h :- ii I 5 I t ll NATIONAL LIBRARY OF MEDICINE NLM 00101711* 3 SURGEON GENERAL'S OFFICE LIBRARY. 1NBEI ----- Section-------------------- „,.„,, Ato...25X£26 W.D.S.G.O. 3_613 NLM001017143 M^^^f*^ RETURN TO NATIONAL LIBRARY OF MEDICINE BEFORE LAST DATE SHOWN 0r-T 1 0 1978 lEECUEIAL YAPOUE BATH; FOYE'S FUMIGATING APPARATUS. THE TREATMENT SYPHILITIC DISEASES BY THE MEECUEIAL YAPOUE BATH: COMPRISING THE TREATMENT OF CONSTITUTIONAL AND CONFIRMED SYPHILIS BY THIS SAFE AND SUCCESSFUL METHOD; Numerous Cases and Clinical Observations.^ by LANGSTON I^EKEB, F.E.C.S.L., CONSULTING SUBGEON TO THE QUEEN'S HOSPITAL, BIBMINGHAM, ETC., ETC. COMPILED FROM THE FIFTH LONDON EDITION BY JOHN W. FOYE, M.D., BOSTON, MASS. , , \ "* / **1 l IP ''11 A. WILLIAMS AND COMPANY, 135 Washington Street. 1874. NMCrX Entered according to Act of Congress, in the year 1874, by JOHN W. FOYE, M.D., In the Office of the Librarian of Congress at "Washington. Boston: Rand, Avebt, 8s Co., Btebeottpebs and Pbintebs. NOTE. The compiler, in calling the attention of the profession to this work, does not pretend to place before them an original production; but to give a resume of his own experience in the treatment of specific disease, by the method revived by the late Mr. Langston Parker, and so ably advocated by Henry Lee and others, and which, in his own practice, has been attended with the most gratifying results. It consists of a condensed review of the opinions of Drs. Parker, and Lee, with observations upon cases, which came under their special treatment. So unerring is its success, that I claim it to be the most perfect system for the cure of syphilitic disease known to medicine. J. W. F. APPARATUS EMPLOYED IN' THE EXHIBITION OF THE YAPOUR BATH. [See Frontispiece."} Fig. 1. — Cabinet having a capacity of twenty- two cubic feet, air tight, where not perforated for ventilation, and sufficiently commodious to allow the patient to stand or sit at will. Light is admitted through two plates of glass at oppo- site points; and the lamp is lighted through a small door (not seen in the plate), which opens on the floor of the cabinet, opposite the entrance. It is fixed upon castors, and easily moved to any part of the room. Fig. 2. — Heating apparatus complete, with a short section of rubber tube attached. Fig. 3. — Copper boiler of the capacity of twelve ounces. It is heated by a jet of gas, which passes through a Bunsen burner to ignite on the surface of a perforated disk two inches in diameter, fur- nishing a blue flame equal in intensity to that of alcohol, and capable of evaporating ten ounces of water in twenty minutes. A funnel passes through the boiler, and supports upon its sum- 1* 6 6 APPARATUS EMPLOYED IN THE mit a small tinned plate, in which the agent to be volatilized is placed. The upper edge of the boiler is surmounted by a flange, by which the vessel is supported upon the heater, (Fig. 4) a hollow cylinder that fits upon the standard, (Fig 5) which has a waste pipe of three-fourths of an inch diameter, that conducts the incombustible gases out of the cab- inet. Although but little attention has been given to the mercurial vapour bath in the treatment of syphilis, except by a few practitioners, sufficient evidence has already been adduced to demon- strate that this form of treatment possesses many advantages, both general and special, over the older and more common modes of mercurial medication. The great superiority of the mercurial over other methods, in the treatment of syphilis in certain of its stages and manifestations, is so almost universally conceded at the present time, that we do not propose to enter into any argu- ment upon this point. We design simply to point out the peculiar advantages possessed by the mercurial vapour bath over the other modes of mercurial treatment in which the use of this drug is indicated. In regard to the general advantages of the vapour bath over the internal administration of EXHIBITION OP THE VAPOUR BATH. 7 mercurials, we note, firstly, the uniformity, and consequent reliability, of its action as compared with that obtained from the internal use of the remedy. Every one in the habit of prescribing mercury to be taken internally is fully aware of the want of uniformity of its action in different persons, and also in the same individuals at dif- ferent times, and in different conditions of the system. In some persons it will be almost impossible, by the use of legitimate and safe doses of any mercurial preparation, to obtain the slightest physiological effect of this remedy; while, in other cases, the administration of a few smaU doses will be speedily followed by unpleasant symptoms of its excessive action. The same holds true in regard to its therapeu- tic effect, and also in regard to the individual; the use of the drug being followed by widely different degrees of its action at different times, and under different circumstances; and, even under similar conditions, the degree of its action may be varied and uncertain. Theoretically the same might be expected to hold true in respect to its administration by means of the vapour bath ; but practically, for various reasons, —some apparent, and others not so obvious, —it does not. After a somewhat prolonged experi- ence in the administration of these baths to the 8 APPARATUS EMPLOYED IN THE extent of five or six daily, we are surprised at the uniformity of their effects both physiologi- cal and therapeutic. In the great majority of cases, one bath suf- fices to produce, at the end of twenty-four or thirty-six hours, the manifestation of the earlier and slighter indications of the physiological action of the drug. There will be some whiteness of the gums, perhaps, from the increased opacity of the epithelium; or, if the effect of the drug be still more marked, the gums may be of a deeper and more livid color than usual, with some ^swelling and tenderness : there may, perhaps, be the slightest tendency to fetor of the breath; or the patient, if a smoker, will remark that his cigar does not taste well. As already stated, these indications of the action of the remedy to a degree to insure its full therapeutic effect are generally observable after a single bath ; if not, the second rarely fails to manifest them, and, in my experience, the third never. And here we take occasion to note particu- larly, a very valuable feature of the effect pro- duced by the bath incidentally indicated above, namely, the rapidity of the action of mercury upon the system when administered in this way. Cases are not unfrequently encountered in which it is desirable to secure the full therapeutical EXHIBITION OP THE VAPOUR BATH. 9 action of this remedy as speedily as possible; but in order to produce this action by means of the administration of the drug internally, with any degree of certainty, it is necessary to give it in rather full and frequently repeated doses, with the result, notwithstanding in a certain number of cases, of inefficient action, while in others, there will be excessive or over action, with aU its disagreeable accompaniments and in- jurious consequences. In other words, in conse- quence of the existence of various causes, we fail in many instances to secure a speedy and efficient, and at the same time, easily controlled action of this drug from its internal administration. By its use in the form of the vapour bath, however, while we almost invariably secure its prompt and efficient action as before stated, we are perfectly safe from its over-action and at- tendant unpleasant symptoms and consequences, after the effect of the first bath has been ob- served; at least this has been our experience. After the physiological effect of the drug pro- duced by the first bath has been observed, the effect of the subsequent ones, may be calculated with great nicety by reference to their duration and frequency. We have never seen an instance in which there has been any excess of its legiti- mate action, and we firmly believe, that, with a moderate amount of care in the administration 10 APPARATUS EMPLOYED IN THE of the baths, over-action or unpleasant effects will never be produced. We have never experienced any difficulty in limiting the physiological action of the mercury to the degree before indicated, and it may be continued in that, or a lesser degree, for an indefi- nite length of time with the greatest ease, pro- vided the patient follows the directions given him in regard to taking his baths; and here we recognize an incidental advantage pertaining to this method of treatment. The patient, in order to continue it, must of necessity be under the immediate supervision of his physician, and con- sequently the action of the remedy may be clearly observed and nicely regulated. The marked impairment of nutrition, and the anaemia so common in certain stages of syphilis, render it of the greatest importance that the digestive organs, oftentimes much enfee- bled by the disease, should be in the best possible condition for the performance of their functions. Mercury given internally has almost always a more or less debilitating effect upon these organs, and consequently, renders the proper perform- ance of their functions impossible; and in some cases, to such an extent, as to wholly prohibit its employment as a remedial agent. Now, when we take into consideration, the injurious effects of mercury internally administered upon the diges- EXHIBITION OP THE VAPOUR BATH. 11 tive organs, already enfeebled by the disease, in connection with the necessity of the full integrity of the nutritive process, and the fact that mer- cury, administered in the form of the vapour bath, does not cause gastric or intestinal disturb- ance or debility, and is found practically to exert no deleterious influence upon the process of assimilation, we adduce an additional and very strong argument in favor of this method of treatment. Again, the benefit derived from the local effect of the mercurials, when administered by this pro- cess upon various syphilitic lesions, whether situ- ated upon the exterior of the body, or in any of the mucous passages, to which the vapour is accessible by means of respiration, is a point worthy of consideration. The fact that different authorities recommend various forms of local mercurial treatment, is of itself good evidence that there exists a general belief in the efficacy of this form of local mer- curial medication; applied in the form of the vapour bath, there can be no doubt of its local absorption, and there is ample evidence of a clinical nature, of its beneficial effects through this mode of operation. That the treatment by the mercurial vapour bath, possesses many advantages over that by mercurial inunction, there can be no doubt. The 12 APPARATUS EMPLOYED IN THE alleged and acknowledged superiority of inunc- tion, over the internal administration of mercury, by reason of the rapidity and certainty of its action, and the ease with which its effect is reg- ulated, together with the absence of any local injurious action upon the digestive organs, is more than equalled by the results obtained from the treatment by the vapour bath, with the ad- ditional advantage, that it is much more cleanly; that the secretions of the skin, instead of being diminished, or checked entirely, over a portion of the body, are in reality increased over its whole extent, and thus, the very essential elimi- nation of morbid products, instead of being par- tially suppressed, is encouraged and augmented; and, as previously stated, the patient receives the benefit of its local application to various lesions, and is also kept under close inspection. The treatment of syphilis by subcutaneous injections of mercury, particularly the bichloride, has undoubtedly proved highly advantageous in some cases, which have shown themselves very rebellious, to the influence of mercury adminis- tered by the mouth; and, the average time re- quired for the removal of certain manifestations of the disease, has been much shorter than when the drug is given internally: but in com- paring the value of this method of treatment with that of the vapour bath, we claim prece- EXHIBITION OF THE VAPOUR BATH. 13 dence for the latter, in that it furnishes many of the same advantages over the former, that it does over the treatment by inunction; and ob- servation has shown us that cases yield more quickly under this treatment, than those are re- ported to, which have been subjected to the treatment by subcutaneous injections, while the pain, local inflammation, and abcesses attendant upon the latter method of treatment are avoided. So far as can be determined from clinical ob- servation, relapses after this mode of treatment, are less frequent, and occur at longer intervals, than in similar cases, in which other methods are employed. Theoretically, this might be ex- pected, and experience so far as it goes, supports such an assumption. Thus far, we have spoken of the employment of this form of mercurial medication in syphilis, in a general way, and without much reference to any particular phases or manifestations of the disease, and will now proceed to mention some of the special lesions and stages of the disease, in which its remedial powers are strikingly manifest. In many cases of inflammatory and phagedenic chancres, in which the use of mercury is gener- ally regarded as contra-indicated, the most favor- able results are very frequently obtained by the use of the moist mercurial fume. 2 14 APPARATUS EMPLOYED IN THE Cases of this class are among the most rebel- lious, and vexatious which the surgeon is called upon to treat; but we lay it down as a rule that they are vastly more amenable to this particular form of treatment, than to any other, and that it will often succeed where all others fail. For the exhibition of the mineral in these lesions, we employ an apparatus designed for the purpose of conveying a jet of the medicated vapour, directly to the ulcerated surface; and the rapidity with which an erosion, that has pre- viously baffled our best efforts to arrest, loses EXHIBITION OP THE VAPOUR BATH. 15 its vicious character, and takes on healthy action is surprising. The more ordinary form of chancre also heals more readily under this treatment, than under any other we have seen employed. It may be alternated with the general bath if deemed proper by the operator, though it is to be remembered that there is a difference of opinion, as to the advisability of giving mercury, until the appearance of the secondary symptoms. The local induration accompanying, remaining after, or succeeding to the primary lesion, is, in our experience, removed more quickly when the patient is subjected to this mode of treat- ment, than when mercury is administered in any other way. The peculiar beneficial results derived from the moist fumes are perhaps nowhere better ex- emplified, than in their effect in affections of the skin and scalp. In some of the scaly diseases of the skin, of the secondary period, which are often entirely insensible, and refractory, to the more common forms of treatment, we have often found that the results obtained from the use of the baths, are much more speedily manifest, and relapses, less frequent, than after the employment of other forms of mercurial medication. In the secondary ulcerations generaHy, and 16 APPARATUS EMPLOYED IN THE particularly those following buboes, and pustular skin diseases, and also in the dry tubercular eruptions of the early part of the tertiary period, the use of the vapour bath is signally beneficial. The same is true in regard to the mucous affections of the mouth, throat, nasal, and air passages. There is a class of sores generally of the third stage, or, perhaps in bad subjects, the latter part of the second stage, comprising the different lesions of the bones, and also some of the graver affections of the nose, throat, and larynx, in which the internal administration of mercury is of doubtful utility, —indeed, if it be not productive of positive injury, — in which a moderate use of the vapour bath, in conjunction with the common treatment of the iodide of potassium, is attended with much more benefit, both immediate and remote, than can be ob- tained from the iodide alone, or in connection with other remedies. Again, in some cases of tertiary syphilis, in which from various causes the iodide of po- tassium is not well borne, and in which the administration of mercurials by the stomach is absolutely out of the question, the proper administration of the baths is productive of great benefit. Why mercury administered in this way is EXHIBITION OF THE VAPOUR BATH. 17 tolerated and proves of service, when it is not well borne, and produces mischievous results if given internally, we will not attempt to explain. We simply know, and state the fact that it is. In conclusion, we wish to say that we do not claim that this method of treatment is a specific for syphilis, or that it will cure all cases of that disease; but we do claim, that in many cases, as set forth in the following pages, it does possess advantages which are not to be found in any other form of mercurial, or other medication. It is unnecessary to add, that in the treat- ment of disease by this method, we employ such auxiliary means, constitutional, and local, as each particular case may seem to demand. a* THE lERCURIAL YAPOUR BATH; BEING AN ACCOUNT OF ITS MODE OF EMPLOYMENT. BY LANGSTON PAEKEE, F.E.C.S., Consulting Subgeon to the Queen's Hospital, Biemingham, Ac. LONDON. 1866. mTKODTJCTOKY. The plan of treatment which the following pages advocate and illustrate, does away with all the evils generally attributable to mercurial treatments, whilst it possesses all their advan- tages. It does not, in ordinary cases, require con- finement; it never impairs the appetite; does not produce salivation or ulceration of the mouth, mercurial erythismus, or blotches on the skin; and if associated with internal treat- ment by mercury, reduces what is required to an exceedingly minute quantity. In addi- tion to this, treatments according to this plan are safer, quicker, more certain, less frequently followed by relapses, —indeed, very rarely so, — and are capable of working cures in obstinate cases which have resisted all other modes of treatment. The method which I practise consists in applying the vapor of the bi-sulphuret, gray oxide or iodide of mercury (or calomel, as sug- 3 4 INTRODUCTORY. gested by Mr. H. Lee), in a moist state, to the whole surface of the body, by which, after the continuance of the process for twenty or thirty minutes, more or less, perspiration is induced. This process is repeated as frequently as the nature of the case may require till a cure be effected, and is or is not associated with inter- nal medicines. The dry mercurial vapour has been long employed in the treatment of various forms of syphilitic disease, and has had many advocates; but whether from the imperfect mode of its application, or other cause, its effects have been uncertain, and it has fallen into disuse. A German surgeon, named Werneck, has used it more methodically, and his success has been much more satisfactory. The moist fume has great advantages over the dry; its effects are certain, and can be regulated to a great nicety, and the heat and moisture produced during the time the patient is exposed to the vapour of mercury, by inducing perspiration, contribute, no doubt, materially to the cure of the disease. However, I have constantly succeeded with this plan, when the dry fumigation has failed altogether, or produced but little effect. The speedy and perfect cure of many of the cases detailed in the following pages has been very remarkable, as a perusal of their history INTRODUCTORY. 5 will show; and a vast number of patients have been perfectly and permanently restored to health by comparatively short treatments by this plan, after the failure of all ordinary treat- ments pursued through a long series of years. The notes appended have been selected from cases observed during a practice of eighteen years in the use of the vapour bath, and the results are similar to those obtained by other surgeons, in various parts of the world, more especially, in India and America. Unlike some other remedies, it has not dis- appointed the hopes I originally entertained of it, and I venture to confirm what others beside myself have said, that the more they see of the action of the remedy, the more highly they esteem its value in the palliation and cure of the disease. THE MERCURIAL YAPOUR BATH. It is now eighteen years since I first introduced the method of treating syphilis, and some other forms of disease, by moist mercurial and sulphur vapour (i.e.), by the mixture of the fumes of vari- ous preparations of sulphur, mercury, and iodine, with common steam. This method, which I shall presently more particularly describe, has been attended with a very remarkable degree of suc- cess, not only in my own practice, and in this country, but in that of other surgeons in most parts of the world. An American physician, D. L. P. Yandall, who lately visited this country (1868), bears the fol- lowing testimony to its value: " During the last twelve or fifteen years I have, in my brother's practice and in my own, treated at least fifteen hundred cases of constitutional syphilis by the mercurial vapour bath; and my faith in the treat- ment increases every year. I consider the mer- curial vapour bath to be in syphilis what quinine is in intermittent fever." This opinion was 7 8 THE MERCURIAL VAPOUR BATH. given to me in my own consultation room by Dr. Yandall himself. Dr. Gross, of Philadelphia, one of the most eminent surgeons in the United States, says, "Another method of employing mercury is by the combination of the fumes of mercury with common steam, which Mr. Langs- ton Parker, of Birmingham, terms ' the mercu- rial vapour bath.' I can testify, from considerable experience of this plan, having effected some very extraordinary cures with it, after all other methods of treatment had failed. "I recollect in particular the case of a young gentleman from Arkansas, who was under my charge on account of tertiary syphilis of long standing, accompanied by an enormous amount of rupial action of the skin, —one of the sores being fully as large as a dinner-plate, — who was promptly cured, comparatively speaking, with the bi-sulphuret of mercury, after a great variety of other means had been fruitlessly employed. My opinion is that this method of treatment is not sufficiently appreciated; it certainly deserves the highest encomiums." The bath should be administered in the following way: the patient is placed on a chair, on the seat of which should be put a thin cushion, he should be covered over with an oiled cloth, or India rubber cape, lined with flannel, or a blanket. The coverings should be made tight about the neck, so as to pre- THE MERCURIAL VAPOUR BATH. 9 vent the escape of the vapour, unless it is intended the patient should breathe it, which, under cer- tain circumstances, is better; under the chair is placed a small copper or tin bath, holding from a pint to a quart of water, and a stand, support- ing a tinned iron plate, on which is placed the preparation to be used; under each of these a large porcelain spirit-lamp ; the patient is thus exposed to the influence of three powerful agents, — heated air, common steam, and the vapour of mercury, which is applied to the sur- face of the body in a heated and moist state. After the patient has remained in the bath from five to ten minutes, perspiration generally commences, and by the end of twenty or thirty minutes, it is generally more or less profuse. The lamps are now withdrawn, and the tempera- ture allowed to subside; in some cases one lamp may be removed before the other. When the patient is sweating freely it is sometimes advan- tageous to remove the water-lamp, and leave him exposed to the mercurial fume alone for five or ten minutes. This is to be recommended where a long-continued and gentle action is required, as in weak patients. Such is the general mode of application of the mercurial vapour bath ; but it admits of a great variety in its use, to suit particular cases. These modifications are easily made by increasing or 10 THE MERCURIAL VAPOUR BATH. decreasing the heat of the bath, or using more or less of the mercurial preparation. When it is wished to induce a quick and decided action, the whole power of the bath should be brought into operation, and the largest quantity of mercury used. In rapidly-spreading ulcers this is re- quired, especially in secondary phagedena of the throat and elsewhere. I have, time after time, seen rapidly-spreading ulcers of the throat, which had destroyed a great part of the soft palate, arrested by one strong bath, after the patient had resorted to ordinary treatment for days or weeks. In chronic cases, and in weakly subjects, where a powerful action would rather oppress the patient than cure his disease, the power of the bath should be modi- fied, and not so much heat, or so much mercury employed. Each particular case may require a greater or less modification of this kind. I have now adopted this treatment in many thousand cases, in almost every form of primary and constitutional disease; and, although it would be too much to say that all were cured by it, still I must look upon the mercurial vapour bath as beyond all question the most