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which absorbs it, and which thus becomes a new source of irritation; it emits also a very fetid odour. This process takes place in the successive patches of the eruption, until the whole surface of the body, from head to foot, is sometimes in a state of painful excoriation, with deep fissures in the bends of the joints, and in the folds of the skin of the trunk; and with partial scaly incrustations of a yellowish hue, produced by the drying of the humour, by which also the irritation is augmented. The extreme pain arising from the pressure of the weight of the body upon an extensive portion of such a raw surface, is sufficient to give rise to an acceleration of the pulse and white tongue, but the functions of the stomach and of the sensorium commune are not evidently disturbed by this disease. The duration of this excoriation and discharge is uncertain and irregular ; when only a small part of the body is affected it may terminate in ten days, but when the disorder has been universal, the patient seldom completely recovers in less than six weeks, and is often afflicted to the end of eight or ten weeks. By so severe an inflammation the whole epidermis is destroyed in its organization; and when the discharge ceases it lies loose, assuming a pale brown colour, which changes almost to black before it falls off in large flakes. As in other superficial inflammations, however, the new red cuticle that is left is liable to desquamate again, even to the third or fourth time, but in smaller branny scales of a white colour, and a roughness sometimes remains for a considerable period, like a slight degree of psoriasis. In some instances, not only the cuticle but the hair and nails are also observed to fall off; and the latter, when renewed, are incurvated, thickened, and furrowed, as in lepra." (pp. 255, 56.)
CARMICHAEL mentions that he “ knew a gentleman who was always attacked by this eruption when he took but a single grain of calomel, and also an instance of the disease being produced by the application of the black mercurial wash to a venereal ulcer.” (p. 326.)
“ Although the Eczema mercuriale is produced by the action of mercury, yet the disease is not always exasperated by persisting in the use of it; for in some particular cases, where,' says PEARSON, I judged it to be of great moment to continue the mercurial frictions, the eruption neither spread universally, nor was it materially increased, although the patients were not relieved from it till mercury was discontinued.'” (p. 173)
(4) Bacot says:-“The character of the mercurial ulceration of the throat is that of an aphthous superficial sore, surrounded with a general blush of inflammation. The tonsils are the usual seats of the ulceration, and they are sometimes also met with on the velum pendulum palati. Occasionally there is much stiffness and difficulty of swallowing, without the appearance of any breach of surface at all. Now, independently of the mere appearance of the sore, these symptoms will always be found in connexion with, or almost immediately following the use of the remedy-that is to say, that when towards the termination of a mercurial course, whether the effects of the mineral have been such as might have been wished for and expected or not, if the patient begins to complain of pain or difficulty in swallowing, and upon examination the tonsils are found either studded with small ulcers or affected with only one larger superficial sore, the patient being himself not quite free from fever, with disturbed rest and feelings of general discomfort, there can be no hesitation in believing that this disease is the result of mercurial action. The same symptoms making their approach within two or three weeks after the mercury has been discontinued, will also admit of the same explanation, and more especially if our patient, after having been confined to the house, or nearly so, during his cure, has been exposed to sudden or severe transitions of temperature.” (pp. 265, 66.)]
860. The character of the mercurial disease is diminished cohesion and atony ; it is a cachexy similar to the scorbutic. The means recommended for it are, leaving off the mercury, the employment of warm and strengthening dietetic treatment, sarsaparilla, saponaria, smilax china, dulcamara, bardana, guiaiacum, mineral acids in connexion with wooddrinks, the tinct. arom. acida,-sulphurico-acida in decoction of fine buds or malt; mild, strengthening, and astringent remedies, bark, cascarilla, folia aurantiorum and fol. ilicis aquifolii in decoction or infusion; subsequently, steel. In the mercurial disease, disturbance of the functions of the liver usually occurs, against which the laxative extracts, and especially the extract. chelid. maj., recommended by the English practitioners, in connexion with soda and the like, are of considerable service (1).
For the local treatment, penciling the ulcers with muriatic acid, and gargles of hemlock and honey ; in the eruptions on the skin, sometimes antimonial, sometimes guiaicum preparations, lig. sapon. stibiati, tinct. guiaic. ammon. ; in pains of the bones, bark, opium, and aromatic baths. STRUTE'S hunger-cure has been recommended as a most important remedy, as also the use of sulphur and ferruginous baths. If after the removal of this cachesy syphilis still exist, the red precipitate of mercury, with wood-drinks, is very efficient. Although it is characteristic of the mercurial disease, that it becomes worse under the use of mercury, and although this disease arises by the immoderate use of mercury, without syphilis being present, for instance, from the operation of mercurial vapour, and so on; yet, however, on the other hand, it is certain, that it frequently is only the consequence of immoderate and improper mercurial treatment, of a repeated suppression of the syphilitic disease, which however continues only under an altered form ; a methodical suitable mercurial treatment is therefore capable of curing both the mercurial disease and the syphilis. From my own experience, I must give the preference to ZITTMANN's decoction be fore all other treatment (a).
