British Medical Journal.] ORIGINAL COMMUNICATIONS. [June 3,1865.

when he had an attack of jaundice. He recoveredfrom this, and remained well till, four years ago, hebecame subject to bilious attacks accompanied by ir-regular action of the bowels. Three years ago, aftermuch annoyance and mental excitement, he sufferedfrom carbuncles on his back. Since that time he hadbeen in bad health; suffering from a feeling of numb-ness in the left leg, and occasional severe attacks ofdiarrhcea. He complained of occasional neuralgicpains, and at times entire absence of sensation in theleft foot. He walked into my room like a man de-bilitated by disease, but in no way resembling a par-alytic. He complained of having been affected withseminal emissions. I examined him very carefullyafterwards in bed, and could find no trace of loss ofparallelism or loss of motor power. I could notsatisfy myself, by the esthesiometer, of any materialimpairment of tactile sensibility; no tenderness ofthe spine and no abdominal derangement were trace-able; nor was there any disease of the rectum orprostate. I commenced the treatment with steel,and the application of an anodyne liniment; and or-dered wine, beer, and nutritious food. The patient,being a teetotaller, was with great difficulty per-suaded to take any fermented liquors. I obtained aspecimen of the morning and evening urine beforemy next interview, when I had a consultation with aleading physician on the case. Both specimens hada specific gravity of 1033, were strongly acid, exhi-bited no increase of phosphates, and containedneither sugar nor albumen. There were no crystal-line forms in either, and specifically no oxalates; butboth specimens almost solidified on the addition ofequal volumes of nitric acid, by the formation of ni-trate of urea. The joint examination elicited noproof of any organic disease; and it was agreed thatthe case was one of azoturia. The quantity of urinenever was large that was passed in the twenty-fourhours; it rarely attained to three pints. I find thaton one occasion I had the advantage of obtaining avolumetric analysis from Dr. Ringer; and the esti-mate was seven drachms and a half in the twenty-four hours-an amount considerably above what Dr.Parkes considers the average in the healthy adult.The gentleman remained under my treatment forthree weeks; and improved materially under the ad-ministration of mineral acids, opiates, and tonics ofvarious kinds. It was not till after twelve days' ob-servation that I discovered a few oxalates in hisurine. In a medical report which I gave the patientat his request, on leaving town, I stated that I re-garded the azoturia as the source of debility; andthat the drain caused by a persistent waste of tissue,indicated by an excess of urea is the urine, suffici-ently accounted for the anomalous nerve-symptomsto which he was liable.

I saw the same gentleman again at the end of1862, when he was passing through London after hehad, without medical advice, been taking the watersof Kissingen, and thereby brought on severe diar-rhcea. He was naturally weak in consequence; butthe urine presented a specific gravity of 1025-lowerthan I had ever seen it formerly, and I have a memo-randum that it contained but little urea.There are many insidious morbid conditions for

which we may find an adequate explanation in theurinary secretion, with important hints as to treat-ment and regime. The insidiousness of degenera-tive renal disease as indicated by albumen, is a pointthat can scarcely be too often mooted; and it is sur-prising how often and how long patients continueailing and complaininig of feebleness and want ofpower without presenting any very tangible symp-toms, when an examination of the urine reveals thecause of the anmmia, the weakness, and the apncea,

and at once suggests the proper indication. Al-though albuminuria is a much more frequent causeof these insidious symptoms than azoturia, still I amsatisfied that there are numerous cases of chronicdisease going through a weary life, for which theundue waste of the nitrogenous tissues indicatedby a high specific gravity of the urine and an exces-sive proportion of its urea affords a satisfactory ex-planation.

ON SYPHILITIC ULCERATION OF THEPALPEBRAL CONJUNCTIVA.

By JOHN WINDSOR, Esq., Consulting Surgeon of theManchester Eye Hospital.

