course has been advocated; the merits of mercury being amply recognised where the class of symptoms demanded, and its employment being dispensed with where a safer and more simple plan of treatment was obviously indicated. Once more, in order to guard against misapprehension, it will be essential to remark that, under the most careful and well disciplined proceeding, relapses will at variable periods recur; but a well-directed treatment at the onset of the primary affection, and a judicious management of the early constitutional disorders, will ensure a mildness of symptoms and a facility of cure, which ill-timed measures and the indiscriminate administration of mercury will invariably exasperate. In this way, it will frequently happen that cases which would in the first instance have been amenable to mild therapeutic appliances, will from previous injudicious treatment present complications, which will subsequently bid defiance to the best directed efforts on the part of the surgeon. The arrangement to which I have adhered, in describing the primary and constitutional forms of syphilis, I have found by experience calculated to impress the mind with clear and methodical views of these diseases; and, above all, to ensure a scientific and successful mode of treatment; and this remark will equally apply, whether we ascribe the varieties in the symptoms detailed to one or a plurality of poisons. That all the constitutional forms of syphilitic affections, if left to

the unaided powers of nature, have a constant tendency to wear themselves out, I am fully convinced. The abundant evidence with which we have been supplied by the non-mercurial school, while it has succeeded in clearing up all doubt upon that once disputed point, has at the same time taught us, by induction, the proper estimate in which we should hold the long-vaunted specific. Firmly satisfied with the truth of this well ascertained fact, I was not a little surprised at finding a contrary doctrine propounded in the most recent work on these affections, viz. ; that when the syphilitic poison was once received into the blood, it remained in the constitution to the end of life; incapable of eradication in the person of the original recipient, it was perpetuated in the form of scrofula to distant generations.* Looking upon this position as altogether untenable, and entirely at variance with recorded experience, it will be quite unnecessary to dwell longer upon it. I shall now proceed to the description of those affections which may be said to be common to all the foregoing classes.

* Wilson on Syphilis, London, 1852.

CHAPTER XIV.

UNCLASSIFIED CONSTITUTIONAL AFFECTIONS.

Tubercular Eruption.-When enumerating the various forms of eruption which usually succeed to certain descriptions of primary ulcers, I studiously avoided ranking tubercles of the skin under any of the classes whose characters I detailed. Mr. Carmichael, while he does not particularly allude to this affection, would nevertheless seem to imply that it presents as one of the usual sequences of the primary phagedenic ulcer; and as regards the more general frequency of its occurrence in this affection, the accuracy of the observation has been fully borne out in my experience. I do not, however, from the deviations I have noted from that rule, feel warranted in describing it as one of the exclusive sequelæ, of that particular form of primary sore; and have therefore deemed it more advisable to appropriate a separate chapter to its consideration. Tubercles of the skin are deep-seated, solid and distinct elevations, containing neither lymph nor pus. They are more prominent, and engage a much larger ex

tent of surface than papulæ; and have their seat in some structure below the surface of the cutis, probably in the sebaceous glands. They vary in colour, sometimes assuming a brown or purple appearance; but, according to my observation, on their first accession they almost invariably exhibit a copper-coloured aspect. They may either present in groups or exist separately, and are usually either round or crescentic in form. Their progress is slow and indolent; and, after continuing in this state for some time, they terminate for the most part in softening and ulceration. When this result takes place, foul excavated ulcers, closely resembling rupial spots, are exposed to view; which, upon healing, leave behind them cicatrices, the centres of which are more or less depressed. Tubercles of the skin are frequently met with in the fore part of the chest, the surface of the abdomen, and back of the neck; in which situations they are usually conical, or present a more or less rounded form. They also engage the alæ or lobule of the nose. M. Ricord has discovered them on the tongue, and on the neck of the womb, where they often simulate carcinomatous indurations; and he has most commonly remarked them in persons of a scrofulous or scorbutic tendency. I have not unfrequently encountered them in isolated groups, about the size of a pea, upon the face; where they exhibit to a remarkable degree their characteristic induration, attended by an erythematous redness of the whole surface, and are most difficult of cure.

Treatment.-As this affection is for the most part associated with a general unhealthy condition of the system, it will be desirable, previous to the employment of any specific treatment, to apply ourselves to the disordered state of the constitution. When this is to a certain extent re-established, the cure of the disease by special remedies should at once be commenced. Tubercles of the skin at the onset are usually accompanied with much surrounding local inflammation; in which case evaporating cooling lotions may be applied with much advantage to the surfaces which they engage. If much irritation be present, fomentations, poultices, and aqueous solutions of opium will be found most useful. Contrary to the experience of M. Biett, I have found that when these tubercles are in a state of induration, their further progress may be arrested by the judicious employment of mercury. The preparation to which in this disease I give the preference, is the iodide in combination with conium. The arseniate of soda is a formula highly spoken of, and has been for some time employed with much success in the wards of the hospital at St. Louis. Some practitioners recommend the alternate use of mercury and iodine in a separate form; from which peculiar mode of practice desirable results are said to have accrued. I have found it, however, more beneficial, when ptyalism has been effected, to follow up the mercurial treatment by the administration of the iodide of potassium. In these instances,