinct impressions upon the mind and memory ofthe reader. — The Charleston Med. Journal. Professor Meigs has enlarged and amended this great work, for such it unquestionably is, having passed the ordeal of criticism at home and abroad, hut been improved thereby ; for in this new edition the author has introduced real improvements, and increased the value and utility of the book im- measurably. It presents so many novel, bright, and sparkling thoughts; such an exuberance of new ideas on almost every page, that we confess our- selves to have become enamored with the book and its author; and cannot withhold our congratu- lations from our Philadelphia confreres, that such a teacher is in their service. We regret that our limits will not allow of a more extended notice of this work, but must content ourselves with thus commending it as worthy of diligent perusal by physicians as well as students, who are seeking to be thoroughly instructed in the important practical subjects of which it treats.—JV. Y. Med. Gazette. BY THE SAME AUTHOR. OBSTETRICS: THE SCIENCE AND THE ART. Second edition, revised and improved. With one hundred and thirty-one illustrations In one beautifully printed octavo volume, of seven hundred and fifty-two large pages. (Lately Published.) The rapid demand for a second edition of this work is a sufficient evidence that it has supplied a desideratum ofthe profession, notwithstanding the numerous treatises on the same subject which have appeared within the last few years. Adopting a system of his own, the author has combined the leading principles of his interesting and difficult subject, with a thorough exposition of its rules o< practice, presenting the results of long and extensive experience and of familiar acquaintance with all the modern writers on this department of medicine. As.an American Treatise on Mid- wifery, which has at once assumed the position of a classic, it possesses peculiar claims to the at- tention and study ofthe practitioner and student, while the numerous alterations and revisions which it has undergone in the present edition are shown bv the great enlargement of the work which is not only increased as to the size of the page, but also in the number. Among other addi- tions may be mentioned ° A NEW AND IMPORTANT CHAPTER ON "CHILDBED FEV^R." by the same author. (Now Ready.) A TREATISE ON ACUTE AND CHRONIC DISEASES OF THE NECK OF THE UTERUS With numerous plates, drawn and colored from nature in the highest style of art. In one handsome octavo volume, extra cloth. of^eionle«lnl,he authotl: ?n .,his work ha? ^een to present in a small compass the practical results of hi> long experience in this important and distressing class of diseases. The great chants intro- duced into practice, and the accessions to our knowledge on the subject withhfthe last fewvear° resulting from the use of the metroscope, brings within the ordinary practiceofeverv ohvsfcian numerous cases wh.ch were formerly regarded*** incurable, and render^ of grLfvalue a £te he present combining practical directions for diagnosis and Ireatment with an ample "er^of il u7 trations copied accurately from colored drawings made by the author, after nature Nosuch accu a thST,h0nS °f ,hC 1a,h0 °SY f t.he."eck of the u,er»* have heretoforebeen"givSn, requS as they do the rare combination of physician and artist, and their paramountimportance? to til physican in whose practice such cases are frequent, is too evident to beLeTurW whilein artistic execution they are far m advance of anything of the kind as yet produced in Xs country BY THE SAME AUTHOR. 0?IiEldI#nTI?NS ,0JJ CERTAIX OF THE DISEASES OF YOUNG OtLLLDREN. In one handsome octavo volume, of 214 pages. -t-vu^u by the same author. (In Press ) °FEvlRIEmNATU?E' SIGNS' ASD TREATMENT OF PUERPERAL fiiVER. In one handsome octavo volume. j. uojxvx ajxv^xjj AND SCIENTIFIC PUBLICATIONS. 21 MILLER (JAMES), F. R. S. E., Professor of Surgery in the University of Edinburgh, &c. PRINCIPLES OF SURGERY. Third American, from the second and revised Edinburgh edition. Revised, with Additions, by F. W. Sargent, M. D., author of " Minor Sur- gery," &c In one large and very beautiful volume, of seven hundred and fifty-two pages, with two hundred and forty exquisite illustrations on wood. The publishers have endeavored to render the present edition of this work, in every point of me- chanical execution, worthy of its very high reputation, and they confidently present it to the pro- fession as one ofthe handsomest volumes as yet issued in this country. This edition is far superior, both in the abundance guage. This opinion, deliberately formed after a careful study of the first edition, we have had no cause to change on examining the second. This edition has undergone thorough revision by the au- thor; many expressions have been modified, and a mass of new matter introduced. The book is got up in the finest style, and is an evidence of the progress of typography in our country.