powerful, and what is more, at the same time, the least harmful ther- apeutic agent that can be employed in the treat- ment of syphilis. The mercurial vapour bath acts with more certamty in some forms of disease THE MERCURIAL VAPOUR BATH. 11 than others. It is especially suited to affections of the tongue, to most forms of skin and throat disease, to secondary ulcerations, and a number of anomalous symptoms of constitutional disease which it is difficult to classify. It acts better in the dry or scaly forms of disease than in the moist; it is more certain in lepra or the dry, than in the pustular or moist forms. In the former it is almost a specific. The skin diseases, which are symptomatic of syphilis may be referred to two great classes, — the dry or scaly, and the moist or suppurative. In the former I include the various forms of lepra and psoriasis, and in the latter, pustular, vesicular, and tubercular diseases, — the latter when softened. Over the former the mercurial vapour bath has a most marked and certain influ- ence, and is, in fact, the most reliable therapeutic agent that can be employed in their treatment. The dry or scaly forms of skin disease almost always yield to a course of vapour, and they are frequently as rebellious to all other forms of treatment. These forms of disease appear to follow a certain law, which I have so frequently observed, that I have at length been led to look upon it as a part of the natural history of the disease. The scaly affections almost always return in the same form after the patient has been apparently cured; but they return in a 12 THE MERCURIAL VAPOUR BATH. milder form, and always yield again to the mercurial vapour. This may occur once or twice, in a still de- creasing degree, always yielding with certainty to the same treatment, and at length returning no more. In a disease like syphilis, which some- times lies dormant for so long a period of time, no plan of treatment can have any claim to con- fidence that has not received the sanction of time and experience; and twenty years practi- cal experience in the treatment by mercurial vapour has taught me that, in the great majority of cases of constitutional syphilis, there is no remedy so effectual, and certainly none so little injurious to the patient, — in fact, in most in- stances, the general health improves under its use. If the treatment of constitutional syphilis by the mercurial vapour bath be compared with any of the other modes of treatment commonly adopted, it will be found to possess incalculable advantages over them. It spares the stomach, it does not interfere with the general health, and, in a vast majority of instances, it removes the symptoms of the disease. Those who object to mercurial treatment very commonly fall back upon the iodides as remedies; but I here wish to repeat an opinion which I have long held and taught on this subject, that prolonged treatments by the iodides are more injurious than those by THE MERCURIAL VAPOUR BATH. 13 mercury. In a great majority of cases, iodine suspends the symptoms of the disease, but does not cure it. I have seen patient after patient infected with a fear or dread of mercury, who have pursued steadily the treatment by iodides in almost poisonous doses for years, where the disease has been kept in abeyance by the remedy, but invariably returns after its discontinuance for a few weeks. Such treatments are not without their dan- gers ; far greater than any produced by the judi- cious administration of mercury.. They under- mine the muscular strength, seriously impair the digestive organs, render the testicles loose and flabby, and produce a condition of iodic cach- exia, from which the patient recovers with diffi- culty, or does not recover at all. The only other methods of treatment worthy of notice, as curative agents in treatment of syphilis, are syphilisation, and Zittman's decoction. Very few persons have either the time, the constitu- tion, or the courage to go through the latter treatment. It consists in a rigid abstinence, and swallowing some quarts of decpction of the woods, sarsaparilla, etc., daily; and this con- tinued for several weeks. It is a favorite treatment in Germany. I have treated and cured several patients by the mercurial vapour bath, in which this treatment has failed signally. 2 14 THE MERCURIAL VAPOUR BATH. I especially call to mind the case of one gen- tleman, who had a scaly eruption on the skin, and secondary ulceration of the tongue. Dur- ing the time he was under treatment, the erup- tion upon the skin disappeared; the ulceration of the tongue did not yield at all; when, how- ever, he resumed his ordinary mode of living, the disease returned, and in a few weeks was as bad as ever. Previous to this treatment by Zittman's decoction, this gentleman had taken so much iodine that, during the sweating pro- cess, it could be smelt, and the perspiration turned his linen brown. A month's treatment by the vapour of calomel and the bi-sulphuret, entirely removed every symptom of the disease, and the patient has never relapsed. The plan of treatment by the mercurial vapour bath does not imperatively re- quire that the patient should be confined to the house during its use. He should, of course, take rather more than ordinary precaution against cold, damp, and night air. It must be admitted that its efficacy would be enhanced by confinement in a moderately warm room, but this is not absolutely necessary, and the patient, in most cases, recovers well without it. There are cases certainly in which exposure or exercise would be positively mischievous under any plan of treatment. In most cases a liberal, but not THE MERCURIAL VAPOUR BATH. 15 stimulating diet, should be associated with the bath treatment, and it is owing to the neglect of this, that failures sometimes occur. In fact, I have frequently seen little or no impression made upon the disease, when the patient lived low ; whilst he has immediately improved, under the same treatment, when this was associated with better living. The same remarks apply frequently to a change of climate, as well as to diet, for although syphilis is, to a certain extent, independent of climate, still, I have occasion- ally seen some remarkable cases where a change of air, associated with the mercurial vapour bath, has brought about a cure, which otherwise ap- peared hopeless. I shall now detail a few cases, by way of illus- trating the efficacy of the mercurial vapour bath, making a few comments upon them as I pro- ceed. CASE I. A gentleman, about forty years of age, who had suffered from various forms of constitutional syphilis for many years, was suddenly attacked with a rapidly spreading ulceration of the throat. The disease came on suddenly and pro- gressed with frightful rapidity; in forty-eight hours half the soft palate was gone. He was sent from a distance to be placed under my care. 16 THE MERCURIAL VAPOUR BATH. I placed him at once in a strong bath, composed of half a dram of calomel and a dram and a half of the bi-sulphuret of mercury, he was kept in the bath forty minutes. The next day the bath was repeated, and the next after in a milder form. The first bath arrested the ulcera- tions. I gave him large doses of opium, night and morning, and continued the same plan of treatment, in a modified form, for some days. In less than three weeks the ulceration had healed, leaving a smaller destruction of tissue than I at first thought would be the case. There are two or three points in this case that demand attention. In the first place, the occurrence of acute symptoms, without any warning, in a constitution long tainted with syphilis; and secondly, the effect of the vapour treatment on such cases. I have so frequently seen the occurrence I have just described in constitutions long tainted with syphilis, that I am led to look upon it, as a part of the natural history of the disease. It especially is likely to occur in weakly subjects, where the health has been broken down by long continued internal courses of mercury or iodine; but it very rarely occurs, if the first symptoms of the constitutional dis- ease, and the earlier relapses, have been thor- oughly treated by the mercurial vapour bath. THE MERCURIAL VAPOUR BATH. 17 In this case again, it must be observed, that the vapour arrested the ulceration at once, and in such instances it almost invariably does so. I have so frequently seen secondary ulcerations in the soft palate, such as those just described, arrested at once by the mercurial vapour bath that I should have hardly thought this case worth mentioning; but for another circum- stance attending it. When this patient first consulted me, he said, " Doctor, I have lost the sight of the right eye for some years, owing to an attack of iritis; I suppose you can do noth- ing for that?" I replied, "I am afraid not; " but towards the end of the treatment, in the third or fourth week, to my great astonishment, and his great delight, he said, " I can see a little with the bad eye." He so far recovered the use of it as to enable him to shoot, — a sport he had been obliged to abandon for some years. Since that time I have seen more than one case, where the vision, partially lost by iritis, has been restored more or less completely by the mercurial vapour bath; and I have no doubt that such improvement in this case, was entirely due to it. Again, a gentleman, twenty-eight years old, consulted me respecting some un- pleasant symptoms, which he thought might be due to a syphilitic taint, having suffered from various symptoms of constitutional disease for three years. 2* 18 THE MERCURIAL VAPOUR BATH. The symptoms now troubling him were edoema of the legs, which were much swollen. On examining his urine it was found highly albuminous; the vision of the left eye was much impaired, — the pupil contracted, the iris muddy, and the whole eyeball generally con- gested. Apart from these symptoms, the health was pretty good. He was directed to use the mercurial vapour bath four times a week, com- posed of a dram of the bi-sulphuret of mer- cury, and half a dram of calomel for each bath. In three weeks the edoema of the legs was gone, the albumen had nearly disappeared from the urine, and the condition of the eye much improved; but it was not till after a six weeks' treatment, that the eye was perfectly restored. It will be recollected that it was three years from the time this patient was first diseased, till the occurrence of the symptoms I have just described; but another accident occurred which corroborates what I have just said with regard to the occurrence of rapid secondary ulcerations, and mutilations, taking place in persons who have been long tainted with syphilis, coming on without any warning. On one visit this patient complained of soreness in the roof of his mouth. On looking, I found a red, hard, elevated spot in the centre of the hard palate, on the right side, neither more nor THE MERCURIAL VAPOUR BATH. 19 less in fact than a node. In a day or two this broke, gave issue to a small portion of offensive pus, and, on examination with a probe, I found the bone rough and denuded. In estimating the value of the curative effects of any remedies, especially in reference to syphilis, those only can be considered valuable which have stood the test of time and expe- rience ; and when we call to mind that it is almost a law in the pathology of syphilis, that the symptoms pertaining to it lie dormant for many years, and then break out with violence, it is necessary to be especially cautious in saying that such a remedy has cured the patient. The disappearance of a symptom is not the cure of the disease. If no other ad- vantage could be claimed for the mercurial vapour bath, than that of arresting in many, nay, in most instances, those rapid ulcerations, and mutilations which sometimes occur in patients, where the syphilitic virus has lain dormant for long periods, it would have accomplished much; but I can say, without the least exag- geration, after twenty years' use of the remedy, and its personal administration in many thousand cases, that no remedy is so likely to prevent re- lapses, and no other is entitled to any thing like the confidence that may be placed in it, in arrest- ing those sudden outbreaks of disease, that muti- 20 THE MERCURIAL VAPOUR BATH. late and disfigure the patient. I may perhaps be permitted to quote the experience of another medical man, himself a sufferer from a very formidable outbreak of secondary syphilis, which had resisted various modes of treatment, but which yielded quickly and permanently to a course of treatment by the mercurial vapour bath. " I can never be too thankful," writes he, "for your excellent treatment, and never lose an opportunity of recommending it to every friend I meet similarly affected. I myself shall never adopt any other abroad, and hope to be able to write to you from New Granada, and give you still further proofs of its efficacy in a tropical climate." An old friend and pupil of mine, Mr. W. J. Moore, who has long practised in India, and who is the author of two standard works on " The Diseases of India," thus expresses himself with regard to the treatment of constitutional syphilis in India: "I hold that the internal exhibition of mercury is uncalled for; especially is this the case in India. Happily, there is an- other method of effecting all the good which is capable of resulting from mercury; this is the mercurial vapour bath, originally recommended and so long and so successfully employed by Mr. Langston Parker. I may be permitted to state the result of my experience, which is, that THE MERCURIAL VAPOUR BATH. 21 for secondary symptoms occurring in India, of whatever variety, there is no remedy so efficient and less hurtful to the constitution as the mercu- rial vapour bath has proved to be." — Manual of the Diseases of India, p. 187. The mercurial vapour bath is especially ser- viceable in secondary ulcerations, — those forms which have resisted ordinary treatment for long periods of time. A gentleman, about twenty years of age, was sent to me a little time ago, with a serpiginous ulceration, resulting from an open virulent bubo. The ulceration had ex- tended down the thigh, and up the abdomen for a considerable distance. Some of the sores were as large as a cheese-plate; they had re- sisted treatment for more than a year1, and con- tinued to extend. They were entirely healed by the mercurial vapour bath, used as I have directed and described, in five weeks. I believe, before the end of the sixth week, they were entirely closed, with a good, firm cicatrix. In the secondary ulcerations again, which follow the rupture of the vesicles, or pustules of secondary syphilis, or the softening of tubercles in tertiary syphilis, the bath sometimes produces remarkable cures. A young gentleman was sent to me two years ago, whose health was entirely broken by repeated outbreaks of constitutional syph- 22 THE MERCURIAL VAPOUR BATH. ilis, which had extended over a period of three years. Various plans of treatment were adopted, but without success, the ulcers healed, and broke open again, and one form of skin disease was succeeded by another, till he was reduced to a state of great weakness. In this condition he was placed under my care. Previ- ous to my seeing him he had been submitted to one or two courses of mercury, pushed to saliva- tion. This patient, when placed under my care, was in a most deplorable state. He had four distinct forms of skin disease. 1. Dark colored spots, left by the healing of old ulcers. 2. Red puckered cicatrices, due to the same cause. 3. Large, foul ulcers. 4. Tubercles, not yet soft- ened. These consisted in large, red, hard cir- cular swellings, varying in size from a split pea to a large marble, they were scattered over the neck and trunk, forty or fifty in number. He had also nodes on both legs, and suffered much from nocturnal pains. In one fortnight after he commenced treatment, the ulcers were healed, the nights good, the nocturnal pains gone. The cure, however, was not complete for nearly six months, although he was not confined by the treatment, and went about his usual pur- suits during the time. The patient has not re- lapsed; he has now been well for more than two years. THE MERCURIAL VAPOUR BATH. 23 This is a very remarkable case; the cure must be attributed to the mode in which the mercury was exhibited. He had been pre- viously placed under mercurial courses, exhib- ited by the mouth, but without effect; and yet the disease yields to the same remedy employed in another way. This is very likely to be explained by the fact that in the mode of giving the remedy, the digestive organs are spared the irritation caused by frequent and repeated doses of mercurial medicines. In fact, the gastric irritation thus produced, frequently sets up a most formidable barrier to the cure of syphilis, and sometimes even to the treatment or palliation of the dis- ease. I am persuaded that the real way to cure syphilis is through the medium of the skin, and not by the mouth. In a correspondence with the late Sir B. C. Brodie on the treatment of syphilis (whose letter from which I quote now lies before me), he says, speaking of some of my published opinions on this point, " I am glad to see that you call the attention of your readers to the advantages of the external administration of mercury, as compared with those derived from the use of it as an internal remedy. The more I see of the treatment of syphilitic diseases, 24 THE MERCURIAL VAPOUR BATH. the more I am confirmed in my opinion on this subject." It must not be supposed from what I have said that the mercurial vapour bath is capa- ble of curing all forms of syphilis without the assistance of other means. There are cases in which the addition of other remedies to suit particular cases and circumstances are found ad- vantageous ; as there is no specific in medicine, neither is there any remedy with which I am acquainted that will cure all diseases. Quinine will not cure all cases of intermittent fever, but still it is the most powerful therapeutic agent with which we are acquainted in the treatment of that disease; yet it occasionally fails, and, as Dr. Yandall has observed, I regard the mercurial vapour bath in syphilis, as I do quinine in inter- mittent fever. The mercurial vapour bath bears the same relation to the one, that quinine does to other. The preparations of mercury that may be used for the bath are the bi-sulphuret, the gray oxide, the binoxide, the iodide, or calomel, as directed by Mr. Henry Lee. But these may be reduced to two, — to the bi-sulphuret and calo- mel, or these two may be used together; and this is the way in which I generally use them. I use an apparatus which encloses all the body except the face, as the whole body should be exposed to the action of the vapour; but an THE MERCURIAL VAPOUR BATH. 25 extemporaneous one is easily adapted with a little management. I use also separate lamps, one for the mercury and the other for the water. There is a great advantage in this, as it enables one to separate the heat and moisture with a much greater degree of nicety, and also to leave the person exposed to the mercurial vapour alone, when a sufficient amount of dia- phoresis has been produced by the steam vapour. This also avoids any degree of debility that might be produced by too much heat, or too much perspiration. The quantity of the mercurial for an ordinary bath would be from half a dram to a dram of calomel, and from one to two drams of the bi-sulphuret. In skin diseases the bi-sulphuret has many advan- tages ; but it should be pure and carefully made, as it is used very frequently for ordi- nary chemical purposes, and is much adul- terated. In certain and rare forms of disease I have occasionally added small quantities of the iodide of mercury, — five or ten grains to each bath. In tubercular or pustular diseases of the skin, I have found this useful; but the fumes are very irritating, and, when used, the face should be carefully protected. I was consulted a short time ago by a surgeon, respecting the condition of a patient of his, who had secondary ulcera- tions of a most formidable character, resulting 3 26 THE MERCURIAL VAPOUR BATH. from the softening of syphilitic tubercles. I suggested the mercurial vapour bath, with the addition of a small quantity of the iodide to each bath. By some mistake he used the bin- iodide instead of the iodide; and the effects were very severe upon the patient, producing sickness, pain in the bowels, and diarrhoea; but the effect was also very remarkable upon the disease, for not more than two or three baths were given, when the ulcerations healed rapidly. The patient, who was before weak and cachec- tic, became strong and fat; she soon after married, and had two healthy children. This was a case of hereditary syphilis, and there are several remarkable points connected with it, in reference to the procreation of diseased and healthy children. This, however, is foreign to the object of this paper, and I must refer the reader, who wishes to inquire further into these points, to my work "On the Modern Treatment of Syphilitic Diseases," p. 296. The ulceration in this case resulted from the softening of nodes on both tibiae; the nodes on each leg suppurated and broke, and the bone exfoliated, as it always does in such cases, to a considerable extent. The cure was here perfect and perma- nent, and the lady is now, and has been for some years, in excellent health, and the mother of several healthy children. She lately con- THE MERCURIAL VAPOUR BATH. 27 suited me on some matters unconnected with her previous illness, and I was surprised at her good looks. There are some otfier modes of using the mercurial vapour bath, locally or par- tially, where a general bath cannot be borne. It occasionally happens that an unfortunate patient shall be so much reduced and weakened by long-continued disease, that he is unable to bear the general application of the remedy; though I must confess that it has hardly fallen to my lot to see but few such cases. They may, however, and do occasionally occur. A gentleman, upwards of fifty years of age, had a formidable attack of pustulo-crustaceous syphilis. He could not bear a general bath, however carefully administered; it struck him that a partial application of the remedy might do him some good, if it was not as beneficial as its general employ. He contrived an apparatus by which he fumed one leg only, and after using this some time, he fumed the other. The legs were covered with foul ulcers, resulting from the rupture of pustules; many of these covered with a dry, hard, rupial crust of dark color. He took plenty of porter, bark, iron, and cod-oil, and fumed his legs regularly with calomel and bi-sulphuret of mercury. In six months he was restored to a very good state of health. I may be permitted to quote, in his 28 THE MERCURIAL VAPOUR BATH. own words, his account of the effects of the vapour locally upon himself. "The moist vapour," writes he, " has turned out most bene- ficial in my case. I was in a sad, suffering state night and day, night perspirations; the ulcers on the right leg had eaten into the mus- cular fibres of the calf, causing constant rest- lessness and great pain; the ulcer was covered with a green slough. In this state it occurred to me to try your bath locally to the right leg alone; the effect was surprising: the first bath of twenty minutes gave instant relief to the pain, and cleared off the green slough, and the bath the next day produced a square inch of healed surface. I then went on with the baths twice a week, taking the tonic as usual. At the end of April, the right leg was soundly cured. I now began to vapourize the other leg, which, how- ever, had greatly improved while treating the right leg ; but a most curious thing occurred, — the left testicle, which had been enlarged for many years, being half as large again as the right, is now reduced to the same size as the other; this clearly shows that the disease was latent in it." The ordinary modes of conducting mercu- rial courses by the use of the drug internally given, not only frequently fail in curing the dis- ease, or rather in removing the symptoms of the THE MERCURIAL VAPOUR BATH. 29 disease for which they are given ; but a class of affections are commonly thereby induced, which are the result of such treatments; so that on many forms of constitutional syphilis being pre- sented to our notice, it is difficult to say what has been produced by the disease, and what by the remedy employed for its proposed cure. Indeed, a peculiar form of constitutional dis- turbance is often set up, which has masked or changed the natural course of the disease, and which condition would not have occurred if mercury had not been given. It may be thought that I am too much wedded to my own views, and my own mode of treatment; but this is not so. When Dr. Yandall called on me from the United States, he said, "My faith in your plan of treatment increases with every year. The more I see of its results the more confi- dence I have in it. Dr. Bumstead, lecturer on venereal disease in the college of physicians and surgeons of New York, says, Mr. Parker's method is safer, quicker, more certain, and less frequently followed by relapses, and more effi- cient in obstinate cases, than any other, and from my own experience I can testify to its very great value." I append a few cases, selected from thousands of others. These I have chosen simply because they show the remarkable effects of the treatment upon 3* 30 THE MERCURIAL VAPOUR BATH. cases, which, without the aid of the baths, as far as I know, must have been utterly hopeless. I say thousands of others : this may seem almost an exaggeration, but when it is considered that I have adopted this practice for more than twenty years, and have, during that time, superintended the administration of the baths, from three to five times every day, the number stated will not be found very far wrong. case n. A gentleman, upwards of forty-five years of age, was sent to me from a distance, with a hope that I might be able to do something for him, in the way of relief. Cure, his friends thought, was out of the ques- tion. He had been confined to his house for many months, and the greater part of the time to his bed, with secondary sores, which resulted from the rupture of the pustules of secondary syphilis. The trunk, the arms, the legs, and the back were covered with these sores in various conditions; and as fast as they healed in one place, they broke out in another. He was weak and emaciated, and tormented with night- sweats. He was so weak that he could not at first bear a general bath, and the lower half of the body only was exposed to the action of the vapour. He used ten grains of calomel and half THE MERCURIAL VAPOUR BATH. 31 a dram of the bi-sulphuret of mercury for a bath, continued for fifteen minutes every night. As he improved, a general bath was used, and the whole body immersed : this was done three times a week. The progress of the case was exceedingly favorable, and in a few weeks most of the sores had healed, and the patient was able to dress himself and ride out. At the end of about six months he was quite well; i.e., all the sores had healed, but the skin presented a very curious appearance; it was rough, corrugated, and uneven in places,— owing to the puckering of the skin caused by the con- traction of the cicatrices of the numerous sores he had upon it. It looked as though he had been burnt, and in fact the healing of such sores gives the idea that the skin has been burnt. I have noticed it time after time, and should have supposed such had been the case, did I not know the true cause of such an appearance. It is almost impossible to convey in writing, a correct idea of the formidable nature of the case I have just narrated, or the very great ben- efit he derived from the vapour treatment, when every thing else had failed. Mercury by the mouth, by friction, the iodides, chlorate of potash, cod oil, sea air, — all had been tried without suc- cess. Yet he began to amend from the third day after the baths were put in operation. 