total or partial adherence. Parts affected with syphilis which are deeply seated, or covered by folds of integuments or mucous membrane, should be daily cleansed by tepid anodyne or astringent injections, according to the character of the accompanying irritation. These injections should be practised quietly, without force, and without creating pain.

Abscesses should be opened early, more particularly if the presence of matter occasions much pain, or take place under fascia or tendinous expansions, where the pus cannot readily make its way to the surface. Long and deep sinuses should be laid open, or if it be practicable, a counter-opening may be made.

All parts in a state of natural or acquired strangulation which offer impediments to the cure of syphilitic diseases should be quickly relieved; this becomes necessary in natural or acquired phymosis or paraphymosis. The circumstances which contra-indicate this practice will be mentioned under the article on the particular diseases themselves.

The non-mercurial, simple, or physiological treatment of syphilis, consists in the employment of the means already passed in review, both local and constitutional, without having recourse to mercury as a specific therapeutic agent in their cure, and this plan may be adopted both in the primary and secondary forms of disease. It will be found, however, that the primary are very much more easily cured than the secondary upon such a plan. It cannot be concealed, that the non-mercurial treatment does not always succeed in the cure of primary syphilis; and that, in a great number of cases, the cures are more apparent than real, the sores breaking out again when the patients return to their customary diet and occupations. Matters go on very well whilst a patient is limited to a rigid diet, and confined to bed, and watched in the wards of a hospital; but in private practice this cannot be done; and hence it has been found by military surgeons, that whilst they could cure the privates, they could not cure the officers on the non-mercurial

1 An exception to this rule is the formation of matter occasioned by the suppuration of a node, either on the cranium, or on the surface of the tibia or other bones. (See chapter xxix.)

plan. In the French memoirs of military surgery,1 the medical officers of the military hospital of Toulon state that, although the non-mercurial plan is useful in allaying the irritation, or inflammatory symptoms which accompany primary venereal sores, yet they were compelled to resort to mercury to obtain radical cures. Fifty-two surgeons met at Nantes, in July, 1835, to discuss this question: they had five discussions; two only, one of whom was M. Devergie, declared themselves in favour of the physiological, or non-mercurial treatment of syphilis.2

As a general rule or principle, I never employ mercury except as an aperient, in the ordinary forms or earlier stages of primary venereal sores. The immediate local or specific effect of the syphilitic virus produces a degree of irritation or inflammation on the parts to which it is applied, during the continuance of which mercury is, to say the least, injurious, except as an aperient; and it is not till rest, low diet, mild opiate or astringent washes, and the other remedies just noticed, have failed in producing a cure, that mercury is to be thought of as a specific agent. When, however, all these have failed, and the case has assumed a perfectly chronic character, mercury may be used with every prospect of a beneficial result, and this is certainly the result of modern experience on this subject.

3

In order that the non-mercurial plan may be successful, it should be employed in that species of chancre which is termed simple or soft; the base or skin upon which the chancre is placed exhibiting no indication either of a specific or inflammatory kind. (See chapter viii.) I have not alluded to the

1 Recueil de Mémoires de Médecine et Chirurgie Militaires,' tom. xxxv. 2 Procès Verbaux des Séances tenues par les Médecins de Nantes, pour discuter la valeur des doctrines nouvelles relativement à la nature et au traitement de la Syphilis ;' Nantes, 1835.

3 Desruelles, of Val-de-Grâce, concluded from observations made on 8810 patients, that the non-mercurial treatment must be considered as the base of all rational practice; "but," says he, "should the ulcers continue without disposition to heal for twenty or thirty days, mercury should be employed to effect a cure."-The same doctrines are taught by Dr. Egan, of Dublin. (Syphilitic Diseases, their Pathology, Diagnosis, Treatment, &c., &c.;' London, 1853, pp. 330-331.) And this is the result of my own experience, drawn from the personal treatment and examination of more than 25,000 patients, in hospital and private practice, during the last twenty years.

treatment by the potassio-tartrate of iron, which consists in applying a solution of this salt to the sore, and taking it internally at the same time. It is indicated in the chronic ulcerative stage of soft chancres, after the acute stage has passed, and the sore continues to spread, or to be approaching a condition of ulcerative phagedena.1

1 R-Ferri potassio-tart., 3vj-3j ;

Aquæ destillatæ, zviij. M.