—Charleston Medical Journal and Review. We recommend it to both student and practitioner, feeling assured that as it now comes to us, it pre- sents the most satisfactory exposition ofthe modern doctrines of the principles of surgery to be found in nny volume in any language.—N. Y. Journal of Medicine. and quality of its material, to any of the preceding. We hope it will be extensively read, and the sound principles which are herein taught treasured up for future application. The work takes rank with Watson's Practice of Physic; it certainly does not fall behind that great work in soundness of princi- ple or depth of reasoning and research. No physi- cian who values his reputation,or seeksthe interests of his clients, can acquit himself before his God and the world without making himself familiar with the sound and philosophical views developed inthe fore- going book.—New Orleans Medical and Surgical Journal. Without doubt the ablest exposition of the prin- ciples of that branch of the healing art in any lan- BY the same author.- (Now Ready.) THE PRACTICE OF SURGELIY. Third American from the second Edin- burgh edition. Edited, with Additions, by F. W. Sargent, M.D , one of the Surgeons to Will's Hospital, &C Illustrated by three hundred and nineteen engravings on wood. In one large octavo volume, of over seven hundred pages. This new edition will be found greatly improved and enlarged, as well by the addition of much new matter as by the introduction of a large and complete series of handsome illustrations. An equal improvement exists in the mechanical execution of the work, rendering it in every respect a companion volume to the " Principles." No encomium of ours could add to the popularity I By the almost unanimous voice of the profession, of Miller's Surgery. Its reputation in this country | his works, both on the principles and pracuce ot is unsurpassed by that of any other work, and, when su rgery have been assigned the highest rank. If we taken in connection with the author's Principles of] were limited to but one work on surgery, that one Surgery, constitu es a whole, without reference to | should be^Mdler's^ns^we regard^ i^supenor to aH which no conscientious surgeon would be willing to practice his art The additions, by Dr. Sargent, have materially enhanced the value of the work. Southern Medical and Surgical Journal. It is seldom that two volumes have ever made so profound an impression in so short a time as the " Principles" and the " Practice" of Surgery by Mr. Miller—or so richly merited the reputation they have acquired. The author is an eminently sensi- ble, practical, and well-informed man, who knows exactly what he is talking about and exactly how to talk it.— Kentucky Medical Recorder others.—St. Louis Med. and Surg. Journal. The author distinguished alike as a practitioner and writer, has in this and his " Principles," pre- sented to the profession one of the most complete and reliable systems of Surgery extant. His style of writing is original, impressive, and engaging, ener- getic, concise, and lucid. Few have the faculty of condensing so much in small space, and at the same time so persistently holding the attention; indeed, he appears to make the very process of condensation a means of eliminating attractions. Whether as a text-book for students or a book of reference for The two volumes together form a complete expose , practitioners, it cannot be too Wrongly ^"I"™' U the present state of Surgery, and they ought to be I e one of the handsomest volumes as yet presented in this country, and as containing the only ex- tended and thorough series of illustrations on the subject. by the same author. (Now Ready.) A TRE VTISE ON THE VENEREAL DISEASE. By John Hunter, F. R. S. With copious Additions, by Ph. Ricord, M. D. Edited, with Notes, by Freeman J. Bumstead, M. D. In one handsome octavo volume, with plates. From the Translator's Preface. « M Rinnrd^s. annotations to Hunter's Treatise on the Venereal Disease were first published at appeared for the last fifteen years." __j , T_ ,u0 „niPR to Hunter, the master substitutes him- Every one will recognize the attractiveness^and In thembole^J H^'n,dn|ive8hi,origiliaMhoH)?hi9 value which this work derives from thus J^enung f^™1^Jj^Jun mar/form it is "true, but in a the opinions of these two masters side by side. But o ihe wo«o ^ intelligible manner. In conclu- .. _.:_. i,„ ~a™;„*a n>i.at has made the fortune of lucitt anu perin.uy iiire> „ ____,„„„,Ki„ ih» host me opinions 01 mesc iwu m«on..