SCHMALZ has, in electrifying patients, in whom it could not be made out, which was to be considered the consequence of syphilis, or which of the immoderate and improper ese of mercury, observed salivation occur without further employment of mercury, and to such an extent, that severe mercurial fever and profuse sweating came on at the fifteenth day. He administered the electric aura to the patient either by a dome placed on his head, or put the chain into his hand, and continued the electric stream at first only for a quarter of an hour. Therewith also he gave water-gruel, with medicine twice a day; took care to keep the bowels open, and to preserve the warm temperature of the chamber, which the patient was not allowed to leave (6).
[(1) “ To prevent the dangerous consequences of this diseased state ( Erethismus percurialis) the patient ought to discontinue the use of the mercury," says Joux PEARSON; “ nor is this rule to be deviated from, whatever may be the stage, or extent, or violence of the venereal symptoms; the impending destruction of the patient forms an argument paramount to all others. * * * The patient must be expressly directed to expose himself freely to a dry and cool air, in such a manner as shall be attended with the least fatigue. It will not be sufficient to sit in a room with the windows open ; be must be taken into a garden or a field, and live as much as possible in the open air until the beforementioned symptoms be considerably abated. The good effect of this mode of treatment, conjoined with a generous course of diet, will be soon manifested; and I have frequently seen patients so far recovered in the space of from ten to fourteen days, that they could safely resume the use of mercury, and, what may appear remarkable, they can very often employ that specific efficiently afterwards without suffering any inconvenience. *** "In the early stage the farther progress of mercurial eretkisaus may be frequently prevented by giving the camphor mixture, with large doses of volatile alkali, at the same time suspending the use of mercury." (p. 157-159.)
“ As a general rule," in Eczema mercuriale, says PEARSON, “I would premise that the administration of mercury must be discontinued on the first appearance of the eruption. The Eczema mercuriale certainly admits of a natural cure, not only when it affects the body partially, but when it is universal; yet, although the troublesome symptoms which arise may be relieved by their proper remedies, I am doubtful whether any plan of treatment has the power of interrupting its regular course, or abridging its duration. I have been confirmed in this opinion of the inefficiency of any medical aid in curing the disease, in the proper sense of the term, by observing that under all the various modes of treatment which I employed, this disease, like some of the eranthemata, par sued its usual mode of progress, without undergoing any apparent change, either in the number of its essential symptoms, or in the comparative mildness and continuance of them." (pp. 176, 177.) PEARSON, however, thinks the patient may derire advantage from medical treatment, so that his general health should not suffer material or per manent injury; and recommends antimonial powder and saline draughts, or liquor of
(a) WEDEMEIER, above cited.
acetated ammonia at the onset, with gentle purging, and opium to allay irritation either with camphor or HOFFMAN's anodyne (spir. ath. sulph. comp.); and “ when the discharge is no longer ichorous, and the tumefaction is subsiding, sarsaparilla with bark may be given liberally.”
“ The cure of the sore throat proceeding from constitutional irritation or cold taken upon mercury must,” says Bacot, “ be effected by purging, by antimonials, by an abstinent diet, as far as animal food and fermented liquors are concerned. * * * When all febrile heat is removed, the bark or sarsaparilla will be found of great efficacy in restoring the vigour of the constitution and expediting the healing of the sore.” (p. 266.)]
The subjects gummata and nodes are considered under ExostosES.
VIII.—OF ULCERS OF BONES. DUVERNAY, Traité des Maladies des Os. Paris, 1751. Part ii. FERRAND, Dissert. de Carie Ossium. Paris, 1765. CLOSSIUS, C. F., Ueber die Krankheiten der Knochen, Tübingen, 1798, p. 40. SCARPA, A., De penitiori Ossium Structura. Lipsiæ, 1799. HEMMER, Dissert. de Spinâ Ventosa. Hafniæ, 1695. AUGUSTIN, F. L., Dissert. de Spinâ Ventosa. Halæ, 1797. Louis; in Mémoires de l'Académie de Chirurgie, vol. v. p. 410. David, Observations sur une Maladie connue sous le nom de Nécrose. Paris, 1782. WEIDMANN, J. P., De Necrosi Ossium. Francof., 1793.
RUSSELL, J., A Practical Essay on a certain Disease of the Bones termed Necrosis. Edinb., 1794.
