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817. The pus of the ulcer is the special vehicle of the venereal contagion, the proximate nature of which is unknown, but by its absorption the general Venereal Disease or Pox (Syphilis unirersalis, Lues Venerea, Lat. ; Lutseuche, Germ. ; Vérole, Fr.) is produced, which is manifested by various signs.
(John HUNTER's assertion that the matter produced in gonorrhæa and chancre is of the same kind, and that the only difference is that the one proceeds from a a secreting and the other from a non-secreting surface, having been already discussed. (pp. 163, 64, and clearly refuted by the observations of BENJAMIN BELL, HERNANDEZ, RICORD, and others, does not require further discussion, as it is now universally held that they are two distinct and independent diseases.-J. F. S.
Various experiments have been made as to the effects of inoculating matter from tients labouring under gonorrhæa, or chancre, from sores on the genitals, supposed to be syphilitic, and from secondary sores on other parts of the body. Some of these were instituted by HUNTER with a view to determine the identity of the poison of gonorrkas and chancre, which he considered he proved, though this opinion is now generally beld to be erroneous; and also to ascertain whether the matter from primary and secondary sores was the same. But we are indebted to RICORD for having proposed inoculatia for the purpose of distinguishing syphilitic sores, whether primary or secondary, from doubtful sores, the situation and character of which might at first lead to the notion of their syphilitic nature, although in reality quite free from that disorder. The following are the very interesting and important observations he has made on this subject :
“ All the natural or morbid secretions of individuals reputed to be syphilitie bate been examined by means of inoculation, and one single forın has furnished constant rè sults, and that form is, the primitive ulcer, otherwise called chancre. The chance. which is to the constitutional pox what the bite of the mad dog is to hydrophobia, doa not produce always a specific pus, but at one certain epoch of its existence, and it is ect. tainly from not having appreciated this so simple fact, that the results of inoculation have been contested or appeared doubtful. It is very evident that the primitive syphilitic ulcer cannot be the same at all its periods, and that it cannot arrive at scarring. if it do not at least pass to the state of a simple ulcer, by the destruction of the cause which tended to keep it up; but we must not require from these different phases, similar characters, corresponding results ; it is in the period of progress, or of the state quo of the ulceration, whilst there is no attempt to scar, that the chancre secretes the venerea! poison.
“The specific nature of the chancre is neither grounded in the organ actually ailing, nor in the vitality or functions and sympathetic reactions of this organ, nor yet in te lation with the greater or less degree of inflammation which may accompany the ular ation. Its seat has so little influence on the special nature of the chancre, that tbat disease cannot be regarded, without error, as peculiar to the generative organs. In re ality, there is no part of the skin which cannot become its seat; no spot, in the requisite condition, and can be voluntarily fixed on, is safe from it; developed on other regions. than the generative organs, it still preserves all its characters without any exception. Thus the chancre of the tip of the finger, of the thigh, of the tongue, of the foot, (if it be not modified,) furnishes pus, inoculable, and capable of producing another chance without the participation of the generative organs; whilst no other alteration of these organs is capable of re-producing a chancre, whatever may be its form, its extent, and the degree of the accompanying inflammation. *** This fact then is established by experiment, and may the mere speculations of the closet dispute it? The chancre, whatever its seit is the consequence of a specific pus, which it alone secretes, and which, as has been su well pamed true leven, peculiar ferment, (véritable levain, ferment special, reproduces 3 identical disease wherever it is fitly deposited.
“But this particular leven, which has no specific action but when it determines an ulcer ation, is produced only during that period of the chancre, which then almost makes, ij tk expression be permitted, an accidental virulent organ. In reality, as we have seen, the chancre has two very distinct phases; the first, to which the name still belongs, is that of growing or stationary ulceration, it is that which furnishes the peculiar pus; the second is, that of reparation, which only takes place by its passing to the state of simple ulceration, permitting the scarring or transformation on the spot, and furnishing no more specific virulent secretion. It may be imagined how important the distinction betwee these two periods of chancre is; for without it every thing is confusion, and the same ulceration which inoculated a few days before no longer giving contagious pus. We must decide on the uncertainty of the experiments, where on the contrary they are of great value.