= ~«-~-.» —-- ■- it must be admitted, what has made the fortune ol the book, i* the fact that it contains the "most com- plete embodiment of the veritable doctrines of he H6pital du Midi," whioh has ever been made public. The doctrinal ideas of M. Ricord, ideas which, if not universally adopted, are incontestably dommantVh.a^ heretofore only been interpreted by moreor 'essftkillul -secretaries, sometimes accredited and sometimes not. | ucia aim p'r«ui «|»'.....—: ......... ,, .. ,,„„, pioii we can say that this is incontestably the best treatise on syphilis with which we are acquainted, and, as we do not often employ the phrase, we may be excused for expressing the hope lhat it may find a place in the library of every physician —Virginia Med. and Surg. Journal. BY THE SAME AUTHOR. t ^nvrn^Q nv QVPTTTT TS addressed to the Chief Editor of the Union MSdicale. L^™^^^ * w-p-Laitimore'M-D-la one neat octavo volume .^^ & ^ ^ ^ ^ ^^ rf ^ yaIuable work. From the Translator's Preface. ,„*,,,, To .hose who ho.e M » -he *. -»"o ZSZtoS. ^? £ ?2fi » Midi, tbi. »ol«me "ill need no con.men.iat.™i, wh.lcmo . w|d ^ ^ iD ,h„ BY THE SAME AUTHOR. A PRACTICAL TREATISE ON ™™ffi;™^^™l& peutical Summary and Special Formulary. Translated bj kidney One volume, octavo, 340 pages. 26 BLANCHARD & LEA'S MEDICAL RIGBY (EDWARD), M. D., Physician to the General Lying-in Hospital, &c. A SYSTEM OF MIDWIFERY. With Notes and Additional Illustrations. Second American Edition. One volume octavo, 422 pages. ROYLE (J. FORBES), M.D. MATERIA MEDICA AND THERAPEUTICS; including the Preparations of the Pharmacopoeias of London, Edinburgh, Dublin, and of the United States. With many new medicines. Edited by Joseph Carson, M. D., Professor of Materia Medica and Pharmacy in the University of Pennsylvania. With ninety-eight illustrations, in one large octavo volume, of about seven hundred pages. This work is, indeed, a most valuable one, nnd ductions on the other extreme, which are neces- will fill up an important vacancy that existed be- sarilv imperfect from their small extent.—British tween Dr. Pereira's most learned and complete and Foreign Medical Review. Bystem of Materia Medica, and the class of pro- SKEY (FREDERICK C), F. R. S., Sec. OPERATIVE SURGERY. In one very handsome octavo volume of over 650 pages with about one hundred wood-cuts. Its literary execution is superior to most surgical treatises. It abounds in excellent moral hints, and is replete with original surgical expedients and sug- gestions.—Buffalo Med. and Surg. Journal. With high talents, extensive practice, and a long experience, Mr. Skey is perhaps competent to the task of writing a complete work on operative sur- gery.—Charleston Med. Journal. We cannot withhold from this work our high com- mendation Students and practitioners will find it aa invaluable teacher and guide upon every topic con- nected with this department.—N. Y. Medical Ga- zette. A work of the very highest importance—a work by itself.—London Med. Gazette. SHARPEY (WILLIAM). M. D., JONES QUAIN, M. D., AND RICHARD QUAIN, F. R. S., 8ec. HUMAN ANATOMY. Revised, with Notes and Additions, by Joseph Leidy, M.D. Complete in two large octavo volumes, of about thirteen hundred pages. Beautifully illustrated with over five hundred engravings on wood. We have no hesitation in recommending this trea- tise on anatomy as the most complete on that sub- ject in the English language; and the only one, perhaps, in uny language, which brings the state of knowledge forward to the most recent disco- veries.—The Edinburgh Med. and Surg. Journal. Admirably calculated to fulfil the object for which it is intended.—Provincial Medical Journal. The most complete Treatise on Anatomy in the English language—Edinburgh Medical Journal. There is no work in the English language to be preferred to Dr. Quain's Elements of Anatomy__ London Journal of Medicine. It is indeed a work calculated to make an era in anatomical study, by placing before the student every department of his science, with a view to the relative importance of each ; and so skilfully have the different parts been interwoven, that no one who makes this work the basis of his studies, will hereafter have any excuse for neglecting or undervaluing any important particulars connected with the structure of the human frame; and whether the bias of his mind lead him in a more especial manner to surgery, physic, or physiology, he will find here a work at once so comprehensive and practical ns to defend him from exclusiveness on the one hand, and pedantry on the other.__ Monthly Journal and Retrospect of the Medical Sciences. SMITH (HENRY H.), M.D., AND HORNER (WILLI AM E.), M.D. AN ANATOMICAL ATLAS, illustrative of the Structure of the Human Body In one volume, large imperial octavo, with about six hundred and fifty beautiful figures. late the student upon the completion of this Atlas, as it is the most convenient work of the kind that has yet appeared ; and we must add, the very bean These figures are well selected, and present a complete and accurate representation of that won- derful fabric, the human body. The plan of this Atlas, which renders it so peculiarly convenient for the student, and its superb artistical execution, have been already pointed out. We must congratu- tiful manner in which it is " got up" is so creditabW to the country as to be flattering to our national pride.