32 THE MERCURIAL VAPOUR BATH. CASE III. A gentleman who had been married for some years, and who had not had any primary venereal disease of any form, since then, consulted me, respecting a painful affection of the arm. The chief complaint was of the left fore-arm, the bones of which were much enlarged and tender to the touch; the night, however, was the period of suffer- ing. Directly he got warm in bed the pains began, and to such a degree as to deprive him entirely of rest; he had not slept without pain one night for seven years. The disease was syphilitic periostitis. Mercury by the mouth, iodine, blis- ters, etc., had all failed in giving more than transient and temporary relief. The bones of the nose were also thickened, and the seat of shooting pains, the left testis, was five times the size of the right. After the third bath the pains returned no more, the tenderness was gone from the arm, and he could bear the bones pressed and examined with a tolerable degree of freedom and force, although previously it had been exquisitely tender. The whole of the symptoms had disappeared after a three months' course of the vapour, which was interrupted from time to time. It has been said, and is generally supposed, that the iodide of potassium is all but a specific THE MERCURIAL VAPOUR BATH. 33 for periostial inflammation of syphilitic origin, and nocturnal or bone pain, without evident marks of inflammatory action. Doubtless, in many cases, it is an excellent remedy, but its good effects are rather palliative than permanent; and there are also many cases in which it totally and completely fails. Not so with the mercurial vapour bath: it is all but certain in its influence over the symptoms of disease I am describing; and the rapidity with which it removes them is sometimes very remarkable. M. Diday, a great authority on syphilis, says, speaking of the effects of the iodide over these pains, " The iodide of potassium palliates these pains more frequently than it cures them, without relapse; but to compensate for this, the relapse, though it be frequent, never fails to obey the remedy." As an illustration of this I narrate the following: — case rv. An officer on foreign service, suffered in a very severe manner from these nocturnal pains. He had suffered for ten years unless he was under the influence of iodide of potassium; but if he discontinued the remedy, he was never free from them for more than ten days. Weary of this constant recurrence of pain, and disgusted with incessantly swallowing physic, which always 34 THE MERCURIAL VAPOUR BATH. left a metallic taste in his mouth, from which he was never free, he got invalided, came home, and placed himself under my care. He was under treatment for about three months, tak- ing a general bath about four times a week, com- posed of ten grains of calomel, five of the iodide of mercury, and a dram of the bi-sulphuret. Writing to me more than a year afterwards he says, "You may remember that when I applied to you for advice, I was suffering from one of my painful attacks, which had generally come on once a month for the last ten years. Since the treatment I went through with you, I have had no return of those attacks, and have had no noc- turnal pain whatever." CASE V. A young gentleman and lady married, with all the prospects of future happiness that fortune and apparent health could give. In due course the lady became pregnant, but miscarried. The same thing happened in her second and third pregnancies; and a good deal of mental uneasi- ness was produced, and some suspicion arose. The fourth child was born alive, but at six weeks old had snuffling, the eyes became bad7 and con- dyloma appeared about the anus. A neighboring physician of great local emi- THE MERCURIAL VAPOUR BATH. 35 nence was consulted, who said rather abruptly, "The child is diseased." The parents, as may naturally be supposed, were shocked and horri- fied beyond measure; the father having at a remote period, before his marriage, been affected with syphilis, but the mother had never exhibited the least symptom of the disease. He was put upon a course of blue pill and iodide of potas- sium ; the mother at first was not treated. A fifth child was born, who at the end of the first month had symptoms of syphilis. The father only was again treated, and a sixth child was born diseased. The mother was again exam- ined, but no trace of disease could be found in the throat, vagina, or elsewhere. The patients were now placed under my care ; I recommended that both should be treated by a full course of mercurial vapour, and that no intercourse should take place during that period. The seventh child was born healthy, and has remained so, and neither father nor mother has as yet exhibited any farther symptoms of dis- ease. This case illustrates one or two very impor- tant points in the treatment of syphilis. First, it establishes the law, which should always be acted on, that in the event of two married per- sons, apparently healthy, having a diseased child born to them, that both should be treated, al- 36 THE MERCURIAL VAPOUR BATH. though the mother has never shown the least sign of disease. Secondly, it shows the efficacy of the mercurial vapour treatment, after the failure of several of the ordinary methods. It is true an exception might he taken to this, since the mother was never treated till the mercurial vapour bath was used; but, on the other hand, it is not probable that the father could have been cured by the previous treatment, or he would not have continued to procreate diseased children. There can be no doubt that this plan possesses an efficiency, and produces results that can be effected by no other. In a great number of cases it is perfectly efficacious and curative alone, without the assistance of any other treatment. In other cases it acts as a powerful auxiliary, and so materially does it assist, that the remedies before employed, do not cure, or remove, the symptoms against which they were directed, till the mercurial vapour bath is used. It is free from all injury or risk, and does not disturb the patient's general health; if properly managed, this commonly improves under it. In many cases such as I have de- scribed, the remedies have been, under the old plans, if not worse than the disease, almost as bad. We need only go back to the late Sir Astley Cooper's account of the treatment adopt- ed in Guy's Hospital in his day, for an illustra- THE MERCURIAL VAPOUR BATH. 37 tion of this. Under the present plan, experience has already proved, and I hope will go still further to prove, that a number of the evils attendant on the class of diseases I have been considering, may be mitigated, and in many, altogether removed. There are one or two points in the management of the bath, which perhaps I have not dwelt upon with sufficient minuteness, and they are of very considerable importance. The quantity of water should not be too large; a pint, or a pint and a half, is quite enough. The diaphoresis should not be too great; if these points are not attended to, the mercury becomes so much diluted, that the specific effect is weakened, or altogether lost. It is very important, again, that two receptacles should be used, one for the water and a second one for the mercurial preparation, and that there should be a second lamp for each. When the patient perspires freely, the lamp under the water should be removed, and the one under the mercury only suffered to remain till the operation is completed. At the end of that time, if the bi-sulphuret has been used, with or without calomel, the body should be wiped dry, and gently rubbed. If calomel alone has been used, and there is not much damp on the skin, there may be no occasion to wipe the skin dry. Mr. Lee thinks that, by suffering the deposit 4 38 THE MERCURIAL VAPOUR BATH. from the calomel to remain, that a still further absorption of the mercury would take place, and its specific effect more surely induced. The time occupied in the cure of venereal diseases by the mercurial vapour bath, is vastly less, than that consumed by any other treatment; its effects are commonly immediate, one full bath very frequently making at once an impres- sion upon the disease. When the hair has been falling rapidly, one bath has arrested this; ulcers, which have been rapidly spreading, have been rendered stationary by one bath. After two or three baths, the improvement is in most instances marked; and the cure is effected in one-fourth, or even one-sixth, of the time usually required for the success of ordinary treatments. The nature of the case determines the time occupied in the cure. In superficial skin dis- eases, or superficial ulcers of the nose and throat, the cure is very rapid. I have known affections of this kind cured in two or three weeks, and with comfort, rather than inconven- ience, to the patient. In enlargements of the bones and testes, in indurations of the penis, and in persistent induration of the cicatrix of a primary sore, the cure is necessarily more tedious; the change of structure produced in such cases must have time for removal; never- theless, in these cases, which require months THE MERCURIAL VAPOUR BATH. 39 of treatment, under common circumstances, and which are not unfrequently considered, or given up as incurable, the moist, mercurial vapour will do more in a month than any other treatment in six. I have known cases of indu- ration of the penis, removed in three or four weeks, which have not shown the slightest amendment, after months of ordinary internal treatment. Some forms of constitutional disease yield more readily to the use of the vapour than others. Some are cured with an extraor- dinary degree of rapidity, and are perfectly cured; which is proved by their not having relapsed, or presented a fresh venereal symptom, after many years. These forms are superficial diseases of the skin, loss of hair, superficial ulceration of the nose and throat. Some varieties require a longer treatment, as diseases of deeper seated parts of the skin, certain forms of ulceration, diseases of the testicles and of the bones. I must not be understood to say that I consider the mercurial vapour bath as a specific remedy in all forms of constitutional syphilis, but I repeat that it is the most powerful therapeutic agent in the removal of disease, and the least harmful to the constitution of the patient, of any remedy with which I am acquainted; neither am I so preju- diced in favour of this remedy, as to reject the 40 THE MERCURIAL VAPOUR BATH. assistance of all others, which, when associated with it, under certain circumstances, produce the best effects, but which effects, I am bound to say, would not, under many circumstances, occur without the assistance of the vapour, since in numerous instances these remedies have failed in curing the disease when used alone. THE CALOMEL VAPOUR BATH; BEING AN ACCOUNT OF ITS MODE OF EMPLOYMENT. BY HENRY LEE, F.R.C.S., StTBGEON TO ST. GEOBGE'S HOSPITAL AND TO THE LOCK HOSPITAL, FOBMEBLY SUBGEON TO KING'S COLLEGE HOSPITAL, LONDON. 1863. ITS MODE OF EMPLOYMENT. Three different ways of giving mercury are in practice with syphilographers, viz.: 1. The administration of the medicine internally. 2. Its introduction into the patient's system through the skin, by means of mercurial frictions. 3. The use of the mercurial vapour baths. The blue bill is one of the most ordinary forms in which mercury is given. From three to five grains, combined with half a grain, or a grain of opium, may be ordered two or three times a day. The hydrargyrum cum creta, may be given in doses of from three to five grains, either alone or combined with an equal amount of Dover's powder. Calomel, either alone or mixed with opium, or in the form of the red pill, may also be given in doses of from one to three grains, two or three times a day. All these preparations of mercury, are very valuable remedies under certain circumstances. But where a sustained or continued action ia a s 4 THE CALOMEL VAPOUR BATH. required they are very apt to produce irritation of the digestive organs. Even when combined with opium, the internal use of mercury can seldom be continued as long as is desirable. It will be found in some way or other to affect the patient's constitution injuri- ously, and to make it extremely distasteful for them to continue the course for a proper and necessary time. Mercury introduced into the stomach and intestines produces, as is well known, a power- ful effect upon the liver. This doubtless depends upon the blood being conveyed directly from these parts through the vena porta to that organ. Sir Ranald Martin, in his admirable work on the influences of tropical climates, observes, that mercury enters into intimate union with the elements of the blood, and that it must therefore modify its plasticity, and influence all the organic functions to which it is subservient. The parts upon which this influence expends itself, when mercury is given internally, are the liver, and intestines. * Even robust and healthy persons can rarely bear any prolonged irritation of the organs with impunity; and in patients of re- laxed enfeebled habits, any sustained mercurial * A case has recently fallen under my observation, in which a young gentleman, after the prolonged use of mercury inter- nally, died of jaundice, to the surprise of all his friends. ITS MODE OF EMPLOYMENT. 5 action which produces its primary and direct influence upon those parts, is quite out of the question as a remedial measure. 2. Mercurial inunction is a very efficient way of using mercury; but it is dirty, laborious, and often little suited to the taste of those who re- quire its aid. On this account, patients very frequently use the remedy with a great deal of irregularity, or even remit it altogether. It is, however, much less liable to produce griping and purging, than when the drug is given internally, and the effect upon the consti- tution is not nearly so debilitating. When mer- curial ointment is used, half a dram or a dram is rubbed into the inside of the thighs by the patient every night. This in winter is conveniently done before a fire. The ointment should be rubbed in until it disappears. The process will occupy about half an hour, and the patient should wear some flannel drawers, and not wash the remains of the ointment off. The application of the ointment must be repeated every night until the gums become soft and slightly spongy; this is the best indica- tion of the proper action of the mercury upon the patient's system, and the action should be maintained by regulating the quantity of oint- ment used, for six, or seven, consecutive weeks, according to circumstances. 1* 6 THE CALOMEL VAPOUR BATH. Many surgeons are in the habit of leaving off the mercury soon after the patient's gums are affected. According to the author's experience, this practice not only fails to cure the disease, but actually does harm. The patient's constitu- tion is weakened to a certain extent, and the disease is not cured, but what is of more impor- tance still, is, that the secondary symptoms, when they do appear, are often of a worse and more intractable character than if no mercury had been given. There are two principal objects in view in treating a case of syphilis; the first is to remove the symptoms, and the second to cure the dis- ease. Now a short course of mercury will often effect the former of these two objects, as will also, in almost all secondary cases, the iodide of potassium; but neither the short course of mer- cury, nor the iodide of potassium, will in general cure syphilis. The symptoms will, it is true, be removed, but they will return; and practically it is found extremely difficult to induce patients, particularly in the upper classes of society, to continue a course of mercurial inunction suffi- ciently long to prevent the occurrence, or the return of secondary syphilis. By introducing mercury into a patient's consti- tution, by inunction, its deleterious action upon internal organs is avoided. The amount ab- ITS MODE OF EMPLOYMENT. 7 sorbed into the blood, produces its influence equally throughout the system, and is not con- veyed direct to the liver, as when the medicine is administered internally. But great as the advantages of the inunction of mercury are as compared with its internal administration, it, nevertheless, is attended with certain inconveniences which prevent its very general use. The inunction of mercurial ointment, so as to insure the proper effect of the remedy, requires considerable labor and perseverance on the part of the patients; and it is with difficulty that they can be induced to continue its use for any length of time, and sometimes it produces a troublesome pustular eruption on the skin. 3. Fumigation of the surface of the body by means of certain mercurial preparations pos- sesses the advantages of inunction, without some of the objections to which this is liable. But, like other modes of using mercury, it was tried in a variety of ways before a safe and efficient mode of administration was adopted. In the years 1786-87, Mr. Pierson had a fumigating machine constructed according to the directions given by M. Lalonette. This apparatus, although it was thought to be new at the time, differed in no material respect from that described by Nicholas de Blegay, in the year 1683. 8 THE CALOMEL VAPOUR BATH. Mr. Pierson made a considerable number of experiments with this fumigating machine, and found that the gums became turgid and tender very quickly, and that the local appearances were sooner removed than by the other modes of introducing mercury into the system. But, to counterbalance these advantages, it was found that the mode of treatment adopted induced debility, and that ptyalism was often excited rapidly, and at an early period. Mr. Pierson found that he was, consequently, often obliged to discontinue his course of treat- ment. Sir Benjamin Brodie's experience coincided with that of Mr. Pierson. He found that it was difficult to regulate the mercurial action; and he observes that by using mercurial fumigation, "you may affect the system too much,* or too little; and you may be taken unawares by the patient's gums becoming all at once excessively sore." (Lectures on Pathology and Surgery, p. 246.) From observations and comparative experiments which I made at the Lock Hospital during the years 1855-6, I feel satisfied that the irregular results noticed by Mr. Pierson and Sir Benjamin Brodie, depended upon the differ- ence in the chemical composition of the powder used for the purposes of fumigation, both before and after it was raised into a state of vapour. ITS MODE OF EMPLOYMENT. 9 The gray oxide of mercury (the preparation generally used), varies much in color as obtained at different shops. Some specimens will not volatilize at the temperature produced by an ordinary spirit lamp under a metallic plate. Other specimens of a lighter color, volatilize quickly enough. When the darker specimens are sublimed, they are decomposed in a greater or less degree. A deutoxide of mercury is formed by the addition of an equivalent of oxygen from the air; and if the temperature be much increased, then the oxygen is driven off altogether, and metallic mercury is sublimed. Under these circumstances, with a mercurial preparation of uncertain composition, and under- going different changes, according to the degree of heat applied, there is no wonder that very different effects should have been produced in different cases. With some samples of the gray oxide, it is necessary to use a considerable quantity of the powder in order to insure any effect; with other samples, a similar quantity produces much more action than is desirable. The gray color of the powder depends upon the admixture of a certain proportion of calomel with the protoxide; and the temperature at which any particular specimen will volatilize, will depend upon the relative proportions of the two. The bisulphuret of mercury, again, 10 THE CALOMEL VAPOUR BATH. which has been extensively used for purposes of fumigation, gives off, when exposed to heat, a vapour, probably the sulphurous acid gas, which has sometimes caused very considerable irritation of the lungs ; and all forms of mercu- rial fumigation have, in consequence, by some, been condemned. Now, all the inconveniences above mentioned may be avoided with certainty, by using a mercurial preparation which is always of the same chemical composition, which does not irritate the lungs, and which is not liable to be altered by an increase of temperature. Such a preparation is calomel. We have here, a defi- nate chemical compound. It is altered in com- position, neither by heat, nor by moist air, and may be relied upon, when used for purposes of general fumigation, for producing its action, as certainly as any medicine administered internally. A very small quantity (as compared with the other mercurial preparations), will insure the required effect, and this may be regulated and controlled with great precision. General calomel fumigation may be used in cases where the administration of mercury by other methods is inadmissible. On account of the small amount of calomel required, it may be used, sometimes with the greatest benefit, even where other modes of fumigation, requiring ITS MODE OF EMPLOYMENT. 11 larger quantities of mercury, cannot be borne. Two remarkable cases, illustrating this fact, are at present (Dec. 1861), under my observation. In one case, a patient who had had his throat affected between eleven and twelve years, and who was unable to swallow even fluids without the greatest inconvenience and distress, was reduced to such a degree that it was feared he would sink. The back of this patient's throat was one mass of phagedenic ulceration. Under the direction of Mr. Davis, of Spring Gardens, and myself, the calomel fumigating baths were administered every night; and at the expiration of three weeks, the ulceration had become quite clean, the patient could swal- low without any inconvenience, and had gained considerably in weight. In the other case, a patient had had his penis " gradually wasted away," by phagedenic ulcer- ation, until the ulcer was on a level with the scrotum. The disease had gradually progressed. Having ordered him a calomel vapour bath every night, I had an opportunity of seeing him exactly three weeks and two days after he had commenced their use. The ulceration was at that period all but healed. Previously to trying the calomel baths, this patient had been subjected to all the ordi- nary modes of treatment. 