OF the secondary symptoms of syphilis, there is onewhich appears to have been rarely observed bywriters on this subject, or, if observed at all, to havescarcely attracted particular notice or description: Iallude to an ulcerated state, evidently, from its his-tory, of syphilitic origin, appearing on the palpebralconjunctiva, and generally involving the adjoiningtarsal cartilage. It is certainly an affection, ascompared with other secondary symptoms, of ratherrare occurrence; and in my own practice, of now along duration, I do not remember (excluding, per-haps, two or three instances of it in congenital syphi-lis) to have met with more than about seven or eightcases; and of these, two of which occurred recently,I am enabled to add a brief report. Before doing so,however, I wish to premise a few remarks.The subject of syphilis has for a long time, but

more especially at a comparatively recent period,attracted considerable attention and research, bothin this country and abroad; from which, I believe, amore correct knowledge of the specific distinctions ofthe disease has been acquired than was previouslypossessed.At the present time, the conclusion arrived at seems

to be, that there are two forms of primary syphi-litic ulceration. One is the soft suppurating sore,sometimes accompanied, or soon succeeded, by en-largement, and not unfrequently suppuration, of theadjoining inguinal glands, but not contaminatingthe system, although communicable to others, andcapable of reproducing repeatedly, by inoculation,similar sores in the same or in a different individual.It may be observed that occasionally, from some in-flammation being excited, a degree of hardness isproduced even in this form, but still distinct fromthe circumscribed and generally characteristic in-duration of the other.The second form is the indurated sore, sometimes

called the Hunterian chancre, the character of whichis, in the first place, the secretion of an adhesive ma-terial, fibrine instead of pus (which latter occurs inthe other form); thus appearing at first often ratheras a pimple or hard tubercle, than a pustule. Withthis second form there is also not unfrequently someindurated enlargement of the adjoining inguinalglands, but it is not apt to undergo a suppurativeprocess. This second form is the one which infectsthe blood; enters into the patient's system, pro-ducing secondary symptoms; and, although commu-nicable to others, is not autoinoculable, except in itsearliest period, before the adhesive effusion takesplace. It, as a rule, occurs only once during life;whilst the first form may occur many times.The first form I would compare to the porrigo (impe-

tigo) larvalis (Willan), which, by contact, is often con-veyed from one part ofa child to other parts, or to thoseof its nurse. The second form I would rather compare,as infecting the general constitution, and mostly oc-curring once only during life, to small-pox, although

558

on 24 June 2020 by guest. Protected by copyright.

http://ww

w.bm

j.com/

Br M

ed J: first published as 10.1136/bmj.1.231.558 on 3 June 1865. D

ownloaded from

June 3,1865.1 ORIGINAL COMMUNICATIONS. [British Medical Journal.

differing by the virus of the latter being in a greatdegree speedily eliminated from the system. Likesmall-pox, also, it has a period ofthree to seven weeks,or more (according to Mr. Henry Lee), of incubation,before the characteristic circumscribed hardness ap-pears in the original fissure, abrasion, or pimple;and we know that another period intervenes beforethe appearance of secondary symptoms.

It seems possible that these two forms of syphiliticulceration may coexist in the same person, and thusbe communicated simultaneously to another; andthus, probably, the appearance of a pustule, notattended by a period of incubation, may sometimesprecede the development of the true incubated

The first, or soft suppurating sore, is curable with-out the use of mercury, and its specific character maybe generally effaced by the early application of caus-tics. The second, or indurated infecting sore, alongwith its secondary constitutional symptoms, or, asnot unfrequently occurs, in its congenital hereditaryform, yields to the action of this valuable medicine,administered seasonably, moderately, and cautiously,according to the circumstances or peculiarities ofeach case. For our present more precise knowledgeof syphilis, we are especially indebted to the re-searches, experimental and practical, of Mr. HenryLee, as shown in his recent work on Syphilis; al-though, doubtless, there have been other able coad-jutors, both domestic and foreign, in the investiga-tion of this important subject.With regard to the more immediate subject of this