—American Medical Journal. SARGENT (F. W.), M. D. ON BANDAGING AND OTHER POINTS OF MINOR SURGERY In one handsome royal 12mo. volume of nearly 400 pages, with 128 wood-cuts. The very best manual of Minor Surgery we have We have earefnltv „,m;„^ »u- , *„ .. seen; an American volume, with nearly four hundred ' well executedS an J n.tS?l! i" >W?rk' ^nd findit pages of good practical lessons, illustrated by about Jhe studen? BesidestZ ™&£apted P the.USe °f one hundred and thirty wood'euts. In these days in works on MinorSaLrvfc'8 "8Ua ll? eml>raced of •' trial," when a doctor's reputation han-s unon on Whin* »™ V burfi:ery' th«e is a short chapter a clove hitch, or the roll of a Ldage, ,t wChTbe , appendix "oVfS^uto VheTuthorV/'"'8' anU *" well, perhaps, to carry such a volume as Mr. Sar- ' cellent work on^h f ,,,hi^ i ^ has given an ex- gent's always in our coat-pocket, or, at all events, I ?»„,raudand^nrhfted Mn'^ fh,.S PUlJ i31?"8 ?ave BuffTMTjZln^ hi8in8'rUCti™s ath°-~ | ThTcraflestL'm^ZrTX ^^ ^~ STANLEY (EDWARD). A TREATISE ON DISEASES OF THE BONES extra cloth, 286 pages. In one volume, octavo. aj*jl» SCIENTIFIC PUBLICATIONS. 27 STILLE (ALFRED), M. D. PRINCIPLES OF THERAPEUTICS. In one handsome volume. {Preparing;) SIMON (JOHN), F. R.S. GENERAL PATHOLOGY, as conducive to the Estahlishment of Rational Principles for the Prevention and Cure of Disease. A Course of Lectures delivered at St. Thomas's Hospital during the summer Session of 1850. In one neat octavo volume. (Lately Issued.) SMITH (TYLER W.), M. D., Lecturer on Obstetrics in the Hunterian School of Medicine. ON PARTURITION, AND THE PRINCIPLES AND PRACTICE OF OBSTETRICS. In one large duodecimo volume, of 400 pages. SIBSON (FRANCIS), M.D., Physician to St. Mary's Hospital. MEDICAL ANATOMY. Illustrating the Form, Structure, and Position of the Internal Organs in Health and Disease. In large imperial quarto, with splendid colored plates. To match "Maclise's Surgical Anatomy." (Preparing.) SOLLY (SAMUEL), F. R. S. THE HUMAN BRAIN; its Structure, Physiology, and Diseases. With a Description of the Typical Forms of the Brain in the Animal Kingdom. From the Second and much enlarged London edition. In one octavo volume, with 120 wood-cuts. SCHOEDLER (FRIEDRICH), PH.D., Professor ofthe Natural Sciences at Worms, &c. THE BOOK OF NATURE; an Elementary Introduction to the Sciences of Physics, Astronomy, Chemistry, Mineralogy, Geology, Botany, Zoojogy, and Physiology. First American edition, with a Glossary and other Additions and Improvements; from the second English edition. Translated from the sixth German edition, by Henry Mkdlock, F. 0. S., &c. In one thick volume, small octavo, of about seven hundred pages, with 679 illustrations on wood. Suitable for the higher Schools and private students. (Now Ready.) This volume, as its title shows, covers nearly all I seen presents the reader with so wide a range of ele- the sciences, and embodies a vast amount of informa- mentary knowledge, with so full illustrations, at so tion for instruction. No other work that we have | cheap a rate.—Silliman's Journal, Nov. 185J5. TAYLOR (ALFRED S.), M. D., F. R. S., Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital. MEDICAL JURISPRUDENCE. Third American, from the fourth and improved English Edition. With Notes and References to American Decisions, by Edward Hartshorne, M. D. In one large octavo volume, of about seven hundred pages. (Just Issued.) We know of no work on Medical Jurisprudence which contains in the same space anything like the same amount of valuable matter.—N. Y. Journal of Medicine. The American editor has appended several im- reference, that would be more likely to afford the aid desired. We therefore recommend it as the best and safest manual for daily use.—American Journal of Medical Sciences. We have heretofore had reason to refer to it in portant facts, the whole constituting by far the best, i terms tlf commendation, and need now" only state most reliable, and interesting treatise on Medical that in the edjtion before the author h/s com. Jurisprudence, and one that we cannot too strongly | pleteiy revised the whole work, making many addi- recommend to all who desire to become acquainted , ti()ns an(J alterations and brought it fuiiy u't0 the with the true and correct exposition of this depart- present state of knowledge. The task of the Ameri- ment of medical literature.