12 THE CALOMEL VAPOUR BATH. Calomel appears to have been formerly used for the purposes of general fumigation, as well as other preparations of mercury. But it was used in the same quantities as those other pre- parations, and was, therefore, open to the same objections as they. M. Rapou published in Paris, in 1824, two volumes on fumigation as employed in various diseases. The mercurial preparations which he recom- mended were cinnabar, Lalonette's mercurial powder (which consisted of a mixture of mer- cury and clay), calomel, and corrosive sublimate. The quantity used for the first three, he recom- mended to be from " a quarter to half an ounce each time." The amount of the corrosive sublimate he says, should not exceed five or six grains. Even with these very large quantities, M. Rapou had only seen salivation produced in three instances, and these were of a very short continuance, and yielded to the use of ordinary baths. M. Rapou recommended the mercurial fumigations to be used with steam, which, he said, calmed the sys- tem, softened the skin, and did not prevent the absorption of the mercury. Now, all the methods of applying mercurial fumigation above mentioned, required the use of a complicated apparatus, which private indi- viduals do not command. ITS MODE OF EMPLOYMENT. 13 In order to adapt this method to general use, it was necessary to so modify the apparatus, that any one could use it in his own room; and this has now been most effectually accomplished. Mr. Langston Parker recommends an appara- tus, for the use of which the patient is placed on a chair, and covered with an oil cloth lined with flannel, which is supported by a proper frame- work. Under the chair are placed a copper bath, con- taining from half a pint to a pint of water, and a tinned iron plate, on which is put from one to three drams of the bi-sulphuret of mercury, or the same quantity of the gray oxide, or the binoxide, or other mercurial preparation; under each of these is a spirit lamp. The mode of treatment by this apparatus appears to have been most successful in Mr. Par- ker's hands. But the apparatus is not one which a patient can procure for himself, so as to give himself his own bath. Using the same large quantities of the mercu- rial preparations as Mr. Pierson and Sir B. Brodie, it is somewhat remarkable that neither M. Rapou nor Mr. Langston Parker has seen any of the injurious effects of this remedy which were recorded by those gentlemen. This may be, perhaps, in a great measure, 2 14 THE CALOMEL VAPOUR BATH. accounted for by the fact that both M. Rapou and Mr. Parker recommend the bath to be used so as to produce a considerable amount of per- spiration. Any action thus induced is determined to the skin, and the intensity of the specific action is thus prevented from developing itself in any internal part. Another, and perhaps a still more important point, is, that, after the bath as em- ployed by Mr. Parker, the body is " rubbed dry." In this process, a very large proportion of the mercury which has been deposited upon the sur- face is necessarily removed. In the calomel vapour bath, as I have now used it for several years at the Lock Hospital and elsewhere, fifteen or twenty grains of calomel only are used; but that which is deposited on the skin is allowed to remain there, and, by a slow process of imbibi- tion, a part of it is probably absorbed into the blood. A continued slight action is thus maintained, and the danger of any violent or sudden effect completely obviated. It may also be observed, that if any great amount of perspiration be induced, it will tend to remove the mercurial powder from the sur- face of the skin, and thus diminish the effects which would otherwise be produced. Several different kinds of apparatus have been ITS MODE OF EMPLOYMENT. 15 made for the purpose of administering calomel fumigation since its introduction at the Lock Hospital. Mr. Matthews of Portugal street, con- structed an apparatus which answered every pur- pose. It consisted of two spirit lamps, one of which volatilized the calomel, while the other boiled a small quantity of water. The patient sat over these, enveloped in a cloak or large blanket fastened round his neck, and became quickly surrounded by an atmos- phere of moist mercurial fume. The most convenient calomel vapour bath, and that which is now generally used, is one made at my request by Mr. Blaise, of 67 St. James Street. This was completed, after many experiments and modifications undertaken and directed by Mr. Pollock, surgeon to St. George's Hospital. In this apparatus there is only one lamp, which sublimes the calomel and boils the water at the same time. In the centre of the top, immediately over the wick of the lamp, is a small, separate, circular tin plate, upon which the calomel is placed. Around this is a circular depression, which may be one-third filled with boiling water. The apparatus is then placed on the ground, and the lamp is lighted. The patient sits over it, with an American cloth cloak, or a Mackintosh, or a moleskin cloak (also sold 16 THE CALOMEL VAPOUR BATH. for the purpose by Mr. Matthews, and by Mr. Blaise), fastened round his neck. He thus becomes surrounded by calomel vapour, which he is generally directed to inhale for two or three separate minutes, during each bath. In doing this, the patient should not put his head under the cloak, but simply allow some of the vapour to escape from its upper part, and breathe it mixed with a large proportion of common air. At the expiration of a quarter of an hour or twenty minutes, the calomel is vola- tilized, and the water has boiled away. A portion of the calomel is deposited, to- gether with the condensed vapour of the steam, on the patient's body, and is to be left there to undergo partial absorption. The quantity of spirits of wine, used upon each occasion, is so regulated, that the lamp goes out of its own accord about the same time that the calomel and the water disappear. The patient then gradually unfastens the cloak, and in about a minute is sufficiently cool to put his night-dress on without much interfering with the very fine layer of calomel which covers his body. He must be particularly told not to wipe his skin, as by so doing he would interfere with the action of the medicine. ITS MODE OF EMPLOYMENT. 17 Of all the modes of administering mercury, fumigation is that which is attended with the least demand upon the patient's constitution. The amount administered in this way can be regulated with the greatest facility; and the action may be maintained without inconvenience for almost any length of time. On this account, as well as for other reasons, fumigation is, in my opinion, less liable to be followed by the recur- rence of secondary symptoms, than any other mode of treatment whatever; and of all the kinds of mercurial fumigation, that by calomel is the safest, and the most convenient, if not the most efficacious. The imbibition of the medi- cine through the skin, prevents the injurious action upon internal parts ; while the small quan- tity used, although quite sufficient to produce any amount of action that may be required, insures the patient against any sudden or violent effects. In this mode of using mercury, the whole of the skin, may act as an absorbing surface; and when requisite, the effect may be still further increased by absorption from the mucous mem- brane of the nose, mouth, and bronchial tubes. In Secondary syphilitic disease, the surface of the body and the mucous membranes are pecu- liarly liable to be affected; and the process of fumigation has here this great advantage, that the remedy is applied directly to the diseased 2* 18 THE CALOMEL VAPOUR BATH. parts, and acts immediately upon them. When administered internally, it has, on the contrary, first to be absorbed into the blood, and carried the round of the circulation, perhaps more than once, before it comes into contact with the affected structures. Many old "and intractable syphilitic ulcerations yield with surprising rapidity to local calomel fumigations; and there is no reason why the same principle should not be taken advantage of in treating the more general forms of the dis- ease. Calomel alone, without the vapour of water, may be used, especially where the local action of the medicine alone is required. But, from a series of comparative trials which were made at the Lock Hospital, in the early part of the year 1856, it became evident that, for the purposes of fumigation, it was advisable that a certain amount of the vapour of water should be present. In the British Medical Journal for July 24, and August 14, 1858, are given tables con- taining the particulars of two hundred and seventy-six cases treated in 1856, by calomel fu- migation, and the time during which the patients were respectively under treatment. These tables might easily be continued up to the present time; but to do so would only be to repeat, ITS MODE OF EMPLOYMENT. 19 without any essential variation, the facts which have already been published. The conclusions, however, which were ar- rived at in the year 1856, may now be emphati- cally repeated, after six years of additional experience. The syphilitic poison, in a very great majority of cases, produces its principal effect upon the skin. Through this organ na- ture attempts to eliminate the poison; and a free secretion from the skin assists the action which nature has already commenced. It appears, from an extensive trial, that not only is the poison eliminated from the system more effectually, where there is a free cutaneous action, but that under this condition the effects of mercury upon the patients' constitutions are of a much milder character than under other circumstances. The calomel vapour bath com- bines the various advantages now alluded to, and its great practical advantage is attributable, 1. To the small quantity of mercury which is re- quired, when used in this way, in order to produce the requisite effect; 2. To the fact that the imbibi- tion of the medicine through the skin leaves the digestive organs unirritated, and the digestion unimpaired; 3. To the circumstance that there is something in the free secretion from the skin, which the combination of steam and calomel produces, that moderates and controls the rner- 20 THE CALOMEL VAPOUR BATH. curial action; so that, out of all the cases which have been treated by calomel fumigation in the Lock Hospital, only one case of troublesome salivation has occurred; and in that case the pa- tient had been taking pills internally, before his admission into the hospital. The action of the calomel bath should gener- ally be continued until all syphilitic symptoms have disappeared, and for a week or two after- wards. During the first few weeks, the patient should not be subjected to the influence of much fresh air; and when practical he should remain in the house. The bath should be given every night; and its effects may be regulated either by the quantity of calomel used upon each occasion, or by the amount of vapour which is inhaled. Within the first few days, a slight tenderness, redness, and swelling of the gums, will indicate the mercurial action. This condition should, if possible, be sustained during the whole of the course; but it is not necessary to produce at any time a greater degree of mercurial action. The length of time during which this action is to be maintained must vary considerably with individual cases. From the statistics collected in 1856, it appeared that the average length of time that the male patients were under treatment ITS MODE OF EMPLOYMENT. 21 at the Lock Hospital, was, for primary affections, twenty-three days; for secondary affections, thirty-one days; and for tertiary affections, sixty- one days. In the female wards, during the same year, the average length of time during which the calomel vapour bath was continued was, for pri- mary cases, thirty days; for secondary cases, forty-five days; and for tertiary cases, sixty-two days. The shorter period of time, during which the male patients remained under treatment, is ac- counted for, from many of them having left the hospital as soon as their symptoms had disap- peared, and without having continued their treatment sufficiently long to afford much secu- rity against a recurrence of their disease. Many of the women, on the other hand, re- mained as long as was deemed requisite, in order that they might, upon being discharged, be ad- mitted to the Lock Asylum. In private prac- tice, a mercurial course should seldom, in the first instance, in my opinion, be less than two months; and it may often, in a modified form, be contin- ued for a much longer period. The mode of administering mercury which I have now- recommended has, I have reason to believe, been adopted in medical as well as in surgical cases. Since its introduction, Mr. Blaise informs me 22 THE CALOMEL VAPOUR BATH. that he alone has sold 787 lamps, for the calo- mel vapour bath, since January, 1857. Local Calomel Fumigation. Different kinds of apparatus have been used for local fumiga- tion. The calomel fumigating lamp, previously described, answers the purpose extremely well. The vapour of calomel, being of light specific gravity, ascends; and any part placed over it becomes coated with a fine layer of calomel. This forms an excellent dressing for intractable ulcers, whether of a primary or secondary na- ture. Tubes of various shapes have also been employed so as to direct the vapour to partic- ular parts. Thus, a long tube has been adapted to the calomel-lamp, with a mouth-piece, for the purpose of inhalation in affections of the throat. A roll of paper has been often used with the same object. But it is evident, that, as the calomel mixes with the air, the simple act of respiration does all that is required; and, as far as the throat is concerned, any tube is much more likely to de- tain the calomel than to direct its course. It is often, however, convenient to direct the vapour of calomel to parts which cannot well be brought over an ordinary lamp; and then an ad- ditional apparatus is necessary. One which has now for a long time been in use in the Lock Hospital consists of a curved earthen- ITS MODE OF EMPLOYMENT. 23 ware tube, open at one end, with a spirit-lamp applied at the other. Some calomel is placed within the tube ; and, when volatilized, may thus conveniently be directed to any part. NOTES AND OASES ILLUSTRATIVE OF THE EFFECTS OF THE lERCURIAL VAPOUR BATH UPON VARIOUS FORMS OF CONSTITUTIONAL SYPHILIS, 4- FROM THE PRACTICE OF LANGSTON PARKER, BIRMINGHAM. /ff'J NOTES AND CASES. CASE I. Various forms of constitutional syphilis for five years; failure of various remedies; rapid cure by mercurial vapour. A physician contracted, in the year 1845, a sore at the orifice of the urethra, which was fol- lowed by two buboes, which did not suppurate freely. The patient's health was very much im- paired by this disease ; and his constitution had been very much debilitated by hard work and an attack of typhus fever. In August, 1849, he had an ulceration of the throat; and in three weeks the palate was destroyed to a consid- erable extent. After the ulceration had healed, an artificial palate was applied: shortly after this, the ulceration again appeared, and has not again healed. In November, 1850, this gentle- man placed himself under my care ; and at that period he was in the following state. A sloughy, foul, phagedonic ulcer occupied the left tonsil, the whole of the pharynx, and the 8 4 NOTES AND CASES. back part of the roof of the mouth. In addi- tion, there was a general faint, copper-colored mottling of the skin, a large, scaly blotch on the chest, and a large, pustulo-crustaceous spot on the back; and on the legs, the cicatrices of what seemed to have been secondary ulcers, suc- ceeding to pustules, or tubercles. The health was much impaired; the weakness great; nights bad; severe pains in the throat; and a fetid dis- charge from the nose. The patient used the mercurial vapour bath every other day; was directed to take the cold infusion of sarsaparilla with lime-water, with half a grain of the hydro-chlorate of morphia, at bed-time, and to wash out the throat fre- quently with a creosote gargle : the diet to con- sist of wine and water, fresh animal food, cocoa, and milk. The seventh bath was administered on Nov. 20th. The copper-colored mottling of the skin was all gone; the pustulo-crustaceous spot on the back shrivelled up into a hard crust, without an ulcer underneath it; all the ulcers in the throat and pharynx rapidly healing; the gen- eral health, appetite, and strength, much im- proved ; nights good; gums sore; no salivation. This gentleman could never take mercury inter- nally under any form : when persevered in for a few days in this manner, it always produced dis- tressing tenesmus, and great bodily and mental NOTES AND CASES. 5 depression. Up to December 2d, the baths were administered every third day. On that date, all the ulceration had healed; a very small, granulating, healthy ulcer only remained in the centre of the site of the old disease; gums sore; appetite good; no salivation. All the skin-dis- ease had disappeared. This patient was under my treatment three weeks, during which time he took fourteen baths. He pursued the treat- ment, after he left me, for some time; but the cure has been perfect. On writing to me a few weeks after, he says, " My medical friends are quite astonished at the rapid progress I have made under the use of the vapour, both in regard to my throat and my general health." case n. Constitutional syphilis under various forms for three years; failure of various remedies, especially the iodide of potas- sium ; cure by the mercurial vapour bath. A young gentleman, apparently healthy, con- tracted a primary sore in 1849, which was four months healing, and which left behind it an in- duration which lasted two months longer. The throat was attacked with secondary syphilitic ulceration before the chancre had healed. In 1850, he had an attack of skin-disease, which i* 6 NOTES AND CASES. was succeeded by nocturnal pains in the head and legs. These pains, being partially benefited by medicine, recurred with so much violence in January, 1851, that he was confined to his bed till March. The pains were always mitigated, and sometimes removed for a short period, by the iodide of potassium; but when this remedy was laid aside, they invariably returned, — a cir- cumstance which very frequently attends the treatment of syphilis by the iodide, which the history of the next case illustrates in a very marked degree. In August, 1851, this patient placed himself under my care. I did not see him in any of the previous attacks which I have mentioned. He had, at the present date, constant severe pains of the arms, legs, and bones, which were worse on damp days and when in bed. There were also pustulo-crustaceous spots on the head, and a dry, red throat. All the symptoms disap- peared under one month's treatment by the vapour, and the use of the decoction of guaia- cum. In twelve months afterwards, no pain was felt. Early in 1852, there was a very slight re- turn ; which was removed by the treatment first adopted, which was again followed for a very short time. Since that period, there has been no fresh symptom; and the patient has ap- peared perfectly well. NOTES AND CASES. 7 case m. Constitutional syphilis for twenty-four years ; repeated saliva- tion ; prolonged use of the iodide of potassium ; failure of these remedies; great relief and cure of many of the symp- toms by the mercurial vapour bath, &c. A surgeon, aged forty-seven, consulted me, in 1850, for various symptoms of constitutional syphilis, from which he had suffered for twenty- four years. He had, when he consulted me, syphilitic sarcocele of the right testis, compli- cated with a small hydrocele; a well-marked syphilitic psoriasis of the hands, which were like a fish's skin, so thick and hard were many of the scales: at times the hands became painful and inflamed. He also had general thickening, with enlargement, of the tongue, which was covered with hard lumps, between which were deep fissures, extending nearly through its whole substance. The patient had taken ten grains of the iodide of potassium three times a day for ten years. His appetite was bad; and he looked dry and shrivelled. When the iodide was omitted, the hands became painful and in- flamed ; but no further progress towards a cure was made by the use of this remedy : when dis- continued for a few days, all the symptoms re- turned as badly as ever. I recommended the use of the mercurial 8 NOTES AND CASES. vapour bath three times a week, ten grains of the extract of conium at bed-time, with the cold infusion of sarsaparilla in lime-water. I must confess I felt very uncertain about the issue of this case. In November, i.e., about six months after I had first seen this gentleman, he called again on me. I did not know him; he had regained his flesh and appetite; and the hands were well, the tongue most materially improved, and the sarcocele much reduced. He was under an engagement to marry; and stated that his health had never been so good as now, since the first outbreak of disease, twenty-four years ago. case IV. Pustular syphilitic disease of the skin, with other symptoms of constitutional syphilis of two years' standing; various treatments without effect; rapid disappearance of the symp- toms by the use of the mercurial vapour bath. A gentleman, aged thirty-four, of delicate health, was sent to me on June 24, 1850, laboring under a most formidable attack of sec- ondary syphilis. He had had primary sores two years before, and various forms of eruption on the skin from that time to the present. This patient's skin, was what I have described as "pustulo-crustaceous." There were large dis- tinct pustules on the face, head, body, and limbs, to the number of about twenty-five. NOTES AND CASES. 9 In two places, the pustules were smaller, and placed in groups; this happened on the fore- head, and on the chest. The pustules soon became covered with dark- colored, laminated, or conical crusts, closely ad- herent to the parts underneath, and surrounded for a short distance by a deep-red or livid mar- gin. The crusts, when detached, were found to have covered ulcers more or less deep; which, if healed when the crust fell off, left behind them a deep and vividly red cicatrix, slightly depressed: if the crusts were detached before the ulcers they covered were healed, the ulcers were superficial, but foul, unhealthy, and disposed to spread. The crusts situated over bones, or on the forehead, ulna, and ribs, when detached, always left a deeper depression than on the skin; and the surface of the bone over which they were placed was always absorbed to a slight extent. In addition to this formidable local mischief, the patient was weak, emaciated, had night-sweats and diarrhoea. The mercurial vapour bath was used for a few minutes each day; opiates were administered at night; and the cold infusion of sarsaparilla in lime-water was given. On July the 5th, a great part of the crusts had fallen, and had left the skin sound under- 10 NOTES AND CASES. neath; many of the sores looked healthy, others not so; the general health much better; appe- tite good; bowels were settled; strength daily improving; patient bears the baths for a longer period with comfort; mouth sore; no salivation. In six weeks, the time I personally treated this patient, twenty baths were taken; and at the end of this period all the crusts had fallen, and all the sores had healed; the bowels were regular, and the health and appetite good. The red color of the cicatrices remained for some weeks, gradually dying away: this is always a work of time. The patient has continued in good health since; and there has been no recur- rence of any syphilitic symptom. case v. Constitutional syphilis for seven years; failure of various rem- edies, amongst others, the iodide of potassium, and mer- cury pushed to salivation; complete cure by the mercurial vapour bath, and very small doses of the biniodide of mer- cury. A married lady, aged thirty, was brought to me by her husband from Paris, to be treated by the mercurial vapour bath. She had suffered from constitutional syphilis for seven years, but had never had any primary affection ; neither, on careful examination, could I detect any dis- ease of the sexual organs themselves. Her dis- NOTES AND CASES. 