with severe and frequent paroxysms of tetanus, and with permanent locked jaw. The symptoms had set in eight days before. On the 10th, he began to take Taylor's extract of conium, and continued its use in five grain doses every two hours, and afterwards every hour, until the 26th. During this period, he took no less than two ounces and a half of the strongest form of extract, without any indication whatever of the physiological effect of conium, but with simply a gradual diminution of the tetanic symptoms. This of course was not an instance of the poison remaining unabsorbed in the stomach, as has been seen at times with opium. I should consider that here the agency of the conium was directed towards the counteraction of the morbid condition, and that hence its normal effects were not manifested.

The object of the foregoing remarks is to induce those who have the opportunity to give a full and complete trial to aconite and other medicines which have a like effect on the nervous system. In looking over the records of cases in which such agents have been given, it appears that generally the ordinary doses have been administered at long intervals. It has been by some assumed that because no benefit has been derived from them when so employed, that therefore no good was to be expected from them at all. There is a feeling, too, very prevalent, that though cases of tetanus sometimes recover, yet that the remedies employed have little to do with such a result. Nor is this surprising, considering the disappointment which has so often followed the more extended use of medicines which at first seemed to promise favourably. The same disappointment will perhaps follow the future employment of aconite. But in a disease so terrible and so hopeless as tetanus, any encouragement, however slight, will be acceptable.

There is one other point in the treatment of tetanus to which allusion may be made. It has been generally taught that free action of the bowels should be kept up by means of powerful purgatives. From cases recently reported, indeed, this course does not appear to be now so generally the rule as formerly. My own belief is that excepting as a preliminary step to remove any matters which may be lodging in the bowels at the time of the attack, no benefit attends the practice, and that often harm is done by keeping up irritation in the alimentary canal, when our object should be to ensure as quiescent a state of the whole system as possible. In a case under my care last year, in which the symptoms were very mild, although it terminated fatally after nearly a month's duration, the bowels were allowed to remain quiet for the first nine days, purgative medicine was then given, and a free action of the bowels obtained, but the general symptoms were aggravated, and this was the case whenever the purgatives were used. Great relief is found from the use of enemata, however, especially those with turpentine. In the present case, the bowels were emptied by this means two or three times only during sixteen days.

ART, III.

On Syphilitic Inoculation. By HENRY LEE, Surgeon to King's College Hospital and to the Lock Hospital.

On the 10th of October, 1853, I had the honour of reading before the London Medical Society a paper on the mode of action of morbid poisons, and of the syphilitic poison in particular. I then attempted to demonstrate that the absorbents were not the means by which poisons were ordinarily received into the blood, and that in those cases where the evidence was most conclusive of great excitement in the absorbent system, there was comparatively little danger of the poison being received, as such, into the general system. I endeavoured to show that the absorbent glands were, in fact, placed as sentinels in different parts of the lymphatic vessels, and that they had the power of refusing admittance to certain injurious agents; or of retaining them, until those agents had undergone a change, such as would render them comparatively innocent when admitted into the general circulation. These principles were illustrated particularly with reference to the morbid actions induced by the inoculation of the syphilitic virus. The primary forms of syphilitic disease I then ventured to divide into four principal varieties-namely: 1st, those in which the application of the poison, or of some irritant applied either with the poison, or shortly afterwards, produced mortification of the infected part; 2ndly, those in which the contact of syphilitic matter produced true ulceration-that is, an action in which the absorbents played a part and took up portions of the infected tissue impregnated with syphilitic matter; 3rdly, those in which a free suppuration was produced, and in which the secretion from the sores consisted principally throughout their course of well-formed pus globules; and 4thly, those in which the morbid action induced consisted of a specific adhesive inflammation. From tables which I read before the Society, it appeared that the first form of disease was not necessarily accompanied by either swelling or inflammation of the absorbents; nor was it followed by any constitutional symptoms: that the second was as a rule accompanied by violent inflammation of the absorbent glands, but was not followed by secondary symptoms: that the third was not ordinarily accompanied by swelling or inflammation of the glands, and was not followed by secondary symptoms: that the fourth was accompanied by an indolent swelling (but not inflammation) of the glands, and was, as a rule, followed by some form of constitutional disease, unless this was prevented by mercurial treatment.