—Northern Lancet. ' n ediu,r nag been t0 pregent all the injporta,,,; No work upon the subject can be put into the ! facts and cases that have recently occurred in our hands of students either of law or medicine which ' own country, bearing on the subjects treated of. will engage them more closely or profitably ; and J No better work can be placed in the hands of the none could be offered to the busy practitioner of I physician or jurist.—St. Louis Medical and Surgical either calling, for the purpose of casual or hasty | Journal. BY THE SAME AUTHOR. ON POISONS, IN RELATION TO MEDICAL JURISPRUDENCE AND MEDICINE. Edited, with Notes and Additions, by R. E. Griffith, M. D. In one large octavo volume, of 688 pages. The most elaborate work on the subject that cu* literature possesses.—British and Foreign Medico- Chirurgical Review. It contains a vast body of facts, which embrace all that is important in toxicology, all that is necessary to the guidance of the medical jurist, and all that can be desired by the lawyer. — Medico- Chirurgical Review. One of the most practical and trustworthy works on Poisons in our language.—Western Journal oj Medicine. It is, so far as our knowledge extends, incompa- rably the best upon the subject; in the highest de- gree creditable to the author, entirely trustworthy, and indispensable to the student and practitioner.— N. Y. Annalist THOMSON (A. T.), M. D., F. R. S., Sec. DOMESTIC MANAGEMENT OF THE SICK ROOM, necessary in aid of Medical Treatment for the Cure of Diseases. Edited by R. E. Griffith, M. D. In one large royal 12mo. volume, with wood-cuts, 360 pages. 28 BLANCHARD & LEA'S MEDICAL TOMES (JOHN), F. R. S. A MANUAL OF DENTAL PkACTIa E. Illustrated by numerous engravings on wood. In one handsome volume. (Preparing.) TODD (R. B.), M. D., AND BOWMAN (WILLIAM), F. R. S. PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN. With numerous handsome wood-cuts. Parts I, II, and III, in one octavo volume, 552 pages. Part IV will complete the work. The distinguishing peculiarity of this work is, that the authors investigate for themselves every fact asserted ; and it is the immense labor consequent upon the vast number of observations re- quisite to carry out this plan, which has so long delayed the appearance of its completion. The first portion ot Part IV, with numerous original illustrations, was published in the Medical News and Library for 1853, and the completion will be isMied immediately on its appearance in London., Those who have subscribed since the appearance of the preceding portion of the work can have the three parts by mail, on remittance of $2 50 to the publishers. TRANSACTIONS OF THE AMERICAN MEDICAL ASSOCIATION. VOLUME VI, for 1853, large 8vo., of 87U pages, with numerous colored plates and wood-cuts. Also to be had. a few sets of the Transactions from 1848 to 1853, in six large octavo volumes, price $25. These volumes are all published by and sold on account ofthe Association. WATSON (THOMAS), M.D., Sec. . LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. Third American, from the last London edition. Revised, with Additions, by D. Francis Condie, M.D , author of a "Treatise on the Diseases of Children," &c. In one octavo volume, of nearly eleven hundred large pages, strongly bound with rai>ed bands. To suv that it is the very best work on the sub- 1 Confessedly one of the very best works on the ject now extant, is but to echo the sentiment of the | principles and practice of physic in the English or medical pross throughout the country. — JV. O. | any other language.—Med. Examiner. Medical Journal. | A s a text-book it has no equal; as a compendium Ofthe text-books recently republished Watson is ('f P»thology and practice no superior.—New York very justly the principal favorite.—Holmes's Rep. Annalist to Nat. Mt-d. Assoc. By universal consent the work ranks among the very best text-books in our language.—Illinois and Indiana Med. Journal. Regarded on all hands as one of the very best, if not the very best, systematic treatise on practical medicine extant.—St. Louis Med. Journal. We know of no work better calculated for being placed in the hands of the student, and for a text- book; on every important point the author seems to have posted up his knowledge to the day.— Amer. Med. Journal. One of the most practically useful books that ever was presented to the student. — N. Y. Med. Journal. WALSHE (W. H.l, M. D., Professor ofthe Principles and Practice of Medicine in University College, London. DISEASES OF TIIE HEART, LUNGS, AND APPENDAGES; their Symptoms aud Treatment. In one handsome volume, large royal 12mo., 512 pages. We consider this as the ablest work in the En- I the author being the first stethoscopist of the day.