paper, it seems, as far as I know, that Mr. Lawrencewas the first to give an accurate description of it, aspublished in his work on Diseases of the Eye, as alsoin his work on the venereal disease of that or-gan. Ithas been since mentioned in the works of Mackenzie,and also of Middlemore, on the eye; and in themanual of Wharton Jones; perhaps, also by others;but I do not see it mentioned in Travers's excellentSynopsis, nor in Morgan's Lectures on the Eye. Nei-ther have I seen any account of it in Scarpa's orWeller's works on the diseases of the eye. It is ad-verted to in Desmarres's, and also in Deval's, Traitesdes MIaladies des Yeux; but not in the earlier worksof Demours or Desmonceux; nor is it noticed, Ithink, except very slightly, by Carmichael of Dublin,or Sir Charles Bell; nor in the comprehensive workof Langston Parker (third edition) on Syphilitic Dis-eases; yet Mr. Parker notices particularly the fre-quent occurrence, in secondary syphilis, of inflamma-tion and ulceration of the mucous membrane invest-ing the nares.Some of the first examples of the affection which

I had an opportunity of seeing occurred in personswhose cases I have recorded as instances of the pha-gedwnic form of syphilitic ulceration; and the soresappearing on the palpebral conjunctiva are noticedincidentally, as seen in a subsequent period of theprogress of the disease. Indeed, at that time (1821)my attention had not been particularly directed tothe subject; and the first edition of Mr. Lawrence'swork, containing his remarks on it, was not pub-lished until 1833.CASE I. I was called on May 16th, 1825, to a gen-

tleman named R. Allen, on account of a rheumaticaffection. At the same time, a hard tumour, ofabout the size of a pea, presented itself near thefrnenum penis, which gradually became more in-flamed, and afterwards ulcerated ; the ulceration soonextending much over the part between the prepuceand the glans, forming a very large irritable sore,with hard ulcerating edges. In this state it pro-ceeded for a few weeks; and then, after the conti-nued use of decoction of sarsaparilla, aperients, and

milk diet, with rest, it began to assume a healingaspect, and was nearly well, when he irritated it byexposing himself to a fresh infection; but, by per-severing in the same treatment, it again presented ahealthy healing appearance, under the application ofpoultices and mildly stimulating mercurial oint-ments. On August 12th, it was nearly well; and aneruption on the forehead, which had troubled him forabout six weeks, had also disappeared, excepting themarks. under the same treatment. Recently. how-ever, the disease had reappeared in the form of fiveor six blotches on the forehead, of a circular form, ofabout the size of a sixpence, or smaller, flat in thecentre and elevated at their margins, all of a cop-pery red colour; one on the head, amongst the hair,discharged matter occasionally from under a crust;and one on his forehead was nearly in the samestate. There were two or three smaller eruptions onhis face, in the form of acne or ecthyma. He conti-nued to take decoction of sarsaparilla; and a solutionof hydrargyrum corrosivum sublimatum was applied.

Oct. 1st. The eruption on the head and face wasnearly well. For the last fortnight he had com-plained of his throat, which, on inspection, lookedrather red, but was not uleerated. The sore on theinferior part of the glans, or rather on the corpusspongiosum behind it, continued open, but had aclean healthy appearance.Nov. 12th. He called upon me. Having gone out

much during wet cold weather, and also living ratherirregularly, he was not so well; his throat had be-come ulcerated on both tonsils, and on the posteriorpart of the pharynx, with hoarseness and some cough.The eruption on the skin continued better; the soreon the penis about the same. His pulse was acce-lerated; his appetite and general health indifferent.I directed him to stay at home, and to live much onmilk diet; prescribing him pills twice a day of ex-tract of conium and rhubarb (sing. gr. iij) ; and decoc-tion of sarsaparilla with dilute nitric acid after eachdose; also to use frequently a gargle of oxymuriateof mercury with tincture of myrrh and rose-water.Nov. 19th. A sore (serpiginous), which he had

had on his forearm, was now healing from the centre,whilst its margin was yet rather ulcerating. Thesore on the penis was healing in some parts from itsedges, but in others was rather ulcerating. Histhroat was about the same. A very large abscess,formed in the perinaeum in consequence of a blow onthe part, discharged freely. A few scattered spotsappeared on the trunk, but were scarcely ulcerating.