“ But if we take some of the secreted matter of a chancre, at the period we have pointed out, and convey it with a lancet beneath the epidermis, see what happens ; in the first twenty-four hours, the puncture, as in cow-pox, reddens; on the second or third day, it swells a little, and presents the appearance of a little papule encircled by a red areola ; on the third or fourth day, the epidermis, raised by a liquid more or less turbid, takes on a form, often vesicular, presenting on its tip a black point, resulting from the dying of the blood of the little puncture ; on the fourth or fifth day, the morbid secretion in creases, becomes purulent, the pustular form is decided, and its depressed tone gives it the navel-like appearance which allies it to the pustule of small-pox. At this period the areola of which the extent and intensity had increased begins to subside or diminish, especially if the disease have not made progress; but after the fifth day, the subjacent tissues, which often have not yet been affected, or have been only slightly ædematous, infiltrate and harden by the pouring out of a plastic lymph which is resistant to the touch, and has the elastic feel of certain cartilages; at last, usually after the sixth day, the pus thickens, the pustule wrinkles, and crusts soon begin to form. If these be not detached, they enlarge at their base, and rising by stratified layers, assume the form of a truncated cone with depressed top. If the crusts be detached, or drop off, an ulcer is found below, seated on a hard base, presenting a ground of which the depth is represented by the whole thickness of the skin, and of which the surface, white, more or less deeply tinged with gray, is formed by a lardaceous, sometimes by a pultaceous matter, or even by a false membrane which cannot be detached by wiping. The edges of the ulcer at this time sharply cut as by a circular punch, are, however, undermined to a greater or less extent, and present under a lens slight indentations and a surface similar to that of the ground; their edge, the seat of a gorging and hardening corresponding to that of the base, presents a kind of ring of a reddish-brown colour, more or less tinged with violet, and which, more prominent than the neighbouring parts, so raises the edges by turning them a little out, as at first gives a funnel-shaped appearance to these ulcerations. (p. 85-90.)]
818. Swellings of the Glands (Bubones) in the neighbourhood of the ulcers, are in many cases to be considered as the first symptoms of general syphilis. They are caused by absorption of the venereal poison (idiopathic buboes); but they may also be the consequence of a consensual irritation attacking them (sympathetic buboes.) They appear mostly in the glands of the groins, whilst the primary ulcer still remains on the generative organs, and usually when the inflammation in the ulcers is not very great, the ulcer not making progress or even after it has healed. The patient first feels a tension and pressure in the groin, and a hard painful swelling of one or several glands appears which may be pushed about beneath the skin, or is attached to it. The swelling increases, the skin over it reddens, the pain becomes constant, and febrile symptoms are not unfrequently set up. The bubo may disperse, but if the pain be severe and throbbing, its passage to suppuration is certain, when the swelling softens at its top, the skin bursts, and an ulcer is produced, with hard everted edges, and its foul bottom often beset with granulations. Burrowing of pus and considerable destruction frequently take place. Buboes may even in a very high degree of inflammation and under dangerous internal and external influences run into gangrene.
[" The true venereal bubo, in consequence of a chancre, is,” says John HUNTER, “ most commonly confined to one gland. It keeps nearly its specific distance till suppuration has taken place, and then becomes more diffused. It is rapid in its progress from inflammation to suppuration and ulceration. The suppuration is commonly large for the size of the gland, and but one abscess. The pain is very acute. The colour of the skin where the inflammation attacks is florid red.” (p. 285.)