11 ease consisted of dusky red patches spread over the whole body, covered with a dry dan- druff of scurf, not to be called a scale: in places the disease assumed the form of irregular patches; in others, circles or rings; they were uniformly spread over the back, arms, chest, &c. On the knee was a ring of rupial crusts, resting on an inflamed base. The patient had suffered from ulcers of the throat, and had entirely lost her hair. For seven years this disease had remained uninfluenced by remedies. A leading surgical authority did me the honor to recommend my form of treatment to be tried in this case; as mercury under the usual forms, iodides, decoc- tions of the woods, &c, had all failed. The treatment by the mercurial vapour bath was commenced on the 16th of July, 1851. The baths were used three times a week, sometimes more frequently; and one-twelfth of a grain of the biniodide of mercury was given in solution three times a day. On the 12th of August the skin was clear; all the coppery red stains, in the circles and patches, had disappeared; the skin was clean and soft; the rupial ring on the knee, or rather the dark stain it left, was fast disap- pearing. At this period the patient left me. The baths were resumed again, after the lapse of a week, for one month; since which period 12 NOTES AND CASES. the cure has appeared perfect: the health has been good; and no other symptom of syphilis has appeared. The gums were sore and spongy from the baths; but no salivation was produced. CASE VI. Constitutional syphilis, with bad health, for seven years; fail- ure of iodine, and mercurial treatments, as commonly con- ducted ; disappearance of all the symptoms after a treatment by the mercurial vapour bath, with the biniodide of mercury, and the iodide of potassium. A barrister, aged thirty, placed himself under my care in August, 1850. He had suffered from constitutional syphilis for seven years, for which he had undergone a variety of treatment, under the combined influence of which, and the disease, his health had been completely broken. When he first visited me, he suffered from the following syphilitic symptoms: The face, arms, and body were covered with large pustulo-crus- taceous patches: these patches consisted of a red base, upon which were placed dark, flat crusts: some of these crusts were large, others small; they did not cover ulcers. In other places there were large, lividly red blotches, elevated above the skin; after a time these suppurated slightly in the centre, and became covered with a thick, black, flat crust. NOTES AND CASES. 13 On the cheek, just below the orbit, on the left side, was a large, solid tumor, lividly red on its surface, but presenting no fluctuation (syphilitic tubercle). Under and around each blotch, the skin was thickened and indurated; this thicken- ing evidently implicating the whole thickness of the skin. Both legs were painful; and the shin bones were uneven, and tender to the touch. The patient was weak, tormented with night- sweats and pains; the digestion bad, and the bowels disposed to relaxation. The treatment was commenced on Aug. 20th, and consisted of the following plan: The mer- curial vapour bath four times a week, with the twelfth of a grain of the biniodide of mercury in solution, with three grains of the iodide of potassium, twice a day; at night, the patient took ten grains of the extract of conium, and drank half a pint of the warm decoction of guaicum; the diet to be good, but not stimulat- ing. This gentleman was treated personally by me for eighteen days. He took fourteen baths. At the end of that time, the skin was soft and healthy, with the exception of some slight red stains, where the ulcers and tubercles had been situated. All the induration and thickening were gone; the pains in the limbs and the night-perspirations had also left; the gums were puffy, swollen, and sore ; no salivation. 2 14 NOTES AND CASES. He was directed to continue the use of the vapour three times a week, and to drink the cold infusion of sarsaparilla in lime-water. Writing to me in October, this patient says: "I have already commenced the beginning of the end of the treatment. I am wonderfully improved in my general health; and every appearance of dis- ease has entirely disappeared. I am enjoying an elasticity of body and mind I have been a stranger to for many years. I shall think it my duty to humanity to become the propagandist of your system of treatment." case vn. Constitutional syphilis of two years' duration; failure of various remedies; cure by the mercurial vapour, without any other remedy. A gentleman, aged twenty-three, placed him- self under my care in January, 1849, suffering from the following symptoms: Sarcocele of the right testis ; severe nocturnal pains in the head, arms, and legs, their severity preventing rest at night altogether; a general copper-colored mottling of the face, chest, and abdomen; three well-marked, large, syphilitic tubercles on the cheek. He had suffered from various forms of secondary syphilis for two years; had taken so much medicine that he declared it was impossi- NOTES AND CASES. 15 ble for him to take any more, let the conse- quences be what they might. I placed him upon a milk-diet, and com- menced the use of the mercurial vapour, on January the 17th. The head was placed in the bath; and on February the 4th every symptom had disappeared. On June the 1st, a few scaly spots re-appeared on the hands. Four baths were taken; and the symptoms disappeared. The patient, whom I frequently see, has en- joyed the best health since that period. No medicines were taken. case vni. Ulceration and pains in the throat; thick, scaly blotches, with burning and heat of the hands and feet; cure by the mer- curial vapour. A gentleman, aged twenty-four, had suffered from many forms of secondary syphilis for eighteen months, many of which had disap- peared under treatment; but there remained an ulceration of the throat, accompanied by occa- sional severe pains in that part. But the chief symptoms of annoyance were the hands, each of which was covered for three parts of its sur- face with a thick, scaly red patch, occupying the whole of each palm and a part of the thumb and fingers. 16 NOTES AND CASES. The hands were always hot; and a painful burning sensation was seated in the extremities of the fingers: the feet were also hot and hard, but had no scale or patch upon them. Medi- cines of many kinds had utterly failed to relieve these symptoms. The vapour treatment was commenced on June 30: and on Aug. 22, the hands appeared healthy ; all the scales were gone; and the skin was soft and pliant. Some heat remained at times; and occasionally the parts became red and mottled. The hands were smeared with a little zinc ointment; and the patient slept with them in compresses soaked in a lotion composed of camphor-mixture, spirits of wine, and glycerine. In three months the cure was perfect. CASE IX. Superficial primary sores; inability to take mercury, healing of the sores under ordinary treatment. Secondary disease in the skin, throat, and nose; cure of all the symptoms by the mercurial vapour bath. A gentleman consulted me respecting certain symptoms which he considered, and which no doubt were, due to constitutional syphilis. He had primary ulcers eight months previously, for which he could not take mercury, the smallest NOTES AND CASES. 17 quantity producing diarrhoea; and it even af- fected him so when used by friction. The ulcers had healed under a simple treat- ment; but soon afterwards the skin became covered with small, scaly blotches; there was a deep redness of the throat and nasal fossae ; and the hair and eyebrows came off rapidly. He had taken iodine and sarsaparilla, under various forms, without success: occasionally there was a partial amendment; but he constantly relapsed when medicine was discontinued. The baths were used twelve times ; the gums rendered uneasy and swollen, but nothing more. Not a bad symptom accompanied the treatment; and the patient has had no fresh symptom for fifteen months. He took no internal medicine while under my care. The third bath checked the falling-off of the hair and eyebrows, which began rapidly to re-appear before the termination of the treat- ment. CASE X. Phagedena of the throat immediately arrested by the use of the mercurial vapour bath. A lady aged thirty-four had a superficial ulcera- tion of the throat, her husband at the same time suffering from the same disease. She had also large, pustular scabs on the legs; and her health 2* 18 NOTES AND CASES. was bad. She took the bi-chloride of mercury with sarsaparilla for some time, and apparently recovered. For six years she remained appar- ently well. In May, 1846, she began to suffer from cough, and emaciated a good deal; yet there was no physical sign of disease of the lungs. At this period, she began to complain of sore throat; and, on inspection, the soft palate had a swollen, thickened appearance. In this state she went into Wales; from whence she returned in a fortnight, her throat having got rapidly worse. There was now a small hole in the soft palate, with a white mar- gin ; and the whole of the throat was intensely red: there was also an ill-conditioned ulcer, with a white slough, in the left nostril, which threat- ened speedily to perforate the cartilage of the nose. The danger was imminent, and the state of the parts such as to lead me to fear a very serious and extensive mutilation; as the ulcers in the throat and nose had only been present two days, and already the soft palate- was eaten through in one place, and two other small ulcers threatened to perforate it in others. What was to be done in such a case ? There was no ordi- nary mode of treatment that could be brought to bear upon such a state of things in less than NOTES AND CASES. 19 three or four days; and by that time the mutila- tions would have been fearful, as disease was spreading with great rapidity. I determined to submit my patient to the action of the mercurial vapour bath ; in which she was placed, with the head immersed, for half an hour. This was re- peated on the next and succeeding days, when the gums became tender and swollen. The first bath arrested the whole of the ulcerative pro- cesses ; and on the third day the sloughs had fallen, and the ulcers looked healthy. Six more baths, at longer intervals, completed the cure; there not remaining, at the end of eighteen days, any apparent disease, except the perforation in the soft palate, which was small, and occasioned but little inconvenience. I directed this lady, who was of a weak habit of body, to take afterwards, for some time, the iodide of iron with a decoction of sarsaparilla. She has had no new symptoms. The cure has been permanent hitherto. CASE XI. Discharge from the urethra as a primary symptom; scaly blotches on the skin and a node on the forehead, as constitu- tional symptoms; perfect cure by the mercurial vapour bath. A gentleman consulted me respecting a lump on his forehead, which was red, tender, and pain- 20 NOTES AND CASES. fill. He had upon different parts of the body, and upon the head more particularly, some dry, scaly blotches; his hair came off rapidly. He had no primary venereal disease except a dis- charge from the urethra, concerning the nature of which there had been some difference of opinion. It clearly had not been gonorrhoea, and had resisted the usual remedies employed in that dis- ease. The discharge no longer existed when I saw the patient; and I could not find in the urethra, on examination, any trace of the pre- vious existence of an ulcer. I recommended the use of the baths, which were given every other day. I prescribed no internal medicines. At the end of three weeks all the symptoms had disappeared, and the hair was coming on rapidly. About a year after- wards this gentleman called on me, when passing through Birmingham, and told me he had not had any return of complaint. Loss of hair is one of the most common symp- toms of constitutional syphilis, and one which generally follows superficial sores: its nature is frequently deceptive, since, if it occur at that period when the hair is lost from natural causes, it is very apt to be overlooked altogether. I have seen several instances of this. On carefully examining a patient where this appears NOTES AND CASES. 21 the only symptom, we shall commonly find oth- ers to strengthen our diagnosis, if the loss of hair arises from venereal taint. One of the most common is an inordinately red condition of the nasal mucous membrane, with or without any in- creased or altered condition of the secretions of the parts. I consider the baths in such cases all but spe- cific, having never seen them fail. In almost every instance, one or two baths have arrested the fall of the hair; and before half a dozen have been taken, the hair almost invariably be- gins to grow and thicken. I have seen the eyebrows and whiskers, lost under these circumstances, quickly restored by the use of the baths. When it is important to produce a marked and immediate impression on the system, to ar- rest the progress of rapid ulceration, as in the various forms of phagedena, this plan of treat- ment cannot be estimated too highly. I have seen phagedena in the nose, throat, and on the penis, stopped at once by immersion in the baths for half or three-fourths of an hour. No other remedy can be brought to bear thus speedily upon diseases of this nature; and the mutilations and loss of substance which occur in such conditions take place while we are waiting for the action of remedies. 22 NOTES AND CASES. CASE XII. Phagedena of the urethra and glans penis immediately arrested by the bath. A gentleman contracted from a suspicious con- nection a discharge from his urethra, which in the commencement was supposed to be gonor- rhoea ; and for it was treated. The discharge did not yield to the remedies employed; and about ten days afterwards there appeared around the orifice of the urethra a white ring of ulceration, which spread rapidly. His surgeon became alarmed, and sent him to Birmingham to be placed under my care. When I first saw this case, there was an ulcer the size of a shilling surrounding the meatus, covered with a white slough; and the whole of the glans penis was intensely red, swollen, and shining. On separating the lips of the urethra, the ulcer was seen to extend some distance down the passage. I placed this patient immediately in the bath, and kept him there nearly an hour: he was directed afterwards to take a full dose of opium, to apply some decoction of poppies to the part, and to confine himself strictly to bed. On the next day the bath was repeated, and the same practice followed. On the third day the bath was again taken; by which time the NOTES AND CASES. 23 sloughs were separating and a healthy granular surface appeared underneath. There had been no extension of ulceration since the first bath. Nine baths completed this patient's cure in less than three weeks; and the medicines employed, as well as the local applica- tions, were of the simplest character. The muti- lation was very trivial. The under-surface of the urethra and glans penis was destroyed to a small extent; but from this the patient suffered very little inconvenience. This was a case of phagedenic ulceration, com- mencing, as it frequently does, in or at the orifice of the urethra, with the nature of which I was unhappily too familiar, having seen frightful mutilations from sores of this nature under ordi- nary treatment. The first case of secondary phagedena of the throat, in which I had employed the mercurial vapour bath, had been so successful, that I felt confident of success here; and the result justified my expectations. I reflected that rules of practice in cases of phagedena were quite unsettled; mercury being frequently employed as a last resource after the failure of other remedies. It is during this period of bringing remedies to bear upon the disease, and the uncertainty of what to use, that the mutilations so often witnessed in such diseases 24 NOTES AND CASES. occur. The remedies which I advocate are with- out risk, and may be employed from the very first appearance of phagedena, with every hope of success, even in the worst cases. case xni. Chronic enlargement of the testis, successfully treated by the mercurial vapour bath. A gentleman aged 26 contracted from a sus- picious connection superficial sores, which were situated on the glans and prepuce; he had, suc- ceeding to these, enlargement of the glands in the left groin, which were painful and tender, but after a time subsided without ulceration. Some time afterwards this gentleman married; and soon after the right testis began to feel heavy and uneasy, and gradually increased in size. When I was first consulted on this case, the testis was as large as a turkey's egg, hard but not painful or tender. I considered it of venereal origin: the patient was not of strumous habit or family; and, on examining him carefully, I found that his hair came off, and that the mucous membrane of the nostrils was intensely red, and that there was one or two spots of superficial ulceration. I recommended this patient to use the baths NOTES AND CASES. 25 every other day. After the fifth bath the gums were a little uneasy, and generally, red and ele- vated. The patient took five more baths at longer intervals; and the cure was completed in six weeks, the patient pursuing his usual avocations during the whole period of treatment. There can be no question as to the venereal origin of this disease of the testis. The history and concomitant constitutional symptoms place the matter beyond doubt. I consider the con- dition of the mucous membrane of the nostrils very important, as a test of the nature of many forms of constitutional disease, about the true character of which there might otherwise be some degree of uncertainty. If this disease of the testis had occurred with- out any other symptom, there might have been a doubt as to its true nature; but co-existing with loss of hair, in a young man, and with an in- flamed and ulcerated condition of the nostrils, we cannot hesitate to pronounce it syphilitic. The ordinary treatment of such a disease would have been either a long, uncertain treat- ment by iodine, or a more certain mercurial course, that would have confined the patient to the house, and most likely to his bed, for an un- certain period. The baths were perfectly successful in a short 8 26 NOTES AND CASES. time, without one hour's confinement or hin- derance from business, and with benefit rather than injury to the general health, — a risk that must be always run under the ordinary forms of mercurial treatment. case xrv. Regular primary sore with induration, succeeded by pustular disease of the skin, and impaired general health; rapid cure by the mercurial vapour bath. A young gentleman contracted a chancre, the knowledge of which, from certain family reasons and fears, he kept to himself. Several weeks afterwards, I first saw him; and he had then undergone no treatment. There was a consid- erable induration between the glans and pre- puce, on the summit of which was the primary sore, not yet healed. The skin was covered with a well-marked pus- tular eruption. The pustules were in various stages, — some recent, and others broken and covered with eschars; and others again had degenerated into open sores. He was pale and emaciated, and his general health much impaired by disease, which had now existed fourteen or fifteen weeks. His state of health was such as to entirely preclude a mercurial course, either by mouth or by friction. NOTES AND CASES. 27 I recommended the use of the baths; and directed him to take half a grain of the extract of opium three times a day, and some warm de- coction of sarsaparilla night and morning. The open ulcers were dressed with a weak black wash, covered with oiled-silk, and bandaged. This patient took fourteen baths. At the end of a month he was well, had recovered his health and strength, and his disease was cured. He has had no fresh venereal symptoms for some years. In this case there was both a primary and a secondary disease to combat, — a primary, indu- rated, venereal sore, yet open, when the constitu- tional or secondary symptoms appeared; and these occurring in a constitution originally deli- cate, and still more impaired by syphilis. It is in such a class of cases, exceedingly common, that the application of the moist mercurial va- pour is invaluable, perfectly harmless in its appli- cation, and all but certain in its effects. case xv. Pustular disease of the skin; ulcers of the throat; severe noc- turnal pains in the hips, legs, and head; impaired general health ; rapid cure by the mercurial vapour bath. A young man aged twenty-four was sent to me, suffering from a formidable skin-disease of 28 NOTES AND CASES. venereal origin. He had, some twelve months previously, what seemed to be a regular primary sore, for which he had taken mercury to saliva- tion. Under this treatment the ulcer closed; but before it was quite well he became covered with a well-marked eruption of venereal pus- tules. The disease had run the regular course of all pustular venereal eruptions. The pustules were in some places recent, in others, covered with dark-brown crusts: the crusts had fallen off in other situations, and left foul, dirty, irregular sores underneath. In one or two places the ul- cers had healed, and left deep-red depressions in the skin. In addition to the skin-disease, there was an ulcer on each tonsil. The patient was pallid, weak, and emaciated, and so crippled with pains in the hips and shin-bones, that he could not walk without a crutch and a stick; and he got up-stairs with the greatest difficulty. He had undergone a variety of treatment without success. This patient was directed to take the baths every other day. I prescribed for him small doses of opium and camphor, and the de- coction of guaiacum to be drank warm morning and evening. The ulcers were dressed as in the last case. After the third bath, this patient walked up- stairs without assistance ; and his pains were all NOTES AND CASES. 29 but gone. In less than six weeks he was cured, had gained flesh considerably, and his appetite and health were good. He has not been con- fined an hour by his treatment; and he has never relapsed, —a circumstance so common after ordinary mercurial treatments. He had tried the common vapour bath, before coming to me, with very little benefit. The mercurial vapour bath is very efficacious in removing those pains compounded of syphilis and mercury, which have been produced by or succeeded to internal mercurial courses, pre- scribed for the cure of either primary or consti- tutional syphilis. The detail of the last case illustrates this posi- tion. I can bring forward another in support of it. CASE XVI. Severe pains in the limbs succeeding to a primary and secondary venereal disease ; treated by large quantities of mercury in- ternally ; radical and quick cure by the baths. A young gentleman contracted syphilis in a seaport abroad, and was treated by large quanti- ties of mercury by the surgeon of his vessel. His primary disease was cured: but a pustular eruption subsequently made its appearance ; and the glands of the groin on both sides became enlarged and tender. a* 30 NOTES AND CASES. Before he returned to England, the skin-dis- ease had nearly disappeared ; but there remained copper-colored depressions in the skin, marking the situations where the pustules had been; and these places were at times much inflamed, and threatened to ulcerate again. The worst symptoms under which this patient labored were pains in the limbs and different parts of the body, due either to exposure during his mercurial course, or to a combination of the remedy and disease yet remaining in the system. The pains harassed him severely; and an appre- hension of a further outbreak of disease rendered his life wretched. I directed the baths to be used every other day, gave him small doses of opium, and directed him to drink some warm decoction of guaiacum night and morning. He got rapidly well; in a few weeks the de- pressions were no longer discolored, the pains had left him, and the glands in the groin were reduced in size. This patient was radically cured: he has never relapsed. It sometimes happens, I may say frequently, that patients who had passed through the whole ordinary routine of treatment for the cure of syphilis, and have been subjected to mercurial courses in different ways three or four times, NOTES AND CASES. 31 apply for relief for symptoms that still remain uncured, or which have appeared after they had believed themselves perfectly safe. These symptoms are very commonly confined to the epidermis and its appendages, and make their appearance in the form of dry scales on the palms of the hands, from which the epidermis ultimately peels off; sometimes the nails crack and break ; or dry shining scales appear about the matrix of the nails themselves. Sometimes there are dry, white patches on different parts of the skin; and with these ap- pearances there is commonly a dryness of the throat and nostrils, and the hair and whiskers almost invariably get thin. There are sometimes, co-existing with these symptoms, pains of various kinds, both in the bones and soft parts. In such states, after almost all varieties of internal remedies have been used, and yet disease remains, the baths become of the greatest utility, and rarely fail of work- ing a speedy and permanent cure. I bring for- ward one or two cases in illustration. 32 NOTES AND CASES. CASE XVII. A regular primary sore; treatment by friction; skin and throat disease as secondary affections; subsequent peeling of the epidermis from the palms of the hands. A gentleman contracted what appeared to have been a regular primary venereal ulcer; for which he took mercury by the mouth, and also used it by friction. He was salivated by this treatment. The ulcer was some time in healing; and, before it was quite closed, he became cov- ered with red shining patches, and had a sore throat. For these symptoms he underwent a further mercurial treatment. For some time he fancied himself well; though occasionally would break out a scaly blotch on various parts of the body. To these he paid little attention. At a later period, the palms of the hands in places appeared as though they had been blistered; the epidermis was raised as by a blister, and then peeled off, spreading in circles exactly like fairy rings. Both hands were affected. He was directed to use the mercurial vapour bath every other day for half an hour, and to drink some warm decoction of guaiacum. There was no complaint remaining at the end of six weeks; and there has been no relapse. He has remained without any fresh symptoms for nearly four years. NOTES AND CASES. 