RINGELMANN, De Necrosi Ossium. Rudolst, 1804.
WISSMANN, L., De rite cognoscendis et curandis nudatione, carie et necrosi ossium, observationes pathologico-medicæ. Halæ, 1820.
RICHTER, Die Necrose pathologisch und therapeutisch gewürdigt; in von GRAËFE und von WALTHER's Journal, vol. vii. part iii. p. 402.
SANSON, L. J., De la Carie et de la Nécrose comparée entre elles. Paris, 1833. 4to.
TROJA, Mich., De Novorum Ossium, in Integris aut maximis ob Morbos Deperditionibus, Regeneratione Experimenta, &c. Lutet. Paris, 1795. 12mo.
STANLEY, EDWARD, Abstract of Lectures delivered before the College of Surgeons ; in London Medical Gazette, vol. xx. 1837.
A.-OF CARIES. (Caries, Lat; Knochenfrass, Beinfaule, Germ. ; Carie, Fr.) 861. Caries consist in a diseased change of the substance of bone, analagous to ulcers in soft parts (1). If the diseased bone be bared of the soft parts covering it, it is found to be brownish, often blackish, its surface rough and uneven, yielding, worm-eaten and destroyed to a considerable extent; the bony layers are fragile, may be easily penetrated with a silver probe, and a grayish brownish or blackish ichor escapes, which gives out a filthy and peculiar smell; the bony layers are frequently loosened, and spongy or fleshy growths (Caries fungosa) spring up from the surface of the ulcer (2).
[(1) “ The term caries," says LAWRENCE,“ does not apply to all the circumstances under which ulceration of a bone takes place. When a portion of a bone dies, that part is separated from the sound portion by a process of ulceration ; but that ulceration does not come under the denomination of caries. Ulceration of bone, in fact, like that of the soft parts, is various in its nature. There is a healthy ulceration in soft parts, enabling them to repair injuries; and there is a similar ulceration in bone. Now to that healing kind of ulceration we do not give the term caries; but we apply the term caries of the bone to an unhealthy species of ulceration, an ulceration which is not of a salutary but of a destructive nature. This kind of ulceration, like the morbid ulceration of soft parts, is preceded by inflammation; the bone first inflames and then ulcerates, just as you observe in the case of a sore leg, where the skin infames first and then proceeds into a state of ulceration. This state, too, is accompanied by the formation of matter, in which respect caries, or the ulceration of a bone, is apalo gous to the same process in the soft structures of the body. Such, then, is the sense in which we employ the term caries; it is a morbid ulceration of the bone, preceded by inflammation, and attended with some kind of suppuration or formation of matter." (p. 356.)
(2) As MIESCHER states, “ Granulations are not entirely deficient, inasmuch as every bony surface, affected with caries, is covered with a certain soft substance, corre sponding to the growing granulations in healthy suppuration ; but they are of a bad kind, of livid colour, and when touched bleed easily ; mostly they are scanty, but sometimes so luxuriate in a kind of fungus, that the roughness of the bone itself can be scarcely, ar not at all, examined. Of whatever kind they be, they never go on to scar, but having been produced by humours, the commixture of which has been corrupted by general disease, and acquiring their life from that part of the body of which its own life has been altered by disease, they have an organic structure but little perfect, and only enjoy a short existence, in consequence of which they soon die, and together with them also larger or smaller particles of the bone itself. Under them new granulations sprout up, but unless the existing disease be got rid of, are not better than the former, and die also in a short time; and thus, with the caries always creeping further, the suppurative inflammation elsewhere of its own nature producing new substance, here seems to run on to nothing but a sort of destructive process. But nevertheless even in caries it appears nature provides, that new organic substance should be produced from the growing granulations, which although of scanty and of bad character, are never entirely deficient. Indeed this is often proved even by the formation of new bony substance; for dyscrasie inflammations as they are called, and especially the syphilitic, not unfrequently, from the very first, produce new formations, from which we know that exostoses are mostly first produced ; but the very carious surface is sometimes studded with new bony, spiny, spongy formations, which as CLOCQUET observes, are analagous to the fungous flesh springing up in soft parts.' The surrounding periosteum is swollen, and between it and the bone itself new bony matter is poured out, and often forms large erostoses." (p. 209–10.)
“ The distinguishing character of caries," observes SYME," is the same as that of cancerous ulcers in the soft parts, viz., obstinacy of action. * * * The disease has, for the most part, remissions more or less complete, and of considerable duration, in which the pain and discharge nearly or altogether cease and the ulcer seems to be on the point of healing, or actually becomes covered with a thin soft cicatrix. But these amendments are only partially and temporary, being always followed by relapse, and there is no natural limit to the duration of the disease, except the life of the patient, who, after months, or even many years of suffering, becomes finally exhausted, either by the caries itself or some other disorder which the irritation produced by the caries has excited. (p. 170.)
