since June 21, 1881, but is well supported, no pain, no local inflammation, and no mercurialization. He still proposes to go up to six, seven, and eight mgrms. (from 1 to 1 of a grain) a day, the result to be noted in another paper.

At the séance of the Academie de Medicine of Paris on August 9, 1881, Dr. Martineau, in reply to questions, said that he had gone as high as 6 (gr. ††) and 7 (gr. †) milligrammes (0.006-0.007) of the sublimate every day, and had now used thirteen hundred injections, and yet never has had any salivation, although the mercury was freely eliminated by the kidneys, as shown by constant tests.

He finds any local irritation very unusual, and prefers, as place of injection, the back, and the sides of the thorax, and some of his patients have had up to forty-five injections, still without the least local accident. He finds this method superior to all others, especially in cases of severe syphilis, with serious symptoms in rapid evolution, and even up to 6 (gr.) or 7 (gr.) mgm. per diem he has seldom any pain, no abscesses or gastro-intestinal irritation, and rapid amelioration of symptoms. He justly remarks that it is yet too early to definitely pronounce upon the probability of relapses. Martineau's cases are highly interesting and valuable. It is curious to note how rapidly the worst syphilitic accidents have disappeared under the hypodermic treatment, and in most cases without irritation or pain. It is very much to be desired that some American syphilographer should reproduce Martineau's experiments, on a large scale, in a hospital, as under such circumstances the method presents many incontestible advantages, even if it be not as well adapted to private practice. (Annals of Anatomy and Surgery.)

In America the attention of observers was called to the experiments of Lewin by Drs. Prægler and Gale, of Illinois, by their translation of his book entitled "The Treatment of Syphilis with Subcutaneous Sublimate Injections." Dr. Julius Kæmmerer, of Philadelphia, treated a number of his patients by this method with very flattering results; his experiences were so satisfactory that he instructed his pupils, Dr. L. Wolff and Dr. Edward Rosenthal, in its use, and at the same time suggested the same method to me. Some three or more years ago I began this treatment in all the syphilitic patients presenting themselves at the Dispensary for Skin Diseases, and my results were so satisfactory that I brought the subject before my class in a clinical lecture, delivered

in October, 1879, which was reported in the November number of The Medical Bulletin of the same year. I have now had, up to this present time, 113 cases, which I have treated in the American Hospital for Skin Diseases, in the Dispensary, and in my private practice, with the subcutaneous injection of corrosive sublimate, and with most excellent results. Of these 113 cases which have received this treatment during a period of three and a half years, forty-nine men and twenty-three women were treated at the above hospital, and thirty-four men and seven women at my office.

Of this number, sixty-six of the men and twenty-six of the women were affected with the various syphilitic eruptions of the skin. There were seven of the men and one of the women affected with gummata of the cellular tissue. Six of the men and one of the women suffered from syphilitic disease of the bones. Three men and one woman had syphilitic affections of the larynx; and one man and one woman were affected with syphilitic iritis.

In my practice I usually selected for my hypodermic injections a good glass syringe. Experience has proven to me that these were the best, the metal ones being unsatisfactory, owing to the metal becoming corroded in using the sublimate solution. The hard rubber syringes were too fragile to answer the purpose, it needing but slight manipulation to break them. To these syringes I ordered especially long needles, of the length of 13 inches or so. My reasons for this were, the other needles are so short, they do not penetrate deeply enough, and my object was to penetrate deeply into the subcutaneous cellular tissue. I had learned from the experience of others that the cause of the abscess following hypodermic injections of corrosive sublimate was due either to the use of a very short needle that would not penetrate sufficiently, or to the operator, who may have failed to push it far enough into the integument; and should the latter be the case, the fluid will be deposited in the stratum of the cuticle in which the absorbent vessels are wanting, and inflammation will undoubtedly supervene, causing abscesses. If, on the other hand, the operator has a sufficiently long needle, and will take the precautions to drive it down to the cellular tissue, which is abundantly supplied with absorbent vessels, no injurious effect will follow. I always, in addition,

had my patients in private practice to own and carry their own needle to prevent any possible contagion.

These needles were usually made of steel, and sometimes were gold and silver plated; but I always observed that they generally rusted, and I therefore endeavored to use another metal for the needles, and I found gold to answer every purpose, as it was the only one of all the metals not affected by the sublimate solution. My gold needle is always in good order, never rusts, and is withal-in proportion to the other needles I use the cheapest.