Nov. 27th. He was in nearly the same state.The phagedaenic or serpiginous sores were still ratherextending. The tonsils and posterior part of thepharynx were almost covered with ulcers. One also,for the last ten days, had formed under the superiorpalpebra of the left eye. That on the penis was ex-tending at the margin, although healing at itsmiddle. That on the arm was cicatrised, but wasred, hard, and elevated. There were several soreson his body, but there was scarcely any dischargefrom them. The sore from the blow in perineoseemed healthy, but was still large. The sores onhis body were dressed with resin cerate, and those inthe throat were touched once or twice a day withoxymel eeruginis. The other medicines were conti-nued.

Dec. 18th. The oxymel weruginis, with an equalquantity of water, the parts being washed immedi-ately afterwards, seemed to have had a good effecton the sores of the throat, penis, forearm, and con-junctiva palpebru; and all of them appeared healing,as was also slowly that of the perineum. The pulsewas still frequent, and the appetite indifferent.

Dec. 28th. The sore on the penis, after being open569

on 24 June 2020 by guest. Protected by copyright.

http://ww

w.bm

j.com/

Br M

ed J: first published as 10.1136/bmj.1.231.558 on 3 June 1865. D

ownloaded from

British Medical Journal.1 ORIGINAL COMMUNICATIONS. [June 3, 1865.

nine months, was now just healed. The throat andother parts were also rather better, and his generalhealth was a little improved.

Jan. 1st, 1822. About a dozen scabbed sores ex-isted on the back and right side of the trunk, varyingin size from that of a sixpence to a shilling. I pre-scribed him hydrargyrum cum creta and rhubarb(sing. gr. iij) three times a day, with an antimonialdemulcent mixture.

Jan. 30th. He was nearly in the same state.Another small ulcer, which had appeared under thesame palpebra, but rather nearer the external can-thus, was touched with the oxymel aeruginis.

Feb. 18th. The conjunctival lining of the superiorpalpebra was nearly healed, but appeared of an un-equal white and red colour, and was not perfectlysmooth. The throat also appeared rough and ulcer-ated in points. Small ulcers on the penis alternatelyhealed and broke out again. The incrustations onthe trunk were in general falling off, but some formedagain. His general health seemed rather improved.

April 20th. The state of the throat, conjunctiva,penis, and perinaum was about the same; and thecutaneous incrustations continued in the same state.He had some cough, and a little cedema of the lowerextremities towards night.June 4th. The palpebral conjunctiva continued a

little red and rugose, but not ulcerated; the otherparts were much the same. The cutaneous scabshad in a great measure fallen off. The cough andcedema of legs were nearly gone. Pulse frequent;appetite and sleep moderate. He walked out now alittle almost daily.June 21st. The palpebral conjunctiva of the left

eye was again ulcerated; that of the right one hadalso latterly become affected, first by a few enlargedvessels appearing, which soon increased so as to pro-duce a dense red spot, the precursor, probably, ofulceration. Numerous scattered spots of acne orcethyma, with a yellowish suppurating point, hadappeared nearly all over the body, producing muchsoreness. The throat was also in the same ulceratedstate as it had been occasionally before. For thelast four or five weeks he had been using, by his owndesire, a mild mercurial course; but during this timethere had been rather an aggravation of his com-plaint.

July 16th. The eruption was rather worse thanbetter, affecting the face (especially the nose, whichwas almost covered with scabs and ulcers), the head,back, arms, and indeed the whole surface of the body.Some of the ulcers were covered with large crusts;others were discharging, and recquiring to be dressed.The throat, palpebral conjunetiva, perinanum, andpenis were much in the same state as before. I de-sired the mercury, which had been taken lately invery minute doses, to be entirely omitted; and orderedhim to take only a mild aperient pill, and the decoc-tion with acid as before.

Oct. 30th. Since last report, he had been stayingin Liverpool; and during that tilme had been chieflyunder the care of Dr. Macartney, who prescribed forhim compound decoction of sarsaparilla, with an ad-dition of extract of sarsaparilla, three tablespoonfulsthree times a day; one-eighth of a grain of bichlorideof mercury three times a day; and six minims ofliquor arsenicalis three times a day; also antimonialpowder, with extract of conium and opium, eachnight; and black oxide of mercury for fumigation.He also took twice a day a pill of two-thirds of agrain of black oxide of mercury, with ten grains ofcompound chalk powder and a grain of opium. Thewarm sea-bath was tried, but it seemed rather to in-crease the eruption. At present he was much better.The scabs had in a great measure fallen off, leaving

560

the parts healed. The ulcers of the conjunctiva werehealed; the penis also. The throat was better, andthe perinceum was healing. His general health wasimproved. Pulse natural; appetite moderate.