— glieh language, on the subject of which it treats; | Charleston Medical Journal. WHAT TO OBSERVE AT THE BEDSIDE AND AFTER DEATH, IN MEDICAL CASES. Publi>hed under the authority of the London Society for Medical Observation In one very handsome volume, royal 12mo , extra cloth (Just Issued.) given to the world, through a small but useful medical organization, a cheap but invaluable book. We do advise every reader of this notice to buy it and use it. Unless he is so vain as to imagine him- self superior to the ordinary human capacity, he will in six months see its inestimable advantages.— Stethoscope. We hail the appearance of this book os the grand desideratum.—Charleston Medical Journal. This is truly a very capital book. The whole medical world will reap advantages from its publi- cation. The medical journals will soon show its influence on the character of the " Reports of Cases" which they publish. Drs. Ballard aud Walshe have WILDE (W. R.), Surgeon to St. Mark's Ophthalmic and Aural Hospital, Dublin. AURAL SURGERY, AND THE NATURE AND TREATMENT OF DIS- EASES OF THE EAR. In one handsome octavo volume, with illustrations. (Now Ready.) So little is generally known in this country concerning the causes, symptoms, and treatment ol aural affections, that a practical and scientific work on that subject, from a practitioner of Mr Wilde's great experience, cannot fail to be productive of much benefit, by attracting attention to this obscure class of diseases, which too frequently escape attention until past relief5 The im- mense number of cases which have come under Mr. Wilde's observation for many years have afforded him opportunities rarely enjoyed for investigating this branch of medical science, and hn work may therefore be regarded as of the highest authority. This work certainly contains more information on the subject to which it is devoted than any other with which we are acquainted. We feel grateful 10 the author for his manful effort to rescue this depart ment of surgery from the hands of the empirics who nearly monopolize it. We think he has successfully shown that aural diseases are not beyond the re sources of art; that they are governed by the same laws, and amenable to the same general methods of treatment as other morbid processes. The work it not written to supply the cravings of popular patro- nage, but it is wholly addressed to the profession, and bears on every page the impress of the reflections of a sagacious and practical surgeon.— Va. Surg and Med. Journal. AND SCIENTIFIC PUBLICATIONS. 29 WILSON (ERASMUS), M.D., F. R. S., Lecturer on Anatomy, London. A SYSTEM OF HUMAN ANATOMY, General and Special. Fourth Ameri- can, from the last English edition. Edited by Paul B. Goddard, A. M., M D. With two hun- dred and fifty illustrations. Beautifully printed, in one large octavo volume, of nearly six hun- dred pages. In many, if not all the Colleges of the Union, it has become a standard text-book. This, of itself, is sufficiently expressive of its value. A work very desirable to the student; one, the possession of which will greatly facilitate his progress in the study of Practical Anatomy.—New York Journal of Medicine. Its author ranks with the highest on Anatomy.— Southern Medical and Surgical Journal. It offers to the student all the assistance that can be expected from such a work.—Medical Examiner. The most complete and convenient manual for the student we possess.—American Journal of Medical Science. In every respect, this work as an anatomical guide for the student and practitioner, merits our warmest and most decided praise.—London Medical Gazette. BY THE SAME AUTHOR. THE DISSECTOR; or, Practical and Surgical Anatomy. Modified and Re- arranged, by Paul Beck Goddard, M. D. A new edition, with Revisions and Additions. la one large and handsome volume, royal 12mo., with one hundred and fifteen illustrations. In passing this work again through the press, the editor has made such additions and improve- ments as the advance of anatomical knowledge has rendered necessary to maintain the work in the high reputation which it has acquired in the schools ofthe United States, as a complete and faithful guide to the student of practical anatomy. A number of new illustrations have been added, espe- cially in the portion relating to the complicated anatomy of Hernia. In mechanical execution ths work will be found superior to former editions. BY THE SAME AUTHOR. ON DISEASES OF THE SKIN. Third American, from the third London edition. In one neat octavo volume, of about five hundred pages, extra cloth. (Jvst Issued!) Also, to be had done up with fifteen beautiful steel plates, of which eight are exquisitely colored ; representing the Normal and Pathological Anatomy of the Skin, together with accurately colored delineations of more than sixty varieties of disease, most of them the size of nature. The Plates are also for sale separate, done up in boards. The increased size of this edition is sufficient evidence that the author has not been content with a mere republication, but has endeavored to maintain the high character of his work as the standard text-book on this interesting and difficult class of diseases. He has thus introduced such new matter as tbe experience of the last three or four years has suggested, and has made such alterations as the progress of scientific investigation has rendered expedient. The illustrations have ateo been materially augmented, the number of plates being increased from eight to sixteen. Of these plates it is impossible to speak too highly. The representations of the various forms of cuta- neous disease are singularly accurate, and the color- ing exceeds almost anything we have met with in point of delicacy and finish.