33 CASE XVIII. Superficial primary ulcers in the commencement; scaly blotches on the skin, superficial inflammation and ulceration of the throat, peeling the epidermis from the palms of the hands, scaly condition of the nails, loss of hair, eyebrows, and whis- kers ; cure by the baths. A gentleman consulted me for superficial ulceration of the throat, which he considered due to venereal disease, and which doubtless was so, for it was accompanied by other symptoms which could not be mistaken. The membrane of the nostrils was intensely red; there were a few scaly spots on the body: the epidermis peeled off in white dry patches from the palms of the hands; and the same scurvy condition ex- isted around the roots of the nails. The eye- brows and whiskers fell from the least touch. This patient had taken mercury in various ways; his disease from time to time abated; but he constantly relapsed, and the symptoms I have detailed had been in existence nine months. The primary disease had consisted of three or four superficial sores which he had been assured were not venereal. As this affection was perfectly chronic and not making any rapid advances, I directed the baths to be used only twice a week, and during their use a teacupful of the warm decoction of guaia- cum night and morning. 34 NOTES AND CASES. In six weeks this patient got well, and after many months had not had any fresh symptoms. I shall speak now of one or two cases of a dif- ferent kind to any previously detailed, namely, the indurations which are left after, or succeed to, the healing of primary venereal ulcers, and in which I have seen the "moist mercurial vapour " succeed after the failure of other modes of treatment pursued for long periods without success. CASE XIX. Superficial primary sores; secondary disease of the skin under the form of shining, red, copper-colored patches ; subsequent- ly a large induration, as hard as cartilage, occupying the site of the original ulcers. A gentleman contracted some superficial sores on the penis, which he was assured were not venereal and would not be followed by constitu- tional symptoms. They healed, and the patient went abroad. On getting up one morning, he perceived his skin covered with red, shining patches; being alarmed, he immediately set off for London, where he was told the eruption was venereal, particularly as there accompanied it an ulcer on each tonsil. He was put upon a mer- curial course; and the eruption after a time got well. About this time an induration made its appearance in the situation of the original ulcers, NOTES AND CASES. 35 and kept increasing till it was as large as a small walnut. Notwithstanding the continuance of the mercury by the mouth, the induration re- mained stationary; and at this period the patient placed himself under my care. There was a large induration, having the appearance and feeling of cartilage, occupying the place of the original sore. It did not seem a general thick- ening of parts, but like a piece of cartilage in and under the skin. Mercury under two or three forms had failed to remove this. I placed my patient under the use of the mercurial vapour bath, which was applied three times a week for one month, half an hour at each sitting. He drank a little warm decoction of guaiacum twice a day, and occasionally took an aperient. A month's treatment was sufficient to remove the induration; and, as no other symptom of syphilis remained, the baths were discontinued. There has been no relapse, a very common cir- cumstance with indurations of this character, which I have known frequently return after the discontinuance of mercurial treatment by the mouth. The indurations which remain after the heal- ing of ulcers of suspicious character, or which come on after they have healed, as they often do, are among the most obstinate symptoms with which the surgeons have to contend. 36 NOTES AND CASES. In themselves they are a sure indication of constitutional taint; and are either, if left to themselves, followed by secondary diseases of a formidable character, or, ulcerating from slight causes of irritation, they give place to rapidly- spreading and destructive sores. They are exceedingly rebellious, and some- times remain after the pursuance of various forms of constitutional treatment for long peri- ods. Local treatment by frictions soon renders them painful, and disposes them to open. In this form of disease, the mercurial vapour is very valuable, though it does not act with the rapidity it generally does in affections of the skin, throat, or nose. case xx. Regular primary sore on the frsenum; mercurial treatment, copper-colored scaly eruption on the back; superficial ulcer- ation of the tonsils; ulceration of the mucous membrane of the nose; discharge of pus, blood, and thick crusts; pains in the hip and shin bones; second mercurial treatment; failure of success; speedy cure by the baths. A gentleman contracted a sore on the frse- num, which healed under a long mercurial course, during which he took one hundred five- grain mercurial pills. He fancied himself well. Three months afterwards, a copper-colored scaly eruption appeared on the back; the tonsils NOTES AND CASES. 37 became enlarged, and their surface was ulcer- ated ; he had a discharge of quantities of hard mucus from the back of the throat, which appeared to come from the nose; and the nos- trils also gave passage to substances of the same character, mixed with matter and blood. His nights became bad; and he was tormented with severe pains in the hips and legs, which pre- vented him from sleeping. For these symptoms, a second surgeon was consulted, who recommended a blue-pill three times a day, and some other medicines. The mouth was kept sore for three months, during which period the patient took one hundred and forty pills. Under this treatment the ulcer on the back disappeared; but the other symptoms in the nose and throat were worse, and the pains in the hips and legs increased in intensity. This patient now came to me from a distance, and placed himself under my care. At this period the tonsils were large, and on each side covered with superficial, ash-colored ulcerations; the mucous membrane of the nostrils was in- tensely red, and covered also with ash-colored spots. No doubt existed of mischief higher up the nose, as the voice was thick, and the breath- ing through the nose obstructed. The patient had now suffered from disease and remedy for seven months. He was pale and emaciated, ana 4 38 NOTES AND CASES. much depressed in spirits. I placed him under the use of the baths, gave him small doses of the extract of opium, and recommended him to drink half a pint of the warm decoction of guaia- cum morning and evening. The nose and throat were better after the first bath; and at the end of five weeks, the baths having been taken every other day, this gentleman had no symptom of disease remaining, had lost his pains, and recovered his strength and spirits. This case is one of the many cases that might be recorded as an instance of the failure of mer- cury given by the mouth, as in the ordinary mode in which it is administered. The quantity given is generally too large; and the patient is not placed in circumstances, whilst taking it, which are favorable to its action. A peculiar class of diseases are by such treatment created, which are compounded of mercury and syphilis, and which are very difficult to cure. These diseases are generally produced by the indiscriminate use of mercury in the treatment of the primary sore. If mercury be required for such a purpose, it must be used according to the plan already laid down. Primary ulcers so treated are never followed by induration; salivation or ulceration of the mouth are never produced; and secondary symptoms very rarely follow. NOTES AND CASES. 39 CASE XXI. Superficial ulceration of the throat and nose; alteration of voice; relapses under internal mercurial treatment for four months ; speedy cure by the baths. A gentleman contracted several superficial sores on the penis, which were attended with considerable inflammation. They healed without induration of the cica- trix ; but as the patient had not been seen by me at this period, I do not know what treatment was adopted. About two months after this apparent cure, his throat became dry, particularly the day after any extra indulgence, such as a dinner-party. To this succeeded ulceration; several small ash- colored spots made their appearance on each tonsil; the nose became dry and uncomfortable; he could not breathe through it easily; it appeared obstructed; and the voice was hoarse and unpleasant. The hair came off in small quantities; and the skin was continually disposed to crack and in- flame on the site of the original sores. This patient had taken mercury internally, at intervals, for six months; but on discontinuing the remedy, the symptoms always returned; and in addition, the medicine, under any form, after a time, so disordered his stomach, that he could 40 NOTES AND CASES. not take it long enough to have any real influ- ence over his disease. No other treatment was adopted in this case except the baths: they were used every other day for three weeks; the head was immersed at intervals during the time that the patient remained in the bath, — a prac- tice which ought always to be followed where the hair comes off, and in diseases of the throat and nose. The gums were elevated, swollen, and red, but nothing more. The cure was complete. In six months there had not been the slightest relapse. case xxn. Pustular skin-disease; induration of the glands in the groin on the left side to a great extent; ulcer and induration on the penis; severe pains in the head and legs; tenderness of the bones of the legs; failure of internal mercurial treat- ment pursued for four months; cure by the baths and opium. A gentleman entered my consultation-room one morning, looking pale and emaciated, and walking with a stick and a crutch. He gave the following history of his disease: Ten months previously, he had contracted a sore, which was situated on the lower part of the glans penis, near the fraenum. For the cure of this, the primary, or for the prevention of. the NOTES AND CASES. 41 constitutional or secondary, disease, he had taken mercury by the mouth to some extent, and for a long period. Whilst taking this medicine, about fifty or sixty small pustules broke out in different parts of the body, chiefly on the arms, legs, and head. His throat about this period became sore; and he had continual discharge from his nose. For these symptoms he was recommended mercury internally in another form. The throat improved, but did not get quite well; some of the pus- tules also dried up and disappeared, but were succeeded by others. The general health, pre- viously good, now began to fail; the appetite went; the patient got thin, and suffered from night-sweats; he was also tormented during the night with severe pains in the legs and head; those in the ankles and hips at length became so severe, that he could not walk without the assist- ance of a stick and a crutch; and yet, ten months previously, the patient had been in good health, and was only now thirty-two years of age. On examination, I found a small fissure near the fraenum, surrounded by considerable indura- tion ; the glands in the left groin were enlarged, hard, and tender, the whole mass as large as a turkey's egg. The throat was red, and covered with four or five superficial, ill-conditioned 4* 42 NOTES AND CASES. ulcers; the nostrils were in the same state; on both sides there were ulcers; the voice was hoarse, and there was constantly expectorated a quantity of thick, adhesive phlegm. There were from twenty to thirty fresh pustules, of small size, on different parts of the body. The general health was broken up ; the appe- tite bad; there was no rest; the tongue was foul, the gums spongy, and the breath fetid. This patient was very much emaciated; and the perspirations in the night were most profuse, bed and body-linen being completely saturated. I looked with considerable anxiety on this case: the local symptoms, bad as they were, I did not fear; these were easily and certainly manageable; but the general health of this poor gentleman was so much impaired, that I feared for the result. He was doubly poisoned, first by syphilis, and secondly by mercury, very proba- bly acting upon a system peculiarly inimical to the use of it, as the general state of health showed; for I never saw such symptoms pro- duced by syphilis, where mercury had not been given for its cure. I ordered this patient to keep his room, and prescribed for him a strong decoction of sarsaparilla, with beef-tea; and recommended him to take, in addition, seven grains of powdered guaiacum, two of opium, and three of camphor, night and morning. The NOTES AND CASES. 43 baths were sent to his lodgings, and he took one on the third day after I first saw him. The bath produced some exhaustion; but he slept well that night without perspiration, and the next day was better. On the third day, again, the bath was repeated with still further improvement; the pustules began to dry up, and the strength was a little improved. Still the appetite continued bad, and the tongue foul; the pains in the limbs still trouble- some, though abated. The baths were repeated every third day, and the medicines were continued. No alteration was made in the treatment; as the patient gained strength, the baths were made stronger, and continued for a longer period. This patient remained under my care two months, at the end of which period he left me in tolerable health, which has continued to im- prove. He has had no relapse. I do not think it would have been possible to have cured this patient without the moist mercurial vapour. The combination of the vapour bath and the mercurial fume is in such cases invaluable; and whenever the patient is able to support himself on a chair, they may be used with perfect safety and without risk; the strength and heat of the bath being regulated according to the particu- lar circumstances of the case. 44 NOTES AND CASES. It is in such states that ulcerations, generally fatal under ordinary treatments, occur in the larnyx, and low down in the pharynx. I have seen, in the earlier years of my prac- tice, several patients die from these ulcerations, who, I firmly believe, would have been saved under the plan I now recommend. Where ulcer- ations are constitutional, local remedies have little influence over them, except for the moment. Mercury given internally is in such cases almost altogether forbidden by the con- dition of the general health of the patient. Under the plan I here recommend, it may be administered in perfect safety, and is almost the only hope for the patient. case xxm. Discharge from the urethra and excoriations, for primary symp- toms ; subsequently, spots on the body, loss of hair and voice, ulceration of the throat and nose; speedy cure by the baths, after a prolonged mercurial treatment with par- tial success. A gentleman contracted from the same con- nection a discharge from the urethra, and super- ficial sores upon the penis, which healed in a few weeks with very simple treatment. Some time afterwards he experienced a dry- ness and a soreness in the throat when he swal- lowed; and his voice became hoarse: these NOTES AND CASES. 45 symptoms increased till at length the voice was almost altogether lost, and he merely spoke in a whisper. He consulted a surgeon, who pro- nounced the disease in the throat to be syphil- itic, and recommended mercury to be taken by the mouth, with the decoction of sarsaparilla. These medicines were continued for some time with partial benefit; but on their discon- tinuance the disease in the throat became worse, while the voice had been hardly benefited at all. The patient now, by the advice of his surgeon, who resided at a distance, placed himself under my care. At this period the whole of the throat had a deep-red appearance; the tonsils were much enlarged and tender externally, and their sur- face covered with superficial ash-colored ulcers, one or two of these ulcers on each side being deeper than the rest. The uvula was elongated, thickened, and had a tuberose appearance; on its extremity were situated two or three small ulcers similar to those on the tonsils; there was a difficulty of breathing through the nose, the mucous membrane of which was intensely red, and superficially ulcerated. There were a few small pustules on the body, and one or two on the head; the hair was thinning fast. The general health was good. The patient took the baths every other day with the head 46 NOTES AND CASES. immersed; he was directed to take also some decoction of guaiacum night and morning; the dose in the evening warm on getting into bed. The gums became very tender after the fifth bath, and his condition was much amended by this time: the spots had disappeared from the skin, and the hair no longer came off; the red- ness was gone from the throat, and the voice was much improved. At the end of three weeks nearly all the symptoms had vanished. The patient still remained a little hoarse, and the uvula had not quite assumed its natural appear- ance. I heard from this gentleman a month afterwards, to say he was quite well. This is another example of that numerous class of constitutional venereal diseases which follow superficial primary sores, the most marked symptoms of which are superficial redness and ulceration of the throat and nose, with spots on the skin varying in their pathological characters, and loss of hair. These symptoms are so constantly grouped together in such cases, that I never see one with- out looking for the others. I believe where the hair comes off, and the disease of the skin affects its surface only, the mucous membrane of the nose will be found always affected as well as the throat. These symptoms always yield with extraor- NOTES AND CASES. 47 dinary rapidity to the use of the moist mercurial vapour, whether this be associated with med- icines taken internally or not. In some cases the cure has been expedited by the decoction of sarsaparilla and guaiacum; but I never pre- scribe medicines internally in such cases, if the patient can take the baths. CASE XXIV. Ulceration of the throat; large single pustular blotches on dif- ferent parts of the body at different times; ulcers of the left nostril; cure by the baths. A respectable female was unfortunately dis- eased by her husband: I know no more of the pri- mary disease, than that she had a discharge upon her, and some superficial sores which soon healed. Her husband and herself had both afterwards ulceration of the throat, which was very rebel- lious to treatment, but at length healed under a mercurial course. Some months afterwards a large pustule made its appearance on the thigh, and on the arm; these soon dried up, and were covered with large irregular black-looking crusts, which on falling off left a foul, excavated ulcer beneath. These after some time healed, leaving a deep- red depression in the skin. At a subsequent period the left nostril became dry and rather painful; and on examination, there was found a 48 NOTES AND CASES. large ulcer, which was covered with a white, thick slough; the remainder of the membrane of the nostril was of a deep dark-red color, which color pervaded also the other nostril; but the latter was not ulcerated. The ulceration was spreading rapidly, and, the patient believed, had only been in existence about two days. When I first saw this ulcer, it only affected the mucous membrane; but the edges were so intensely red, and the disease was proceeding with so much rapidity, that I apprehended a speedy perforation of the carti- lage, having more than once seen the soft palate eaten through by an ulcer of this kind in twenty- four hours. I mentioned my fears to my patient, and told her I knew of but one way of speedily, if not immediately, arresting her disease, supposing her case should be as fortunate as some others I had seen submitted to a similar plan of treat- ment ; and this was by means of the moist mercu- rial vapour, which I advised her instantly to use. The head was immersed in the bath, and the patient kept in for half an hour. The vapour produced, as it sometimes does, a great discharge from the nose. On the next day the redness of the nose was less. The bath was again repeated on this day in the same manner, and for the same time. NOTES AND CASES. 49 On the third day the slough had separated; there was very little redness of the nose, and the ulcer looked healthy and disposed to heal. The baths were now continued every other day; and by the time the eighth had been taken the ulcer had healed, and very little complaint remained. Indeed, all that could be said was, that the mem- brane of the nostril was slightly more red than it ought to be in a perfectly healthy state. This patient did not take any medicine during the time she was using the vapour, the gums being very tender after the fourth bath. She was directed to live upon beef-tea, milk, eggs, and cocoa ; and her general health, which was before bad, became good; she got fat, and has not relapsed. CASE XXV. Primary sores treated by an internal mercurial course; after- wards violent pains in the head, spots on the skin, ulceration of the nose. A gentleman contracted a sore on the penis, for the cure of which he was directed to take mercury internally: this was done to some extent; and after a time the sore healed, leaving a thickened condition of the prepuce upon which it was situated. Before the termination of the mercurial course, he began to suffer from violent pains in the 5 50 NOTES AND CASES, head, which were at times so severe as to induce delirium. The mercury was now given up : the pains became less, but did not leave him; and, in addition, the hips and legs were affected with similar pains; the nose became dry, and dis- charged from time to time, hard, foul crusts; and there was also a few scaly blotches on differ- ent parts of the skin. The patient now placed himself under my care; and I recommended to him the moist mer- curial vapour, and prescribed for him small doses of opium and a decoction of the woods to be drank warm night and morning. At this period there was superficial ulceration in each nostril, and the membrane generally was intensely red. The patient was in an agony of distress about his nose, fancying it would fall in, in spite of all my assurances that there was no disease, either of the cartilages or bones. His monomania was most distressing: it rendered his life miserable. After a few weeks' treatment the symptoms yielded, the pains were gone, and the ulceration of the nose had healed; though it still remained red, and occasionally discharged a lump of hard mucus. This gentleman had no confidence in any treatment except the baths; and, on two occa- sions, fancying himself worse, travelled from the North of Scotland to have them administered NOTES AND CASES. 51 under my care. In about three months from the time of my first seeing this patient, he was per- fectly well, did not present a trace of venereal taint, and his mind had become more tranquil; he had confidence in the permanence of his cure, and felt satisfied that his nose was no longer in danger. CASE XXVI. Chronic disease of the throat, and loss of hair; failure of or- dinary treatments; cure by the baths. A commercial gentleman aged thirty-four was sent to me by his surgeon for my opinion re- specting his throat, which had been affected with syphilitic ulceration for several months, and had resisted the ordinary means of cure, or re- lapsed when medicines were discontinued. This patient had suffered originally from sev- eral small superficial sores on the penis; some time after the healing of which his throat became dry and inflamed, and his hair began to come off. When I first saw this gentleman, the throat was intensely red, the tonsils enlarged, and their surface covered with several ash-colored ulcers; the membrane of the nostrils was also very red, and he could not breathe easily through them; his sense of smell was very much impaired; and 52 NOTES AND CASES. he had entirely lost his hair, and was obliged to wear a wig. I could not learn the exact mode of treatment that had been employed, but his mouth had been made sore two or three times by mercury. He was directed to use the baths every other day, and to take very small doses of the bichloride of mercury, not exceeding the twelfth of a grain for a dose, with some decoc- tion of guaiacum and an opiate at night. This plan was pursued for a month, at the end of which period the throat was well, and he has never again relapsed. It is a singular fact, and one which I have verified in some hundreds of cases, that the same medicines which have been unsuccessful before the use of the baths will speedily act beneficially when employed in conjunction with them, though given in very much smaller doses; and the treatment which has been followed by repeated relapses without the baths, becomes permanently efficacious when employed with them. CASE XXVII. Superficial primary sores; inflammation and enlargement of the glands in the left groin; mercurial frictions, &c, with- out success; cure by mercurial frictions and the baths. A gentleman consulted me respecting some abrasions on the penis, which he had perceived NOTES AND CASES. 