Dec. 6th. The pills and arsenical drops hacl beencontinued; but, some diarrhcea having come on, Idesired him to discontinue them for a short time. Aspot of ulceration, of about the size of a split pea,had appeared on the velum pendulum palati. Hewas prescribed half a pint of compound decoction ofsarsaparilla twice daily, and to use the gargle as be-fore for his mouth and throat.

Feb. 20th, 1823. About three weeks since, whilstthere was a very severe frost, he continued to go outdaily. Calling upon him at this time, I found thethroat, tonsils, uvula, and pharynx presenting asloughy appearance. Two sores upon the front ofhis leg had also a nearly similar aspect. His pulsewas frequent, but his appetite tolerable. I desiredhim to keep the house, to live pretty well, to use hisgargle warm, and to apply to his leg a linseed poul-tice. In about a week, the throat became cleaner;the greater portion of the uvula, sloughing off, cameaway. The ulcers on his leg had a sloughy andulcerating appearance. I desired the linseed poul-tice to be exchanged for a bread and milk one, whichimmediately effected a favourable change, the soresassuming a granulating state, and soon beginning tocicatrise. His general health again improved. Theconjunctival sores healed; those of the penis andperinuum nearly so. His skin was pretty free fromtuberculous or eethymatous eruption, but almostcovered with large cicatrices.March 27th. He continued better as to the ex-

ternal complaints, these being confined to a fewsmall clean ulcers on his legs; but he had now be-come decidedly the subject of ascites, with cedema ofthe lower extremities.Having already related this case so much at length,

I will refrain from further details, only stating that,by the means adopted, the dropsical symptoms wereremoved.

Mlarch 1825. After the last report, he had a re-turn of tuberculous or acne-like eruption all over hisbody, with much headache and some sore-throat;but he had now for some time been in tolerablehealth, only he was considerably altered in his ap-pearance by the very long duration of his illness andthe numerous cicatrices on his face.

Since reading the work of Langston Parker, I aminclined to think that the disease would probablyhave had its course arrested by larger use of somemercurial fumigation.Having dwelt so long on the recital of the above,

as I consider, very interesting case, I will endeavourto be more brief in what has to follow.CASE II. In October 1827, I saw a gentleman

named Daniels, affected much in the same way asAllen was. He had ulcers on the palpebral conjunc-tiva and tarsal or ciliary margin; also an enlarge-ment of the left testis, or what has been called syphi-litic arcocele. Under the use of decoct. sarza andliquor arsenicalis, he soon improved, and in about twomonths was almost well, the sores being all healed,except one on the left arm, now also healing. Thetestis also was much reduced in size, under the appli-cation of ol. palmwe camphor. I saw him occasion-ally for a while; and on April 5th, 1828, I found hehad been well for some time. I should add, that hehad been under good medical advice for some timebefore I saw him.CASE III. September 1841. I attended a Mrs. B.,

affected with an eruption of rupia and the phage-daenic form of secondary syphilis. The throat wasulcerated, and there was ulceration of the palpebralt

on 24 June 2020 by guest. Protected by copyright.

http://ww

w.bm

j.com/

Br M

ed J: first published as 10.1136/bmj.1.231.558 on 3 June 1865. D

ownloaded from

June 3, 1865.1 ORIGINAL COMMUNICATIONS. [British Medical Journal.

conjunctiva near the ciliary msargin. There was alarge prominent crust in the hairy scalp, near theforehead; and a smaller one behind it. There wasan ulcer on one thigh, succeeded by a few others onthe foot. She had a good deal of pain, with someswelling and tenderness of the knees.