—British and Foreign Medical Review. The "Diseases of the Skin," by Mr. Erasmus Wilson, may now be regarded as the standard work in that depPirtment of medical literature. The plates by which this edition is accompanied leave nothing to be desired, so far as excellence of delinea- tion and perfect accuracy of illustration are con- cerned.—Medico-Chirurgical Review. BY THE SAME AUTHOR. ' ON CONSTITUTIONAL AND HEREDITARY SYPHILIS, AND ON SYPHILITIC ERUPTIONS. In one small octavo volume, beautifully printed, with four exqui- site colored plates, presenting more than thirty varieties of syphilitic eruptions. Dr. Wilson's views on the general subject of Syphilis appear to us in the main sound and judi- cious, and we commend the book as an excellent monograph on the subject. Dr. Wilson has pre- sented us a very faithful and lucid description of Syphilis and has cleared up many obscure points in BY THE SAME author. (Now Ready.) HEALTHY SKIN: A Popular Treatise on the Skin and Hair, their Preserva- connection with its transmissibility, pathology and sequelae. His facts and references will, we are satis- fied, be received as decisive, in regard to many questiones vexatse. They appear to us entitled to notice at some length.—Medical Examiner. tion and Management.' Second American, from the fourth London edition. royal 12mo., with numerous illustrations. Copies can be had done up in paper covers for mailing, price 75 cents One neat volume, WHITEHEAD (JAMES), F. R. C. S., Sec. THE CAUSES AND TREATMENT OF ABORTION AND STERILITY; beinsr the Result of an Extended Practical Inquiry into the Physiological and Morbid Condition ofthe Uterus. Second American Edition. In one volume, octavo, 368 pages. (Now Ready.) The simple title of this work gives a very imper- fect idea of its contents. The subject of sterility occupies a mere fraction of space, and upwards of one-half of the whole volume is taken up with an elaborate account of menstruation as a physiological nroeess, and of the disorders which its deviations from health are apt to produce.—Medical Chirurg. Review. Such are the advances made from year to year in this department of our profession, that t;he practi- tioner who does not consult the recent works on the complaints of females, will soon find himself in the rear of his more studious brethr»n. This is one of the works which must be studied by those who would know what the present state of our knowledge is respecting the causes and treatment of abortion and sterility.—The Western Journal of Medicine and Surgery. 30 BLANCHARD & LEA'S MEDICAL WEST (CHARLES), M. D., Physician to the Hospital for Sick Children, &c. LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD. Second American, from the Second and Enlarged London edition. In one volume, octavo, of nearly five hundred pages. (Now Ready.) From the Preface to the Second Edition. In the preparation of the second edition of these Lectures, the whole work has been carefully revised. A few formulae have been introduced and a minute alphabetical index has been appended while additions amounting altogether to fifty pages, have been made, wherever I felt that more extended observation, or more careful reflection had enabled me to supply some of those deficiencies which I am well aware, are still far too numerous. The work now contains the result of 640 observations, and l'J9 post-mortem examinations, chiefly made among 16\276 children who came under my notice during the ten years of my connection with the Children's Infirmary in Lambeth. We take leave of Dr. West with great respect for his attainments, a due appreciation of his acute powers of observation, and a deep sense of obliga- tion for this valuable contribution to our profes- sional literature. His book is undoubtedly in many respects the best we possess on diseases of children. The extracts we have given will, we hope, satisfy our Teaders of its value; and yet in all candor we must say that they are even inferior to some other parts, the length of which prohibited our entering upon them. That the book will shortly be in the hands of most of our readers we do not doubt, and it will give us much pleasure if our strong recommend- ation of it may contribute towards the result.