53 after a suspicious intercourse. They quickly healed; but after a hard day's hunting, he per- ceived a tenderness in the left groin, and the next day walked with difficulty. Being at that time in the North of England, he consulted a surgeon, who told him he was suffering from bubo, and a mercurial course was necessary. He took mercury by the mouth, and rubbed mercurial ointment into the thighs, till the mouth was sore. The glands in the groin continued to enlarge, and it appeared probable they would suppurate. Getting alarmed about his state, he now placed himself under my care. At this period he could not walk; the mass of inflamed glands were as large as a turkey's egg, red at the summit, exceedingly painful and tender; and, from a feeling of fluctuation given to the finger, it appeared probable that matter had already formed. I had, however, so repeatedly seen surgeons deceived as to the presence of matter in cases like the present, and protracted diseases pro- duced by incisions, that I abstained from making a puncture in this case; and believe that the lan- cet in all cases of this description should be used with extreme caution. The patient was much emaciated, and worn out with pain, want of rest, and night-perspira- tions. 6* 54 NOTES AND OASES. I applied a blister over the bubo, gave him an opiate at bed-time, and, after two or three days' rest, recommended that he should commence the use of the baths every other day, and rub in every night half a scruple of mercurial oint- ment. This patient left me well in five weeks. He had pursued mercurial treatment for three months previously without the slightest benefit; not the least impression had been made upon his dis- ease. This gentleman has remained perfectly well; it is fifteen months since he was under my care, and he has had no relapse of any kind. It is remarkable what small quantities of mercury are required internally to combat very formida- ble diseases, when this treatment is given in con- junction with the baths. Mercurial treatments so conducted are never attended with mischief; and salivation or ulcer- ation of the mouth is never produced at least with the most ordinary care; whilst the disease as certainly yields. I will now detail another case where mercury had been taken at intervals for five months for an induration succeeding to the healing of a venereal sore; whilst the patient got well, placed under the same circumstances, when he used similar remedies, and took the baths in conjunc- tion with them. NOTES AND CASES. 55 CASE XXVIII. Superficial primary sores, succeeded by extensive indurations; spots on the skin, node on the arm; relapse, after an appar- ent cure by internal treatment alone; permanent cure by the baths. A gentleman contracted three or four super- ficial sores, which quickly healed; but soon after there appeared on the substance of the prepuce an induration which surrounded the upper por- tion of the penis. Under the advice of his sur- geon, he took mercury internally, and also used it by friction; and under this treatment, contin- ued for three months, the induration disappeared. About a fortnight after the discontinuance of the medicines, the induration began to re-appear, and in a few days was harder and larger than before. The patient now recommenced the use of medicines; but after having taken them nearly four months, the induration still remained the same; and the periostium of the left ulnar became inflamed, and a few scaly spots made their appearance on different parts of the body. The patient, at this period, came under my care ; the induration, the principal feature of the disease, was like a piece of cartilage under the skin; but the whole of the upper portion of the prepuce was full and red, and the induration was tender to the touch. I recommended the 56 NOTES AND CASES. baths every other day, and advised the medi- cines to be continued, which consisted of a solu- tion of the bi-chloride of mercury in a decoction of sarsaparilla. The spots soon disappeared, and were seen no more; the tenderness of the arm next yielded; the induration was longer in giving way; after the third bath, however, it was manifestly softer and less tender, but had not entirely disappeared for ten weeks, the treatment having been from time to time interrupted by the business avoca- tions of the patient. I do not believe it would have been possible to have cured this patient by internal medicines alone. He had continued them for three months in the first instance before the induration yielded; and it was clear that the constitutional taint still remained, by the return of the disease, the moment the remedies were suspended, with the addition of fresh symptoms. In the second instance the internal remedies were of no avail, although continued for nearly four months. Yet the disease yielded in ten weeks, when the baths were used, and the same medicines were taken with them. There has been no relapse after the second treatment, and the cure has been perfect. NOTES AND CASES. 57 CASE XXIX. Constitutional syphilis of two-years' duration; enlargement of the left testis ; nocturnal pains; night perspiration; emaci- ation ; thickening of the bones of the nose on the left side; ulcer of the septum of the nose, and obstruction of the naso-lachrymal canal; failure of ordinary treatments pursued for two years; cure by the vapour in four months, with the exception of one symptom. A delicate-looking young man came to request my opinion respecting the symptoms under which he labored, which had harassed him, with little variation, for the last two years. Latterly he had become worse; and the com- plaint in his nose rendered him very anxious, more especially as his surgeon had given him a very unfavorable opinion with regard to its ter- mination. About two years and a half ago he had con- tracted superficial sores upon the penis, which had healed under ordinary treatment, and for which he had taken mercury by the mouth, though I could not learn to what extent. About two years ago, he observed a continual discharge from the nose; and this was sometimes mixed with matter, and occasionally with blood; at intervals of two or three days or a week, there came from his nose hard crusts of dry mucus, bearing the shape of the spongy bones of the nose, and having, on the surface that had 58 NOTES AND CASES. been adherent, spots of pus, as though they had been thrown off from an ulcerated surface. These symptoms were chiefly confined to the left nos- tril ; and the bones of the nose on this side were considerably larger than those on the right, and tender to the touch. After these symptoms had continued for some months, the eye on the same side began to water, and the tears from time to time flowed over the cheek. On pressing the lachrymal sac, the tears, with occasionally a few drops of pus, could be pressed through the puncta. About this period, the bones of the legs became very painful, particularly at night when in bed; the left testicle began to enlarge with- out pain; night perspirations set in, the appe- tite was lost, and the general health became altogether impaired and bad. At this time the patient came under my care. He was then pale and emaciated: on examination of the nose, I discovered a dirty-looking superficial ulcer of the septum, and of the inferior turbinated bone on the left side; the membrane of the nostrils on both sides was intensely red; the patient spoke thick, and was at times hoarse, doubtless resulting from the condition of the nose. The bones of the nose and cheek, on the left side were enlarged, tender to the touch, and NOTES AND CASES. 59 the skin was slightly red over these parts. The throat was dry and uncomfortable occasionally, though neither inflamed nor ulcerated. I directed this patient to use the vapour, with the head immersed.; to continue it for half an hour, using three drams of the binoxide of mercury for each bath, which was taken two days together, and then omitted for one. At the same time, I recommended ten grains of the compound powder of ipecacuanha, with as much guaiacum, to be taken night and morning; and twice in the day a glass of the warm decoction of sarsaparilla, with five grains of the hydrio- date of potass., and twenty minims of the wine of colchicum. At the end of a fortnight, the improvement was very marked: the pains were gone; perspiration had ceased; the patient could eat; and the swelling of the testicle was nearly reduced; the tenderness had disappeared from the bones of the nose, and the fulness was much less. There remained, however, still some dis- charge from the nose, and the tears still ran over the cheek. The treatment was continued at intervals for three months; and, at the end of this time, the patient appeared in very good health; he had not a symptom of constitutional taint, unless the partial obstruction of the nasal duct, was to be considered as such; and this canal was evidently assuming, though slowly, its 60 NOTES AND CASES. natural condition. I have already stated that an inflamed and ulcerated condition of the mucous membrane of the passages of the nose is a very common symptom of constitutional syphilitic taint; and I have seen a number of cases where it has continued for a very long period of time without extending farther than the mucous membrane lining the nose; though in other instances its advances are more rapid, and its consequences more serious. In some instances, syphilitic affections of the nose are limited to a mere chronic inflammation of the membrane lining the meati, and are accompanied by dis- charges of thickened, dry, mucous crusts, having the shape and appearance of the bones them- selves ; and this I have known to continue for many years without getting much worse. On examining the nostrils of such patients, they are found to be intensely red, covered with mucous crusts, and the membrane in places slightly ulcerated. The previous history of the patient, the co-existence of some other symptom of vene- real taint, and the effects of appropriate treat- ment, leave no doubt as to the nature of such diseases. In other instances, more serious forms of ulcer- ation are present, and these ulcers assume either a chronic or an acute character. I have seen two instances, in one of which there had been a NOTES AND CASES. 61 constitutional taint for six years, and in the other for nine, and the nostrils affected the whole period; where an acute ulcer has perforated the septum in a few days. In some rarer cases, the chronic inflammation of the nose is not limited to the meati, but extends from the inferior one up to the nasal duct, and partially or completely obliterates it. I have seen three cases of this kind, one of which had existed several years; and the dis- charge of tears over the cheek coincided with that of the peculiar syphilitic crusts from the nose, on the side on which the obliteration of the duct existed. This is a probable, and, I believe, a common cause of that disease known as " stillicidium lachrymarum." CASE xxx. Superficial primary sore, followed by bubo; ordinary treatment; constitutional taint five months afterwards, in the shape of copper-colored blotches on the face, head, and back, with loss of hair, superficial disease of the throat; the disease sta- tionary under ordinary treatment six months; cure by the vapour in nine weeks. A gentleman contracted, in February, 1847, a superficial sore, which was succeeded by a bubo which did not suppurate ; the patient was treated in the ordinary manner; and he fancied for three or four months that he was quite well. 6 62 NOTES AND CASES. In June of the same year he had a superficial ulceration of the throat; and about the same time he perceived a large copper-colored or dark-brown spot on the forehead, just above the root of the nose ; another soon appeared on the side of the nose, one on the right cheek, and several of smaller character on different parts of the face, head, and back. The hair at this time came off in large quan- tities when brushed or combed, and soon became very thin. These spots were neither preceded, accompanied, nor followed, by inflammation, ulceration, or desquamation of the skin; and they are to be distinguished from that kind of discoloration of a venereal character which is seated in the cicatrix of a constitutional ulcer of the skin after it has healed, which cicatrix is always depressed in the- substance of the skin itself, and of which I have already related some examples. From June to September this patient under- went various kinds of treatment for the spots, which continued stationary, or rather increased during this period; and early in October he placed himself under my care. At this time the spots were dark-brown discolorations, nearly circular, unaccompanied by pain, uneasiness, or inflammation of any kind, and did not disap- pear under pressure. He had evidently been NOTES AND CASES. 63 submitted to a mercurial course; as there were two or three ulcers in the mouth, the gums were spongy, and bled from the slightest fric- tion, and there was strong mercurial fetor of the breath. I directed this gentleman to use the vapour twice a week, with half an ounce of the bi-sulphuret for each fumigation. He also took a tumbler of the compound de- coction of guaiacum twice a day, with two drops of the liquor potassa arsenitis. The treatment was not varied; at the end of nine weeks the spots could not be perceived, and the general health had much improved. This is a very rare form of constitutional vene- real taint, and is to be distinguished from all other varieties of syphilitic disease of the skin. Cazenave corroborates from his experience the rarity of its occurrence, and mentions cases in which it has been confounded with other cutaneous affections. These copper discolorations, however, of vene- real origin, due to an altered condition of the pigment of the skin, almost invariably co-exist with other symptoms, whose nature is more unequivocal. In the case just detailed, the previous history, the condition of the throat, and the loss of hair, leave no doubt as to the true nature of the dis- ease. Syphilitic alterations in the color of the 64 NOTES AND CASES. skin (maculae syphiliticae) are rarely, if ever, ushered in or accompanied by that febrile action which is common at the commencement of ordi- nary venereal eruptions; they are not accompa- nied by any other alteration of the skin beyond change of color; there is neither inflammation, ulceration, nor desquamation. These rare forms of disease are slow in their progress, and rebellious to all ordinary treat- ments : indeed, it is rare to find them cured at all under such circumstances. Cazenave quotes a case of this nature from Biett's practice, in which the patient's health was entirely destroyed by the means adopted to remove them, which, even in the hands of men of such ample experi- ence, were unsuccessful. The case I have just detailed, of even aggra- vated form (for the spots on the face and back were as distinct and deep as though they had been painted on the skin, and completely ban- ished the patient from society), was cured by the vapour in nine weeks, after five months' treat- ment by the ordinary remedies, during which time the spots rather increased than diminished, and the health was beginning to fail under the remedies employed. Other forms of u maculae," or discolorations, are less vivid, and do not even always attract the patient's attention, though they render some others very uneasy. NOTES AND CASES. 65 It is common, during treatment for other vene- real symptoms, to find on undressing the patient the surface of the abdomen, chest, or thighs covered with light copper-colored blotches, which are of precisely the same nature as those which I have just described. If the treatment by the mercurial vapour is being followed, they commonly if not always yield to it, though sometimes very slowly; but ordinary treatments, though pursued for months, appear to have little or no influence over them. CASE XXXI. Constitutional syphilis of ten years' duration: periodical attacks of disease in the throat; affections of the nose and testis; at the end of nine years, an acute attack of disease in the throat with speedy perforation of the soft palate; failure of mercurial and iodine treatments conducted in the ordinary manner; speedy and remarkable improvement of all the symptoms, and disappearance of many of them, under treat- ment by the vapour. Mr. C----, aged 23, consulted me, when pass- ing through Birmingham in 1840, for a slight eruption and sore throat, both of which were of syphilitic origin; he had had primary sores some months previously, for which he had taken mer- cury to salivation. I neither saw nor heard from this patient for nine years; but early in 1849 he came again to me. He stated that he had never been well since 6* 66 NOTES AND CASES. he first saw me; that from time to time he had had attacks of inflammation and ulceration of the throat, which had yielded to medicine (the hy- driodate of potass.), but had always recurred after the medicine had been discontinued for a little time. He had suffered also from discharges of hard, thick crusts from the nose; the nasal duct had been obstructed, and the operation for its restor- ation had been attempted and failed; and the patient suffered consequently from lachrymal fistula. He had enlargement and induration of the left testis; he was pale, emaciated, and weak, and suffered from profuse night-sweats. Such had been the condition of the patient dur- ing the nine years which had elapsed between his first and second visits to me. The immediate cause of the second consultation was the state of the throat. Four days only previous to this visit, he began to suffer from pain in the roof of the mouth, which was much inflamed; and on the second morning after these symptoms had first been observed, he discovered a large hole in the roof of his mouth. The whole of the roof of the mouth and soft palate were at this period intensely and liv- idly red; and at the junction of the soft with the hard palate, there existed an ulcer of the size of a sixpence, which had perforated the NOTES AND CASES. 67 velum, and through which the nasal mucus flowed, as it was close under the posterior nares; the ulcer was rapidly spreading, and threatened destruction to the whole of the contiguous parts. The pharynx and fauces presented no trace of inflammation. Encouraged by the success which had attended the use of the fumigation in two other cases, I immediately proposed it to my patient, who was immersed in a powerful bath for half an hour, for which was used two drams of the binoxide and two drams of the bi-sul- phuret of mercury. On the next day, the pain was gone, the ulcer had not extended, and the inflammation was certainly less. On the second and third days, the baths were repeated in the same manner, and of the same strength. The mouth had now become so sore that they could not be continued, although neither ulcera- tion nor salivation was produced; merely an even redness and swelling of the gums. The patient was directed to take twenty drops of Battley's solution of opium three times a day, with plenty of sarsaparilla broth.* At the end of a fortnight, the testis had recov- ered its natural state, the inflammation in the * Decoct, sarsar. co., Bj ss. : Carnis bovis. lb ss. Coque simul super lento igne ad dimidium, Dose, Ad libitum. 68 NOTES AND CASES. mouth had entirely disappeared, and the ulcer was granulating and contracting fast; the mouth still continued sore. At the end of two months, this patient did not present any symptom of constitutional taint; the perforation in the palate remained, though it had much contracted, and did not occasion much inconvenience. There has been no fresh symptom for ten months. This case is remarkable and instructive in many points, and forcibly illustrates certain laws in the history of secondary syphilis. It shows, in the first place, that acute and mutilating diseases not unfrequently occur in constitutions broken down by long-continued venereal taint. It shows, again, that the condi- tion of the nose, and the nature of the discharges from it, are very frequently the chief symptoms that mark a latent venereal taint; this is a point which I have before had occasion to allude to, and it is one of very considerable importance. The treatment of this case illustrates the power of the moist mercurial fume in arresting formid- able diseases of this nature, and arresting them so quickly, so certainly, and so safely. I do believe that no other plan of treatment could have been framed which would have saved the whole of the roof of the mouth from horrible mutilation. This ulcer was evidently of nasal NOTES AND CASES. 69 origin, and the velum had been perforated from behind; it had not been preceded by any ulcer- ation in the throat, or on the fore-part of the velum; and the first knowledge the patient had of the existence of the ulcer was the sight of the perforation in the palate. I repeat, that in all cases of secondary syphilis the passages of the nose should be carefully examined, as they furnish some of the best tests we can have of the existence of a constitutional taint. This patient has had no relapse, (June, 1860). case xxxn. Constitutional syphilis of three years' duration: discharge of crusts from the nose, with ulceration; great wasting of body, with hoarseness, difficulty of swallowing, and pain in the larynx; local employment of the vapour of the binoxide of mercury; cure. E. F----, aged thkty-six, was admitted into the Queen's Hospital under my care, early in 1849. She had been the subject of constitu- tional syphilis for about three years, during which time she had undergone a great variety of treatment. She was at the period of her admission, much emaciated, had night perspirations, and could only speak in a whisper. She had superficial ulceration of the septum 70 NOTES AND CASES. of the nose, the whole lining membrane of which was vividly red, with daily discharges of the characteristic crusts. The chief complaint, however, was of pain deeply seated in the throat and neck; and the larynx was very tender when handled or pressed. I suspected that she had syphilitic ulceration of the windpipe. By means of an apparatus, easily contrived, a stream of the vapour, made with half a dram of the binoxide of mercury for each fume, was directed into the fauces and up the nostrils every morning. After four or five inhalations the mouth became sore, and the remedy was used less frequently. The symptoms entirely disappeared under this treatment; and three months afterwards, when the patient called on me, she had recov- ered her health and strength, and appeared per- fectly well. I have, in many instances, employed the vapour of the binoxide, the iodide, and the gray oxide of mercury locally, in many anoma- lous symptoms, which were consequent upon protracted constitutional syphilis, and which did not appear to require the general application of such remedies. These diseases have been, fissures and cracks in the tongue, pains in the throat, fauces, and notes and cases. 71 larynx, which had previously been the seat of ulceration ; fissures of the anus, cracks about the lips, &c. One of these cases I have just detailed, and I could bring forward a very considerable number, in almost all of which one remedy or the other has been perfectly successful. In cases where it is the tongue, throat, or nose, it is better to use calomel or the gray oxide, as the iodide or the vapour of the bi-sulphuret produces so much sneezing and coughing, that some persons are unable to bear the application long enough to be useful. case xxxm. Constitutional syphilis of four-years' duration: treatment by the vapour; uneasiness and pain in the throat still recurring at times ; local application of the vapour of the binoxide of mercury; disappearance of the symptoms; no relapse. A commercial traveller placed himself under my care to be treated for secondary and consti- tutional syphilis, from which he had suffered for nearly four years. The symptoms consisted in superficial ulcera- tion of the throat, pains in the bones of the nose, with superficial ulceration of its mucous mem- brane, and discharge of pus, blood, and mucous crusts, with some suspicious spots on the skin, and a general cachetic condition, — the result 72 NOTES and cases. probably of large quantities of mercury which he had taken for the cure of the primary disease. He was treated by the moist vapour of the bi- sulphuret and binoxide of mercury. In about ten weeks he had perfectly recov- ered; and at the end of three months had be- come very florid, and got very fat. There remained, however, some uneasiness in the throat; and from time to time a blush of redness spread over the pharynx and fauces, accompa- nied by dryness, and slight pain when he swal- lowed. These symptoms rendered him uneasy: but as they did not appear to me sufficiently important to condemn him a second time to a full course of treatment, I directed a half a dram of the vapour of the binoxide of mercury to be directed into the throat three times a week. Each appli- cation gave him great relief: at the end of three weeks the throat no longer troubled him, and for twelve months there has been no return of dis- ease in any form. It not unfrequently happens that a single symptom continues to annoy patients, when they do not present any appear- ance of general constitutional taint, and when the treatment previously adopted has been suffi- cient to render the mind pretty easy on such a point. These symptoms generally consist in periodical attacks of redness and dryness in the NOTES AND CASES. 