She was soon relieved by the use ofae. odyles andthe iodide of potassium. The throat healed oververy soon; and also the ulcer on the thigh, whichwas dressed with resin cerate and a small addition ofred precipitate. The ulceration of her palpebrae con-tinued for some time; and the crusts on the headwere very slow in falling off and healing, the largerones especially.CASE iv. Ann Barlow, aged 23, married about

f3urteen months, came under my care as an out-patient of the Manchester Eye Hospital October28th, 1847. The ciliary margin cf the superior pal-pebra of the right eye was ulcerated away, except asmall portion towards the external canthus. Therewas also an ulcerated state in the middle portion ofthe ciliary margin of the lower palpebra, which wasmore especially covered with a puriform fluid. Theglobe itself was unaffected, only it had been a littlered occasionally. There was an enlarged gland,rather sore when touched, in front of the right ear;and a similar one just below the angle of the inferiormaxilla on the right side. She complained of muchpain, of a burning, throbbing, and lancinating kind,in the palpebree and surrounding parts. That side ofher face was hotter and redder generally than theother. About fourteen weeks previously, a small ulcerappeared under the upper eyelid. Her medical at-tendant at Ashton-under-Lyne applied to it stimu-lants and escharotics; but the ulceration extended tothe tarsal margin, and had extended during the lastfortnight. Pulse 96; tolngue pretty clean; bowelsconfined; appetite indifferent; she complained ofheadache; the catamenia had not appeared since hereye was affected; and she thought she might bepregnant. She had hact one child born at sevenmonths-on May 3rd. It died of convulsions, whenfive weeks old. It had nlo particular eruption on theskin. About seven mionths after marriage, she be-came affected with sore places about the pudenda;and, some time before that, she had much vaginalsoreness. Some months afterwards, her throat be-came sore and ulcerated; it was about two months inhealing. Afterwards, her eye became affected; and,within the last fortnight, red hard spots had ap-peared on her legs; they were very sore to the touch,and apparently intermediate between nodes and ery-thema nodosum. There were several of them on theright leg, and a few on the left; they were not all onthe periosteum. There were about three also on theleft thigh, quite cutaneous. She could ascribe nocause for the complaint, except infection from herhusband, who appeared to have had syphilis. Pre-viously to her marriage, she was very healthy.A colleague of mine, who accidentally saw the case,

was, at first view of the palpebrae, impressed with theidea that it was a malignant and intractable affec-tion; but, judging from its history and my formerexperience, I was inclined to entertain a more favour-able opinion. I prescribed ten grains of blue pillthree times a day; and with each dose two table-spoonfuls of an iodide of potassium mixture, andzinc ointment to the tarsi.$ Potass. iodid. 3ij; syrup. pap. f. 3iv; aquLi ad f.

xiJj.Nov. 1st. The ulceration of the palpebrm looked

cleaner, more kindly, and was attended with lesspain.

Dec. 1st. The ulcerated parts were now nearlyhealed, the improvement having progressed regularly

since last report. The tarsal margins were againnearly even, being only slightly indented in one ortwo points. She had continued her medicines regu-larly. Sulphate of copper had been occasioAally ap-plied to the ciliary margin.

Jan. 10th, 1848. She continued pretty well, andscarcely any difference was observable in the twoeyes.

September. She called again to express her thanks,and to show that her eyes remained well.CASE V. July 29th, 1840. Jane Beresford, aged

21, married, came under my care as an out-patient ofthe Manchester Eye Hospital. She said that, abouttwelve months since, she became infected with syphi-lis by her husband. After suffering from secondarysymptoms, in a few weeks she became affected withsore-throat, followed by uleerating blotches on herlegs and back, not more than two or three on theformer, and one or two on the latter, all now nearlyhealed. Latterly the palpebrse had become affected,presenting a reddish swollen appearance, along withsome ulceration of the ciliary margin, extending alittle inwards upon the conjunctiva. I prescribedfor her the same treatment as mentioned in the pre-ceding case.Aug. 3rd. The palpebrfe were still reddish, and a

little swollen; but the ulceration was already almosthealed, and her general health was improving.Nov. 12th. She had been for some time pretty