* The diseased part," observes MAYO, “ ofteu neither can recover itself, nor be ab sorbed ; neither does it become necrosed. Left to itself, the caries would continue year after year, undermining the constitution of the patient, gradually invading the adjacent sound bone and finally threatening with destruction the neighbouring joint. It is often extremely difficult to tell whether an inflammatory enlargement of bone is abscess, or caries, or necrosis.” (p. 38.)]
862. These changes of the bone are always dependent on previous inflammation, which has its seat either in the periosteum and outer layers of the bone, or in the medullary membrane, in the parenchyma of the bone. The formation of a bony ulcer is therefore always preceded by dull, deep-seated, frequently very severe, wide-spreading pain, with swelling, not very great but slow, over which the colour of the skin is not changed. After a shorter or longer time a swelling dependent on the collection of puriform fuid takes place, sometimes on the very seat of the diseased bone, sometimes at a distance from it, which, if the bone be covered with few soft parts, seems connected with it, and is surrounded at its base with a hard edge. If this swelling be opened, an ill-conditioned variously-coloured ichor is discharged, which sometimes has a very bad smell. If the destruction be great, hectic fever sometimes occurs. If the inflammation have begun in the interior of the bone, it is often thereby changed partially, or throughout its whole extent, into a spongy, wide-spreading mass accompanied with severe pains which increase especially as the patient warms in bed; the neighbouring soft parts are also much expanded, and finally fistulous sores arise (Spina ventosa, Caries centralis, Pædarthroce, Lat. ; Winddorn, Germ.).
Besides these appearances the diagnosis is specially determined by examination with the probe, in which the bone is found rough and variously changed; further, by the peculiar form of the ulcerated openings in the soft parts, which have a shrivelled appearance, are contracted, and callous, or have their circumference surrounded with fungous excrescences. The silver probes employed in examining carious ulcers are frequently blackened; this, however, is no very definite sign, as it may be produced by any impure and ill-conditioned pus. The patient usually feels deep-seated pain.
[" In considering the primary attack of bone by caries, the question,” says MIESCHER, " arises, in what way is the bony substance in this disease destroyed ? how is it that suppuration, naturally producing a new substance, should in this case deviate into a destructive process? Comparison of caries with ulcers in soft parts throws no light on the subject, nor is it more set forth in them, how organic subtance is destroyed by ulceration. *** Doubtless ulceration of bones or caries, is most suitable for clearing up this ambiguous question, because this tissue, abounding in earthy parts, even when deprived of life, for a long while resists chemical decomposition, and then may be distinguished in the pus or adhering to the very surface of the ulcer. We see it asserted in the works of not few writers, that in a carious ulcer the pus may be perceived to be as it were sandy to the touch, and containing bony particles oftentimes pretty apparent, and that if a probe cannot be used to the affected bone, that this alone certainly indicates caries. But nothing final can be obtained on this very point, as no one speaks distinctly upon the question. For what HIMLY (a) contends for, that the surface of the bone always dies, is not sufficiently coufirmed by argument. And the same may be observed as to BELL'S statement, that in caries there is often no exfoliation; and who has even described that peculiar form of it which he calls phagedenic, which spreads most rapidly on every side, without any exfoliation, and merely by the violently excited action of the absorbent vessels.” (p. 210-12.) In the instances of caries in different bones examined by MIESCHER, he says : -" In all these, minute bony plates were discovered dead, and more or less separated; some entirely separated lay on the surface of the ulcer, and beneath them was a soft substance, consisting of numerous vessels, overspread with bone, as is constantly observed in a separated necrotic bone; some still adhered to this soft substance by some tougher filaments; in others the separation had proceeded less far, so that more or less still adhered to the bone itself. These dead plates were not only found on the external surface of the bone, but more frequently at that part where the ulcer penetrated more deeply, and their irregular surface appeared here and there covered with mucous dirty matter, which probably was produced by the decomposed soft substance. Elsewhere, this soft substance only was observed in which places the dead parts seem to have flowed off with the pus. The whole surface therefore attacked with caries presented various stages of separation of the dead plates, by which the roughness felt with a probe, was easily explained as well as the corroded appearance of the softened bone, which although less conspicuous, is discovered after the separation of large pieces of bone.” From the review of these circumstances and of those connected
(a) Uber den Brand der harten und weichen Theile. Goett., 1800, p. 96.