73 throat, in soreness and occasional discharge from the nose, in fissures and superficial ulcera- tion of the tongue, and the interior of the mouth, in scaly, dry blotches on the palms of the hands and soles of the feet, and in pains deeply seated in the neck and throat. In all such cases (and I could bring forward instances of every form I have mentioned) a local treatment by the vapour almost invariably suc- ceeds in removing the symptoms, which, I believe in such cases to be most commonly local, and where a general treatment is much more likely to do harm than good. I bring for- ward one or two cases in illustration. case xxxrv. Constitutional syphilis of fifteen months' duration; removal of the symptoms under treatment by the vapour of the bi-sul- phuret of mercury ; subsequently fissure and red elevations upon the tongue; treatment locally by the vapour of the iodide; permanent and perfect cure. A young gentleman who had been suffering from secondary and constitutional syphilis for about fifteen months, came under my care in the early part of 1848. He was treated method- ically by the fumigation, and took in addition some decoction of guaiacum, with the syrup of the iodide of iron, as he was of a weak and deli- cate constitution. About two months after the 7 74 NOTES AND CASES. disappearance of any venereal taint, a long fis- sure or crack came in the tongue, and four or five large, red, hard elevations appeared, having the appearance of small strawberries. The tongue was red and painful. These symptoms appeared to me of venereal origin, although his health appeared good, and he presented no other appearance of taint. I suggested to him the use of a local fumigation of the vapour of five grains of the iodide of mercury every other day. No other remedy was used; and in three weeks the fissure had closed, and the tongue presented its natural appearance. I have seen several instances in which fis- sures, superficial ulcerations or indurations, thick- ening and unevenness, of some parts of the tongue have remained for years after the pa- tient has been cured of all other symptoms of syphilitic taint; and, I believe, although these are occasionally dependent upon a general affec- tion, they are, nevertheless in many instances local diseases only. They are almost always rendered worse by mercury given internally, and proba- bly are merely forms of chronic stomatitis, pro- duced originally by the internal administration of this drug. It will easily be discovered whether they are symptoms of general infection, by the co-existence of some of the other symp- toms of which I have so frequently spoken. If NOTES AND CASES. 75 the health be good, and such symptoms be ab- sent, they are local diseases. They yield in a rapid manner to treatments by vapour; and the cures are generally perma- nent. CASE XXXV. Excavated ulcers of the throat; treatment internally by a full course of mercury; a third attack of ulceration; complete and permanent cure by the vapour of the iodide of mercury. S. P----was treated by a full course of mer- cury internally for two deep ulcers of the throat, one seated on each tonsil; and under this treat- ment the ulcers healed. A short time afterwards the throat again ulcerated, and the patient was a second time submitted to a mercurial course, pushed to salivation; the ulcers again healed, but in a short time again broke out. The patient was, at this period placed, under my care. The health was a good deal broken by the two courses of mercury previously employed: the patient was thin and weak, and the appe- tite bad. I directed him to take the compound infusion of gentian, with dilute nitric acid, and some of the compound decoction of sarsaparilla, with two grains of the extract of opium, every night. The vapour of three grains of the iodide of mercury was also directed into the throat every other day. 76 NOTES AND CASES. In eighteen days the ulcers had healed, and the patient has not again relapsed. This is not a solitary case: I have seen a great number exactly similar, where ulcers which had healed under mercury, internally administered, have fre- quently again broken out, and have at length rapidly and permanently healed under treatment by the vapour. Of all local treatments to vene- real ulcers of the throat, none are equal to the moist mercurial fume. Whether there be mere redness, the excavated ulcer, creeping or super- ficial ulcers, this is the local remedy par excel- lence. Clara C----, a patient in the Queen's Hospital, had superficial ulceration, with much redness of the throat, with shining copper-colored blotches on the head and other parts. She had been treated by a long course of the bi-chloride of mercury, which had cured the skin-disease; but the ulceration of the throat, although at times disappearing, kept constantly recurring. She had also two small ulcers of the tongue. Both the ulcers of the throat and tongue healed rapid- ly under the use of the vapour of the iodide, and the cure was permanent. NOTES AND CASES. 77 CASE XXXVI. Constitutional syphilis of seven years' duration; nocturnal pains, with enlargement and tenderness of the bones of the nose, and of the bones of the left arm; sarcocele of the left testis; failure of the ordinary treatments; complete cure by the Author's method in four months, without relapse. A dramatic artist of celebrity, who had been married for some years, and who had not had any primary venereal disease, in any shape or form, since his marriage, consulted me in the early part of 1849. He came to me as a forlorn hope, despairing of relief, as he had constantly relapsed after discontinuing the best-framed ordinary treatments, conducted by eminent sur- geons, amongst whom may be mentioned the late Mr. Ashton Key. When I first saw this gentleman his chief com- plaint was of the left fore-arm, the bones of which were much enlarged, very painful, and tender to the touch; but his sufferings were much increased during the night, when the pains were at times so excruciating as to deprive him more or less completely of rest; he had not slept one night, without pain, for seven years. The radius and ulna near the wrist were much enlarged, were nodulated and uneven. The bones of the nose were a good deal thickened, and he had shoot- ing pains in them. The left testis was five times 7* 78 NOTES AND CASES. the size of the right, heavy, and lobulated, but neither painful nor tender. I consider this case as one of decided venereal character; although mercury pushed to saliva- tion, and iodine had previously failed in affording more than a mere transient and temporary relief. Knowing the benefit which I have derived in former cases from the use of the baths, I held out to my patient a hope that they might be serviceable to him also. , I directed him to use half an ounce of the bi- sulphuret of mercury and half a dram of the iodide of mercury, for each of the first three baths, which were to be taken every third day; and to take internally some small doses of the hydriodate of potass, with colchicum. After the third bath, which had slightly affected the mouth, the nocturnal pains had dis- appeared, and the tenderness was gone from the arm; he could bear the bones pressed and han- dled, although previously they had been exqui- sitely tender. The treatment was continued at intervals for three months; sometimes the baths were taken once a week, at other times not so frequently ; the medicines also were continued. The pains never returned; and, at the end of the period I mention, the nose and testis had been long perfectly well. NOTES AND CASES. 79 This was a well-marked case of chronic syphil- itic periostitis; the treatment of which, by my method, was rapid, safe and successful. Perhaps no forms of constitutional syphilis are more formidable than those seated in the perios- teum and bones; and such affections are very frequently due to exposure, neglect, or want of care during a mercurial course which has been prescribed for the cure of some form of second- ary disease, but which not only frequently fails in curing it, but disposes the system to the pro- duction of new symptoms of a still more formida- ble character than those for which the remedies were originally prescribed. It has been said that the iodide of potassium is all but a specific for periosteal inflammation, more particularly that of a syphilitic origin : it. is certainly, in many cases, an excellent and effi- cient remedy; but there are many cases also in which it totally and completely fails. Not so with the plan of treatment I am advocating: it is all but certain in its influence over such dis- eases; and the rapidity with which it cures is very remarkable. The patient whose case I have just detailed was so convinced of the supe- riority of this method, that I could with difficulty prevent him sending the details of his case, and its treatment to a metropolitan daily paper. He had been under the best ordinary treat- 80 NOTES AND CASES. ment for nearly seven years with little or no benefit; and he was completely and permanently cured in three months. In such cases I believe, after several exper- iments made on the subject, that the best remedies to employ are combinations of the bi-sulphuret and the iodide of mercury, in the proportions, or nearly so, which I have men- tioned in the details of the case. The next case is equally remarkable in the effects of the reme- dies employed, although the duration of the dis- ease was not by any means so long as the preceding; but still in many respects the symptoms were of an equally formidable char- acter. CASE XXXVIL Secondary disease of six months' duration, consisting in copper- colored, scaly blotches on the neck, pustules and tubercles on the face, thickening with tenderness of the bones of the right leg, and disease of the testis; failure of ordinary treat- ments; rapid and permanent cure by the vapour of the iodide and bi-sulphuret of mercury. A young gentleman, aged twenty, contracted gonorrhoea, and a primary sore, late in the autumn of 1848, for which he was treated by a surgeon in the North of England, where he re- sided. The primary diseases were apparently cured; but soon after the disappearance of the NOTES AND CASES. 81 discharge from the urethra, a rash made its ap- pearance all over the body (roseola syphilitica? ), which soon died nearly, but not completely, away. Some time afterwards, blotches of a more decided character appeared on the neck and on the face; and he began to suffer from pains in the right leg, which were at times sufficiently severe to occasion lameness. About this time the patient became languid, and was troubled occasionally with profuse night- perspirations. For these symptoms he took various medicines under the direction of experi- enced surgeons; and about six months after the first appearance of the skin-disease, he placed himself under my care. When I first examined this gentleman, he presented a most formidable array of constitutional symptoms. On the face were forty or fifty pustules, with hard, nodular bases; and, in the substance of the left cheek, two tubercles, each as large as a horse-bean, and one on the back of the neck still larger, the surfaces of which were begin- ning to inflame. On the fore-part of the neck were a number of copper-colored scaly blotches of the size of a shilling; and the body generally was covered with a faint copper-colored mottling, into which the first rash had subsided. The right testis was three times the size of the left, and the tibia of 82 NOTES AND CASES. the right leg much enlarged, very painful at night, and tender to the touch; the patient had evidently taken mercury, for his gums were spongy, and the breath had a strong fetor; yet his disease had gradually progressed, and new symptoms were from time to time added to the old. Formidable as the details of this case must appear, I felt certain of a speedy and permanent cure under the use of the moist vapour of the iodide of mercury in a short time. I directed a bath with three drams of the bi-sulphuret of mercury, and one of the iodide, to be adminis- tered every other day, with the head immersed, and to be continued for half an hour: the patient was ordered also to take freely of the compound decoction of guaiacum, with small doses of the iodide of potassium, and three grains of the acetic extract of colchicum, and one of the extract of opium every night. The first bath relieved the pains in the leg and other parts; and, after the second, the tibia might be pressed without flinching; and the pains, except at such a time, were altogether gone; the hard bases of the tubercles, even at this early period were less, and the tubercles softer. Very little medicine was taken in this case. The patient drank a cup of guaiacum-tea two or three times a day, in which were dis- NOTES AND CASES. 83 solved three grains of the iodide of potassium; and he took also a dose of opium at bed-time. Such remedies alone, and in such doses, would have exerted but little influence over so formidable a disease; and many of the symp- toms could not have been expected to yield at all to such medicines. The cure was complete in five weeks; and it has been real and permanent, — no relapse nor return of complaint in any form. The general health has been also, as it commonly is, much improved by the treatment. In cases of complicated constitutional syphilis, such as the one just detailed, we cannot estimate too highly the plan of treatment by the moist mercurial fume. In such and similar cases the symptoms are so numerous and varied, that in the ordinary way we are almost at a loss to know what kind of internal treatment to recommend. No plan is, laid down by authors of the greatest experience for cases like the present. CASE XXXVIII. Syphilitic lepra with alopecia in the husband; i. e same dis- ease communicated to the wife; cure of both by moist mer- curial vapour. A gentleman contracted a superficial primary sore, which healed without leaving a mark or 84 NOTES AND CASES. induration behind it. Being apparently in good health, he married. Three or four months after his marriage, he perceived on his body numer- ous red, smooth, elevated, scaly blotches. Very shortly his wife broke out with an eruption of similar character; and the hair came off rapidly in both patients. In this state they were sent to me. Neither had any primary disease, and the lady had never had the slightest irritation in the genito-urinary organs. I examined them both frequently and carefully, and I am positive the wife had never suffered from sore, excoriation, or discharge. I placed them both on a rigid diet, and the use of the moist vapour of the bi-sulphuret of mercury. In about six weeks they were both appar- ently well, and have remained so for three years. CASE xxxix. Phagedena of the body of the penis, spreading by rapid ulcer- ation; failure of ordinary treatment; cure by mercurial fumigation. A young gentleman, of delicate constitution, aged twenty-two, contracted a sore on the body of the penis. It appeared first as a pimple, but ulcerated and spread. I saw this patient seven- teen days after the first appearance of the ulcer. It was then as large as half-a-crown, covered NOTES AND CASES. 85 with a tenacious yellow slough, the edges hard, elevated, and red, but no characteristic indura- tion. The pain from the ulcer was most severe, its surface very sensitive; the patient could not sleep, and was tormented with profuse perspira- tions. Various local remedies were tried with- out effect; the irritability and sensitiveness of the sore were so great that I feared to use caus- tic to avert the spread of the ulceration, which increased daily. The only local remedy which could be borne was the unguentum zinci with powdered opium. For twelve or fourteen days I kept this patient in bed, and gave him large doses of conium with opium, sarsa with nitric acid, &c, with very little, or I may say, no good effect. The ulceration continued to extend, and threatened to involve the whole integument of the penis. I now resorted to the moist mercurial fume. I placed him in a strong bath, in which he only remained ten minutes, the pain produced was so great; and when he was removed he fainted. On the next day the ulceration had not spread; the bath was again used, with less pain; on the third day there was no pain, and one or two healthy spots made their appearance in the centre of the slough which covered the sore, and the edges were less hard. After the fifth bath the ulcer was covered 8 86 NOTES AND CASES. with healthy granulations, and very shortly healed. The gums were very slightly affected. CASE XL. Indurated phagedenic ulcer of the glans penis; failure of or- dinary treatment; cure by mercurial fumigation. A commercial gentleman, very healthy, twen- ty-eight years of age, contracted a sore on the under surface of the glans penis, near the frae- num. I did not see it till near the third week of its existence, during which period the patient had pursued his usual avocations, and used vari- ous local remedies. When I first saw this case there was a deep burrowing ulcer involving the whole under surface of the glans, having destroyed the fraenum, and extended to the in- tegument on the under surface of the penis: this ulcer was covered with a tenacious slough, black in some places, white in others. The glans penis was swollen and much in- flamed, and the whole body of the penis was in a similar condition. The patient was now con- fined to bed, placed on a low diet, the parts enveloped in a bread-poultice, and aperients with nauseating doses of antimony exhibited. In two or three days, the ulcer continuing to spread, I destroyed the whole surface with the acid nitrate of mercury; and after the separation NOTES AND CASES. 87 of the eschar, no improvement having taken place, I did this a second time. The slough was again reproduced, the ulcer still spreading, and threatening to open the urethra, — a circumstance I have seen more than once consequent upon ulcers in this situation. It is to be remarked also that the general inflammation in the glans and penis were very little reduced by the rest, diet, and antiphlogis- tic treatment. I now resorted to the mercurial fume. The patient was immersed daily for forty minutes: there was no extension of the disease after the second bath. At the end of eighteen days the sore had healed without induration, leaving, however, an excavated cicatrix on the glans. The mouth was moderately sore. Profuse night-perspirations also accompanied the ulcer- ating and sloughing stages. CASE XLI. Discharge from the urethra as a primary symptom; scaly blotches on the skin, and a node on the forehead, as consti- tutional symptoms; cure by the mercurial vapour bath. A gentleman consulted me respecting a lump on his forehead, which was red, tender, and painful; he had upon different parts of his body, and on his head more particularly, some dry, scaly blotches; his hair also came off rapidly. 88 NOTES AND CASES. He had never suffered from any primary vene- real disease, except a discharge from the urethra. When I saw him this no longer existed; the urethra presented no induration in any part, a bougie passed easily, and he made water in a good stream. I recommended the use of the mercurial vapour bath, which was administered every other day. I prescribed no medicine internally. In a month the cure was complete. I could multiply such cases, which leave no doubt as to the fact that discharges from the urethra, apparently in no way different from ordinary gonorrhoea, and which are not accom- panied or followed by any perceptible organic change in the urethra, are the primary causes to which secondary syphilis is occasionally due. CASE XLII. Localized constitutional syphilis, simulating scirrhous mamma; cure by the mercurial vapour. M. J----, a married lady, mother of two healthy children, in the fifth month of her preg- nancy of her third child, was sent to me for my opinion respecting the nature of a tumor near the nipple of the left breast, which had been seen by many surgeons, who had considered it cancerous, and recommended its removal. It NOTES AND CASES. 89 was a hard, solid lump, covered with a livid blush, and evidently on the point of ulceration. The position and character of the patient put the idea of syphilis quite in the background. On my third visit my patient said, " Will you look at a lump on my forehead, which at times gives me great pain, especially at night ? " I examined the lump, which was a circumscribed periostitis of the frontal bone. It struck me immediately that the disease was venereal, the lump on the forehead a node, and the lump on the breast a syphilitic tubercle, or a gummy tumor. I made my suspicions known to the husband, who admitted that he had gone astray, but was assured that he was not diseased, but had only a chafing. On examination I found a discharge from the base of the glans penis, the site of which was thickened and hard. There was now no doubt, as intercourse had continued under these circumstances; yet on the part of the lady there was no sexual irritation, no ulceration or discharge. The lady was put on a course of mercurial vapour, with sarsaparilla, &c. The symptoms of syphilis disappeared under the treatment; but she was prematurely delivered of a dead child. She has since, however, enjoyed good health, and has had a healthy living infant. 8* 90 NOTES AND CASES. CASE XLHl. Hoarseness with relaxed throat and loss of voice, for three years; no benefit from ordinary treatment; subsequently an attack of tubercular syphilis ; cure of the former symptoms by the treatment of the latter. A. B----placed himself under my care to be treated for secondary syphilis. The symptoms consisted in the presence of a large round tuber- cle, covered by a patch of inflammation, in the substance of the left cheek. On the nates, and on the upper and back parts of the thigh, there had been also several of these tubercles, which had ulcerated and become deep, irregular, foul discharging ulcers, seated on an indurated base. He had suffered from primary sores seven years previously; and three years ago the throat had become painful on swallowing, was relaxed but never ulcerated, and the voice hoarse and feeble. For these symptoms he had consulted several physicians in London, and had used counter-irri- tation local applications, and had been submitted to internal treatment of various kinds, with little or no benefit; as he got thin and weak he began to fear threatenings of laryngeal phthisis. Seven weeks previous to my seeing the patient, tuber- cles on the back and thigh appeared, which slowly increased, ulcerated, and ran into foul NOTES AND CASES. 91 sores. The tubercle on the face had also recent- ly made its appearance. For these symptoms, doubtless syphilitic, the patient placed himself under my care. He was placed on the use of the mercurial vapour bath, a milk diet, and the biniodide of mercury with the iodide of potassium. The tubercle on the face had disappeared after the sixth bath; and the ulcers, which were dressed with the ung. hyd. nit. oxyd. and unguent, elemi., looked healthy and were healing rapidly. In six weeks all the symptoms had disap- peared ; but what is remarkable, the hoarseness and uneasy feelings in the throat, were gone, and they have never returned. In speaking of complicated syphilis, Ricord says, " We must treat the epiphenomenon of the disease, let it be whatever it may: the worst treatment is that which is exclusively directed towards the removal of one symptom, when ten others require modifications." When the disease has been still further com- plicated by the internal administration of mer- cury, and we find fetor of the breath with a spongy condition of the gums, and a certain amount of debility and malaise, with night-per- spirations, which commonly set in at these periods, the difficulties of treatment are much increased. 92 NOTES AND CASES. In such cases a further internal treatment by mercury is inadmissible, and might even prove fatal; and iodine offers but little better prospect of success. At these periods and in such cases the moist mercurial fume, employed in the man- ner and with the modifications I have already detailed, is all but certain in its effects. The patient soon begins to amend; the evils caused by the internal administration of mer- cury soon pass off; the appetite, strength, and general health rapidly improve; whilst the symptoms of constitutional taint are quickly, and in most cases permanently, eradicated. / 4 , mm Hi Bf' LIBRARY OF MEDICINE Nl_n DDIDITIM 3 W- ru ■il I' >ij i-. ^4r ^^ NLM001017143