well, and discontinued her medicines soon after lastreport.CASE VI. On December 30th, 1863, I was con-

sulted by Mr. N., a middle-agred man, unmarried, onaccount of an affection of his eyes and throat, whichhad been coming on for a week or more. The diliarymargins appeared red and somewhat swollen; and,on everting the superior palpebrae, two small ulcerswere visible on one of them, and one only on theother. Each ulcer was a little excavated, presentinga yellowish base, and was about the size of a splitpea. They were all on the palpebral conjunctiva,quite within the ciliary nmargin, and, therefore, notobservable until the palpebra were everted. On excamining the throat, a rather large yellowish ulcer wasseen on the left tonsil. I prescribed him the samemedicines as in the preceding cases, and a lotionfor his eyes.

Jan. 3rd, 1864. The ulcers on the palpebral con-junctiva and left tonsil had lost their yellowish coat-ing, and seemed healing.

Jan. 9th. The ulcers were now scarcely visibleeither on the palpebrie or tonsil. The medicineswere continued.

Jan. 15th. The ulcers were now healed, and hisgeneral health was improved. He had, however,still som-e ulcers on his legs-a frequent, if notgeneral, concomitant of this form of syphilis; theulceration being often of a sloughy, phageduenic, orserpiginous character, at least in one period of itsprogress.CASE VII. October 29th, 1864. I was consulted

by a Mr. B., aged about 30, malTied, residing untilrecently at New York. He had an ulcer occupyingthe tarsal margin of the left superior palpebra, andextending.somewhat within the conijunctival surface.The surrounding textures appeared reddish andthickened. He first noticed the affection about threeweeks ago, and it had gradually become a littleworse. He had not hitherto used any particular treat-ment for it. About eighteen months since, he becameaffected with a cutaneous eruption in large spots(ecthyma?) on his legs and shoulders, and also withulcerated sore-throat; but these were now all healed,leaving rather large cicatrices on the skin. He saidthat he had gonorrheea about the commencement of

561

on 24 June 2020 by guest. Protected by copyright.

http://ww

w.bm

j.com/

Br M

ed J: first published as 10.1136/bmj.1.231.558 on 3 June 1865. D

ownloaded from

British Medical Journal.] REVIEWS AND NOTICES. [June 3, 1865.

his complaint, but was not certain as to the exist-ence of primary sores. I prescribed for him nearlythe same medicines as in the preceding cases; theblue pill being united with an equal quantity of ex-tract of conium and mixture of iodide of potassium.The affected lid to be brushed occasionally with tepidwater, and anointed afterwards with the milder mer-curial ointment.

Nov. 2nd. The ulceration of the ciliary marginand adjoining palpebral conjunctiva, as well as theaccompanying redness and swelling, were diminished.The cicatrices on his legs, etc., varied in size fromthat of a sixpence to about that of a shilling.

Nov. 7th. The external ulceration of the tarsuswas now healed; that of the conjunctiva internallywas contracting, and presented a healthy granu-lating surface. The swelling and redness of themargin had disappeared.

Nov. 19th. The ulceration was quite healed, leav-ing a slight, scarcely perceptible depression in thesite of the lately ulcerated. ciliary margin; and thecilia corresponding to that part had quite disap-peared.

REPORT ON THE CHEAP WINES FROM FRANCE,ITALY, AUSTRIA, GREECE, AND HUNGARY, ETC.By ROBERT DRUITT, MI.R.C.P., etc. Pp. 179.London: 1865.