Soon after the period to which I have referred, I had reason to believe that these different forms of disease were not all equally communicable in the same way. It appeared to me that the adhesive form of inflammation was not capable of being communicated by inoculation as readily as the suppurative form. More than one occasion offered itself for publicly discussing this point, and I was told in friendly criticism that I had not selected my cases for inoculation rightly-that, in fact, I had inoculated some sores during their period of repair, and

some previously to that period, and that this had given rise to the differences I had observed. As time advanced, fresh opportunities presented themselves of testing the truth of the doctrine, and in 1856 I published in the British and Foreign Medical and Chirurgical Review' several cases where inoculation with the lancet in the ordinary way had failed, and yet when every doubt seemed to be removed as to the cases being genuine primary syphilitic sores in a period of progress. The importance of such observations could not be doubted if the experiments had been rightly performed; for in that case, what became of the inoculation test as the sole means of distinguishing primary syphilitic affections from other diseases? This test had been loudly proclaimed from one end of Europe to the other as the only one that could be relied upon as a certain indication of a primary syphilitic sore; and any opposition to this universally-received doctrine, at the time I speak of, was regarded as originating in some mistake. Nevertheless, those who were in the habit of seeing inoculations most frequently performed had their secret misgivings upon the subject. It was, for instance, in the year 1851 that Professor Boeck, travelling through the Northern part of Italy, became attracted by the new doctrine of syphilization. On his return to Christiania, he resolved to try the new plan as soon as he was, to use his own words, "able to obtain some inoculable virus." This was not until the month of October, 1852! Are we to suppose that during the first months of the year 1852 there was no such thing as a primary chancre in Christiania; and that the disease during that time was not communicated there by natural intercourse? Or may we not rather see the lurking impression on the Professor's mind, that one form of syphilitic disease was much more easily inoculated than another? In a town where syphilitic disease was known to be as rife as in Christiania, we must take for granted that the Professor had under his care many cases that he well knew were genuine cases of primary syphilitic disease; but from what he had witnessed, he instinctively believed that the secretion of one particular kind of sore would serve his purpose best, and for this he waited.

Although those who practised inoculation were everywhere asking for good pus for their experiments, the universal belief nevertheless obtained that all chancres during the period of progress were alike inoculable. Very few at that period seem to have thought of asking themselves the question, how are the sores which do not furnish good pus communicated? or, whether there was any difference in their mode of being propagated? The dictum of M. Ricord was very universally received, and the characteristic pustule produced by inoculation was as universally acknowledged as the test of a true primary syphilitic sore. M. Ricord had said that the inoculation, when properly performed, never failed, and that the results were regular, characteristic, and uniform. As usually happens after a theory has been too hastily received, a period of undue reaction now threatens to set in. From the hasty generalization, that all primary syphilitic

* Traité Pratique, pp. 94, 135.

sores are equally inoculable by the point of the lancet, we now hear that the indurated variety of chancre is not inoculable at all, upon the patient who has it. In the Gazette Médicale de Lyon' for the 16th of January last, M. Rollet asserts, that as secondary syphilis is not inoculable on the patient, so neither is the primary infecting sore:"La syphilis secondaire n'est pas inoculable au malade; mais le chancre infectant ne l'est pas davantage." (p. 36.)

"Inoculez la syphilis à la lancette . . . . même l'accident dit primitif, le chancre infectant, et vous n'obtiendrez pas davantage la pustule d'inoculation."

"Il n'y a qu'une maladie vénérienne qui soit inoculable par piqûre au malade lui-même, et cette maladie, c'est le chancre simple, et son dérivé le bubon chancreux."

Here we have one kind of chancre alone acknowledged, as capable of being communicated, by inoculation upon the patient himself, with the point of the lancet; a complete revolution in doctrine since the year 1856.

one.