Cap. cochlear. ij. larg. ter die.

A lotion of the same strength to the sore. This, however, requires dilution in many cases.

CHAPTER II.

THE MERCURIAL TREATMENT OF SYPHILITIC DISEASES.

IN this chapter I shall point out the circumstances which modern experience has indicated for the use of mercury; for although this remedy cannot be considered in any measure as a specific against syphilis in any of its forms, still there are numerous cases in which it is the most powerful and certain therapeutic agent we can oppose to them.

Why is mercury to be employed in the treatment of syphilis ? When is it to be employed? In what manner is it to be employed? What are the states of the constitution and of the sore which are to guide us in pursuing its use or giving it up? And when is it to be discontinued? These are the practical questions which suggest themselves to us in reference to the use of mercury in venereal diseases, and to them I shall give the answers that modern experience has sanctioned.

Modern surgeons employ mercury with a view of healing a syphilitic ulcer that has resisted other modes of treatment, or to diminish the chance of secondary symptoms. When (says

1 This statement requires some comment. That mercury, however administered, will not in all cases prevent secondary symptoms, is a fact as certain, as that secondary symptoms do occur. One reason why mercury is not more successful under this point of view, is owing to the manner in which it is given, and the irregularities of the patient during its exhibition. That mercury should fulfil its intentions, it is necessary that it should be employed properly or not at all, and that its use should be limited to that description of sore hereafter spoken of. The mode of its administration should also be considered, and the patient should be subjected to those rules of diet and regimen which have already been laid down in the chapter' On Non-mercurial Treatment.' It is owing to a neglect of these precautions that secondary diseases so frequently follow mercurial treatment, which under other circumstances would not happen. The particular modes of its employment will be considered further on.

Cullerier) the local applications before mentioned are insufficient to produce the cicatrisation of a chancre, the patient must be placed upon a general mercurial treatment.1

There are several circumstances which particularly indicate the use of mercury in primary syphilis. 1. When a soft chancre which has resisted other modes of treatment remains long open, and shows no disposition to heal under the nonmercurial plan detailed in the last chapter. 2. When secondary symptoms appear before the primary disease is cured.2 3. In well-marked indurated chancre, with a chain of indolent, indurated glands in one or both groins, without any tendency to suppuration.3 4. In certain cases of rapidly-spreading ulceration, hereafter to be described.

Mercury is not to be used during a state of fever or local inflammation which is present during the first days of venereal ulcers, nor till our patient is prepared for it by appropriate diet and medicines. When the fever and local inflammation or

1 Recherches Pratiques sur la Thérapeutique de la Syphilis, ouvrage fondé sur les observations recueillées dans le service et sous les yeux de M. Cullerier, par Lucas Championnière;' Paris, 1836.

2 In Norway, a general specific treatment is never adopted till constitutional symptoms appear.- Medical Times and Gazette,' Sept. 5, 1857.

3 The term induration, as limited to a primary sore, is to be understood to mean a cartilaginous hardness of a whitish colour which immediately surrounds the sore, on the top of which the ulcer is sometimes seated, or in which it is dug out; the redness or inflammation accompanying the one is generally on the outside of this white hardness, which is moveable under the skin; this appearance of induration sometimes does not come on at first, but makes its appearance during the progress of a sore, and in other instances the induration appears on the site of the cicatrix after the sore has healed, but under which circumstances it is prone to ulcerate again. Specific induration must not be confounded with the swelling, oedema, or inflammation which accompany other ulcers of the penis, nor again with a thickened condition of the edges of a sore, which is frequently produced by improper local treatment, or appears when simple ulcers become indolent. "In such cases," says M. Ricord, "six months never elapse without secondary symptoms manifesting themselves, unless a specific treatment be employed." It is also the experience of M. Puche, who has verified its truth in hundreds of instances, without an exceptional case. "This is an universal law which there is no means of eluding, but by mercurial treatment." (See Ricord's Letters, by Stapleton, p. 51.)