THE writer advocates the largely increased use ofwine in diet and in medicine, and the use of greatervariety. His is not a formal treatise on wine; buthe takes the various cheap wines actually on sale inLondon at the present moment, and describes theirqualities and uses. First, he discusses the differencebetween pure wine and fortified wine, observin thatthe English differ from every other civilised peopleon the face of the earth by their predilection forwine which has been dosed with about 20 per cent.of proof spirit. He shows that conmmon spirit ismore or less contaminated with fusel oil and otherirritating substances, and is made out of the cheapestand commonest grain; and that this common spiritis largely exported to Portugal, and returns in theshape of port wine! He shows that pure wine, ofnatural strength and unfortified, has about 20 percent. of natural spirit, derived from the fermenta-tion of its saccharine element. He teaches us howto judge of wine, laying especial stress on the bodyof wine-i. e., the totality of its sapid and aromaticingredients, as contradistinguished from mere alco-holic strength. A mixture of spirit and water, hesays, however strong, has no body. The question ofacidity is also treated of, and a table is given withnew determinations of the acidity of twenty-fourkinds of wine. The headaches, heartburn, gout, etc.,which follow the use of wine, he attributes to thewine being imperfectly fermented, or to $he admix-ture with it of ardent spirits; and, let the wine onlybe pure, and there is no fear in drinking of it plen-tifully. Taking half-a-crown per bottle as a defini-tion of cheapness, he gives a description of morethan a hundred samples of cheap wine of all sortswhich he has purchased and drank in Londonwithin the last two or three years; beginning withthe Bordeaux and Burgundy;-then taking the lessknown Greek, Hungarian, Austrian, and Italian

wines, of which he details the names, prices, taste,alcoholic strength, etc. Amongst the Hungarianand Austrian, he describes all, whether cheap ordear. There are also remarks on cider, mead, cham-pagne and sparkling winies, and on cheap port andsherry, etc. The whole is interspersed with constanteulogies of that mode of philosophising which theNvriter calls " empirical", and which consists in argu-ing from the results of experience, and not from apriori considerations. Sonie space is devoted to anexamination of hypotheses on which certain wineshave been recommended by well known chemists andphysicians, as, for example, Liebig. He and some ofhis disciples have asserted that good wine is " rich inphosphorus"; and have asserted of some wines, thatthey are good because rich in phosphorus, which is avery different thing. Our readers must often havenoticed a wine advertisement in which the words" No LIFE WITHOUT PHOSPHORUS" appeared instaring letters. It seems to give the writer a pecu-liar satisfaction to tear these hypotheses to rags andtatters, and to decry all systems of medicine anddiet which do not rest upon experience.The subject is naturally an attractive one even to

teetotallers, and our author has certainly treated it in apractical and attractive manner. The British con-sumer of wine will derive both pleasure and profitfrom its perusal; but that he will be seduced fromhis strong and old-fashioned glass of port and sherryto the lighter draughts of Rhenish and Austrian,etc., produce, we will not venture to prophesy. Ne-vertheless, the author deserves our thanks for throw-ing his stone at the system of brandying naturalwines and poisoning them with bad spirits.

A MANUAL OF THE DOMIESTIC PRACTICE OF MEDI-CIN.E. By W. B. KESTEVEN, F.R.C.S. Pp.339. London: 1865.

"IT is not," says the author, " the intention of thisManual to supersede the office of the professionalattendant." But many persons are themselves obligedto practise medicine, because they cannot procurethe benefits of medical skill; and it is for the benefitof such that this book is written. Mr. KESTEVEN saysthat he has reason to know that the first edition ofhis Manual has been of service both at home and inthe colonies. We have no doubt it has been so; butthen, unfortunately, books of this kind are apt to bea source of error to the well-intentioned. A fewdistinct practical rules, comprehenisible to ordinarynon-professional understandings, are no doubt veryserviceable to all persons, as well to those who can asto those who cannot obtain professional assistance;but works which enter too minutely into the subjectare likely to be the source of mischief in the hands ofthe good-natured busybodies who generally under-take the duties of doctor in village and outlying dis-tricts, where doctors' aid is not readily procured.How, for example, can my Lady Bountiful, even withthe help of this manual, make a diagnosis of " Brain,Inflammation of ; Acute Water on the Brain; AcuteHydrocephalus"? Is it safe to tell that good ladythat, in cases of this kind, she must give " an adultten grains of calomel" and a senna purge; and, afteraction of the bowels, " calomel in doses of twograins every four or six hours" until the gums be-come inflamed; and also to tell her that, " when this

562

on 24 June 2020 by guest. Protected by copyright.

http://ww

w.bm

j.com/

Br M

ed J: first published as 10.1136/bmj.1.231.558 on 3 June 1865. D

ownloaded from