—The Dublin Quarterly Journal of Medical Science. Dr. West has placed the profession under deep ob- ligation by this able, thorough, and finished work upon a subject which almost daily taxes to the ut- most the skill ofthe general practitioner. He has with singular felicity threaded his way through all the tortuous labyrinths ofthe difficult subject he has undertaken to elucidate, and has in many of the darkest corners left a light, for the benefit of suc- ceeding travellers, which will never be extinguished. Not the least captivating feature in this admirable performance is its easy, conversational style, which acquires force from its very simplicity, and leaves an impression upon the memory, of the truths it conveys, as clear and refreshing as its own purity. The author's position secured him extraordinary fa- cilities for the investigation of children's diseases, and his powers of observation and discrimination have enabled him to make the most of these great advantages.—Nashville Medical Journal. BY THE SAME AUTHOR. (Ill Press.) AN ENQUIRY INTO THE PATHOLOGICAL IMPORTANCE OF ULCE- RATION OF THE OS UTERI. Being the Croonian Lectures for the year 1854 In one neat octavo volume, extra cloth. This work will appear in the " Medical News and Library" during the latter portion of 1854, and will be published in a separate form about December. WILLIAMS (C. J. B.), M. D., F. R. S.. Professor of Clinical Medicine in University College, London, Sec. PRINCIPLES OF MEDICINE; comprising General Pathology and Therapeu- tics, and a brief general view of Etiology, Nosology, Semeiology, Diagnosis, Prognosis, and Hygienics Edited, with Additions, by Meredith Clymer, M. D. Fourth American, from the last and enlarged London edition. In one octavo volume, of 47G pages. (Now Ready.) This new edition has been materially enlarged and brought up by the editor. It possesses the strongest claims to the attention of the medical student and practitioner, from the admirable manner in which the various inquiries in the different branches of pathology are investigated, combined, and generalized by an experienced practical physician, and directly applied to the investigation and treatment of disease.—Editor's Preface. ff"cu The best exposition in our language, or, we be- I Few books have proved more useful or met with I.eve, in any language of rational medicine, in its a more ready sale than this and no nra?titi7ner present unproved and rapidly improving state.- should regard his library aComplete without it British and Foreign Medico-Chirurg. Review. \ -Ohio Med. and Surg. Journal without it. BY THE SAME AUTHOR. Ao£?A£TICf} ™EATISE ON DISEASES OF THE RESPIRATORY YOUATT (WILLIAM), V. S. THE HORSE. A new edition, with numerous illustrations- together with a BY THE SAME AUTHOR. THE DOG. Edited by E. J. Lewis, M. D. With numerous and beautiful illustration.. In one very handsome volume, crown 8vo., crimson cloth, gilt DeaUtltul AJND SCIENTIFIC PUBLICATIONS. 31 B. & L. subjoin a condensed list of their publications in general and educational literature, of which more detailed catalogues will be furnished on application. HISTORY AND BIOGRAPHY. BROWNINGS HISTORY OF THE HUGUE NOTS. 1 vol. 8vo. CAMPBELL'S (LORD) LIVES OF THE LORD CHANCELLORS OF ENGLAND, from the earl- iest Times to the Reign of George IV. In seven handsome crown octavo volumes, extra cloth or half morocco. CAMPBELL'S (LORD) LIVES OF THE CHIEF JUSTICES OF ENGLAND, from the Norman Conquest. In two handsome crown octavo vols., to match the " Chancellors." DIXON'S LIFE OF WILLIAM PENN. A new work. 1 vol. royal 12mo , exira cloth. GRAHAME'S COLONIAL HISTORY OF THE UNITED S T A PES. 2 vols. 8vo. A new edition. GUIZOT'S LIFE OF CROMWELL- Two large vols., royal 12mo. (Now readv.) HERVEY'S MEMOIRS OF GEORGE II. 2 vols. royal 12mo.. extra cloth. HUGHES'S OUTLINES OF SCRIPTURE GEO GRAPHY AND HISTORY, I vol., royal 12mo., with colored maps. (Just issued.) INGERSOLL'S HISTORY OF THE LATE WAR. 2 vols Svo. KENNEDY'S LIFE OF WILLIAM WIRT. 2d edition, 2 vols. Toyal l2mo., extra cloth, with Por- trait. Same work, library edition, 2 vols. Svo. KAVANAGHS WOMAN IN FRANCE IN THE EIGHTEENTH CENTURY. 1 vol. royal 12mo., extia cloth LOUIS BLANC'S FRANCE UNDER LOUIS PHI- LIPPE, 1S30-1S40. 2 vols, crown Svo., extra cloth. LOUIS BLANC'S FRENCH REVOLUTION. 1 v«l. crown Svo . extra cloth. MARSH (MRS.) ROMANTIC HISTORY OF THE HUGUENOTS. 2 vols, royal 12mo.. extra cloth. NIELSUHRS ANCIENT HISTORY. By Leonhard Schmitz. In three handsome crown octavo vols., (Lately Issued.) PARDOE'S FRANCIS TIIE FIRST. 2 vols, royal l2mo.. extra cloth. PALGRAVES NORMANDY AND ENGLAND. In three vols crown 8vo.. (Preparing.) RUSH'S COURT OF LONDON. 1 vol. Svo. 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