As I have found that the rust of the steel needles is hastened by the wire that is passed through them, I have remedied this by using bristles, and oil them previously to passing them. Formerly I had prepared for injection the following solution: Corrosive sublimate, Aquæ destillata,

grs. vj
31

But now I have altered this proportion, which renders the division of the doses simpler. The formula is—

Corrosive sublimate,
Aquæ destillata,

1 part 100 parts

In using the first solution I usually began in weak patients with one-tenth grain (10 minims) doses, and continued the same every day until the disease showed signs of abating or the patient experienced the constitutional effects of the drug. In stronger subjects I began the dose at the same quantity, and gradually increased the dose, minim by minim, every second or third day until the same result had been obtained. After the patient had received a full mercurial impression in the manner above given, in case any of the syphiloderm should still be present, the doses were gradually diminished, just giving a sufficient quantity to keep the system under a gentle influence of the drug until all traces of the disease had disappeared.

In some of the cases (those of an especially obstinate character) I was compelled to push the drug until I obtained the constitutional effects, which were marked by headache, vertigo, hyperemia of the mouth, gums and cheeks, increased flow of saliva, difficulty of mastication, disturbances of digestion, and diarrhoea, before the syphiloderm would disappear.

In others (about nine), who were peculiarly susceptible of mercury, all the constitutional effects followed after several

injections of one-eighth grain, although I tried the peptones, chloride of ammonia, water and glycerine, together and separate, at various times, without avoiding the stomatitis, that Dr. Martineau has since reported did not result in his hands with all of the above-named combinations. I was always compelled in these cases to begin with one or two minims of the solution, and gradually increase the dose, minim by minim, until I reached the point where the patient showed slight evidences of intoxication from the drug; and then again decreased it. After using all the various combinations upon the cases under my care, I came to the conclusion that plain water and the sublimate gave me the best results. (See my paper in The Medical Bulletin, February, 1882, page 40.)

The parts which I usually chose for the injection were, the infra-scapular and sacral regions; which are the least sensitive, and are also well supplied with a large quantity of subcutaneous cellular tissue, in which to inject the solution. I have also made injections into the gluteal regions on either side, into the tissues on the side of the thorax, and into the thigh and leg; but my conclusions are, that the infra-scapular and sacral regions are decidedly the best, as, in my experience, the pain of the injection is not so often or persistent as in the other parts.

In making the injection, I first took the precaution to see that the barrel of my syringe was well cleansed, as I have sometimes noticed that small pieces of the leather or of other foreign bodies were sometimes found; and also to see that the needle was clean and sharply pointed. I then would fill the syringe with the sublimate solution, and with the needle pointed, open, and well oiled, I would pick up a fold of the integument on one of the regions just named with the forefinger and thumb of the left hand; and with the right-previously everting the syringe and tapping it slightly, and then forcing out the air-I would drive the needle down deep into the cellular tissue, while I gently pressed the piston and forced out the contents. The needle was then slowly removed by rotating with the forefinger and thumb of the right hand, whilst the fingers of the left were used in pressing back the skin from its adhesion to the needle, in pressing out and distributing the solution in the surrounding cellular tissue, and in covering the point of the puncture of the needle, after which the syringe and needle were always well washed in plain water, dried, oiled, a bristle run through the

needle, and the instrument laid aside for the next patient, or for the next day's use.

The skin surrounding the puncture would become a little red and swollen in a short time, which would disappear at longer or shorter intervals, at the most in a few days' time, though in some of the cases they would remain for quite a time, forming hard spots about the size of a shellbark, which would eventually disappear, as it were, by degrees, leaving no bad results. During the whole time, in the treatment of the 113 cases I gave 2,132 injections in the course of 206 days, and I have not had any inflammation or abscesses.

Of these cases 36 disappeared at various times during the course of treatment, and failed to continue the same to a complete cure; 68 took from day to day the injections until they were discharged; and of this number 41 were entirely cured as far as I have been able to learn. The remaining 27 had relapses at various times; 10 having a first, 13 a second, and 4 a third; whilst there are 9 under treatment at the present time receiving their injections daily.

Of those suffering relapses I have only a record of five that have entirely recovered; three having recovered in the first, and two in the second relapse. The majority of these relapses were due to the habits of the patients more than the want of efficacy of the sublimate injections. The greater number were individuals addicted to all sorts of excesses,-to drinking and dissipation; and who would not give medicines of any kind an opportunity to act properly.

Many of the patients to whom I gave the sublimate injections had had mercury previously given them by the mouth without any decided results, either upon the disease or any toxic evidence of the absorption of the mercury by the intestinal canal; others were totally unfit to receive the drug internally, being debilitated and broken down, or having weak digestive organs and an irritable state of the intestinal canal. In such patients it is the only medicinal means, I believe, that can be used successfully in neutralizing the specific poison in the system. It also enables the physician (as I did in the majority of the cases he referred to) to give tonic remedies by the mouth, together with a good, substantial, and nourishing diet which can be properly digested, and the combination will act promptly and effectually upon the discase.