In the last work published under the direction of M. Ricord,* that distinguished Professor still clings to the belief, that sores affected with the specific adhesive inflammation may be inoculated in the same manner, and that the inoculation will produce the same result as in sores affected with the specific adhesive inflammation. He says:"Ce que je viens de dire de l'inoculation et des développements du chancre, se rapporte presque aussi bien à l'une qu'à l'autre de ces variétés." Farther on in the work, however, M. Ricord's faithful expositor and distinguished pupil, M. Alfred Fournier, gives a table of 99 cases in which the secretion from an indurated chancre had been inoculated. The result was negative in 98 instances, and positive in In this case, however, the specific pustule was produced. As no explanation is given of this apparently strange exception, it is not impossible that this may have been an instance of a suppurating sore having become originally inoculated upon a sore affected with specific adhesive inflammation; or of the converse, of the base of the sore having taken the specific adhesive action, while the original inoculable pus was still being secreted from some part of its surface. This explanation has suggested itself to me as probable, from the somewhat analogous results obtained by clinical observation. During parts of the years 1855-56, I examined 100 cases of sores, in which the secretion appeared to be well formed pus. These were considered to be local suppurating sores, and were treated accordingly without mercury. Two only of the whole number returned to me with secondary symptoms, as the result of the primary suppurating sores. Now, in both these cases, upon making a further minute inquiry, it appeared that the patients had subjected themselves to more than one source of contagion shortly before the appearance of the primary disease. It is therefore quite possible that one form of chancre may have been inoculated upon another, and so have masked the diagnosis; and in M. Fournier's case I am inclined to believe that this is what actually did occur, be

Leçons sur le Chancre, p. 31. 1858.

cause he does not note that the characteristic pustule which was produced differed from the ordinary pustule resulting from the inoculation of a suppurating sore.

Are we, then, to believe with M. Rollet, that the secretion of the indurated syphilitic sore cannot be inoculated upon the patient affected? Are we to make a complete revolution in our opinions, and from believing, as formerly, that all primary chancres were equally inoculable by the point of the lancet, now hold that the indurated variety cannot be inoculated at all upon a patient who has once been affected?

As in 1856 I hesitated not to express my belief that all primary syphilitic chancres were not alike inoculable, and that inoculation was therefore no proper test of an ulcer being syphilitic; so now I venture to affirm that it would be error to suppose that indurated infecting sores those affected with specific adhesive inflammation-are not inoculable at all upon the patients themselves. This I would do upon three distinct grounds:

1st. From the result of direct experiment in inoculating the secretion in the ordinary way.

2ndly. From clinical observation.

3rdly. From the result obtained by inoculation, when the sores from which the secretion is taken have been subjected to certain kinds of irritation.

1. In the beginning of the year 1856 a medical student became diseased for the first time. He inoculated himself on the thigh, and presented himself to me three or four days afterwards. The inoculation succeeded, and became a small hard button-shaped induration, exactly resembling the original: a small point of whitish lymph was at first visible in the inoculation, but both sores subsequently remained as small, hard, circular indurations, furnishing scarcely any secretion from their surfaces. In this case the student had, it is believed, applied some caustic to the sore before he inoculated himself. Here, then, we have an unequivocal case of an indurated sore (subject, probably, to previous artificial irritation) producing, when inoculated with the point of the lancet, not the characteristic pustule, but an indurated sore like itself.

2. The same point may be demonstrated by much more numerous instances, although not so conclusively in any one case, by clinical observation. There is a man now in the Lock Hospital with an indurated cicatrix upon the upper part of the thigh exactly corresponding to a similar induration upon the extremity of the prepuce. There was in this case other causes of local irritation; but no one upon seeing the case would doubt that one induration had been communicated by inoculation from the other. Cases are not very uncommon in which opposed surfaces, of the labia, for instance, present well marked indurated sores of exactly the same size, shape, and appearance. There can here, again, be no doubt that this affection is communicated from one situation to the other by inoculation. But in all the cases which I distinctly remember there has been some cause of irritation superadded to that of the specific adhesive inflammation.

3. The most interesting proof of the inoculability of the secretion of