RICORD has ascertained by inoculation that buboes are of seven kinds :-/st, The bubo may be simply inflammatory ; a, by propagation of the inflammation, without reference to the particular nature of the primary cause of its production, whether a clap, a chancre, or every other lesion; b, by sympathetic reflection. 2nd, It may be viru
lent, that is, dependent on the direct absorption of the specific matter of the syphilis, and then it is the strict consequence of chancre, the pus of which can alone produce it 3rd, It may be superficial or deep, or may appear in both forms. 4th, It may have its seat in the cellular tissue, in the lymphatic vessels or ganglions, separately or conjointly. 5th, It may be acute or chronic. 6th, It may be preceded by the other symptoms called primary, or it may appear at once. 7th, When other symptoms have appeared before it, it may either follow them immediately, and then be only a successive symptom, or it may present itself at the period of the general symptoms of the pox, and constitate secondary bubo. * * * * "Whenever an inflammation of the cellular tissue or of the lymphatic system of the inguino-crural or other regions has been consequent on any other cause than chancre, and suppuration has been the consequence, no result has beco obtained by inoculation, whatever have been the period and the conditions under which the pus has been taken. Thence, for instance, when a clap has preceded the babo, and suppuration has occurred, no inoculable pus is obtained; it is only when preceded by a chancre that a specific pus capable of inoculation is furnished. But it is not sufficient that a chancre should have preceded the bubo, for the latter of necessity to furnish a specific pus; for that purpose the bubo must be neither the result of a simple sympsthetic or successive inflammation, but there must have been absorption; but absorption, when it occurs after a chancre of the generative organs, affects only the superficial ganglions, and most commonly only one at a time, although more ganglions, either superficial or deep, may be inflamed or swollen at the same time, so that one ganglica actually presents all the characters of a virulent bubo, whilst the neighbouring ones, in which the inflammation has reached to suppuration, as well as the surrounding cellular tissue, present simple and not virulent characters. I was some time before I could veil make out these conditions and explain why all the buboes would not inoculate, as those who had repeated my experiments without well knowing them, had asserted; and bor it happened that a bubo of which the pus would not inoculate one day would do son the following; or why in a bubo with separate centres, and which might be called multilocular, one centre furnished inoculable pus and the other did not. I then set about being more exact in my experiments, and first inoculated all buboes, immediately on opening them, with the first pus that escaped, and the result was negative, which explained M. CULLERIER's statement, who had perhaps only experimented under these circumstances, or with simple buboes. I then, at two, three, four, five days and more after opening, took some pus from these same buboes, and then the pus exhibited in many instances positive results, and in others the inoculation continued to produce nothing. In the former case the centre, as well as the edges of the opening, delayed not to take on the characters of chancre, whilst in the latter the abscess followed the course of simple phlegmonous or lymphatic abscess to its cure. An important question then remained for decision, whether in the case where the pus of the bubo had pot inoculated at the instant of the opening, it had not acquired its inoculable quality by contact with the air, or by the external mixture, after opening with the pus of a pre existing chancre, or in some other manner. The solution appeared very difficult, when a patient came to me with a bubo following a chancre, and with large suppuration. I opened the abscess, but after having discharged the pus from the cellular tissue, I found in the middle of its centre a very large lymphatic gland fluctuating in its centre. This I opened, and with the pus it contained made an inoculation, and at the same time a similar one with pus from the neighbouring parts, that is, from the cellular tissue ; and whilst the pus from the ganglion produced the characteristic pustule, that from the cellular tissue produced nothing. * * * The same results were obtained by pus from the course of the lymphatic vessels. • * * But as to the deep ganglionic swellings called deep buboes, when they suppurate, which is much more rarely than the superficial, the pus furnished from them never inoculates, unless in a purulent they are found after the cut bathed in the pus of a neighbouring chancre or by an infected superficial ganglion ; but never in this case are the deep ganglions infected by absorption.” (p. 62-6; Fr. edit., p. 138-146.)
Upon the question of the existence of syphilitic buboes, without primary sore, Hos. TER Speaks with caution. He says, indeed, “ the first and most simple mode (of absorp tion) is where the matter either of a gonorrhæa or chancre has only been applied to some sound surface without having produced any local effect on the part, but has beco absorbed immediately upon its application." But almost immediately after he observes:“ It must be allowed that this mode of absorption is very rare; and if we were to examine the parts very carefully, or inquire of the patient very strictly, probably a small chancre might be discovered to have been the cause, which I have more than once seen.” Another concludes, “ there is, however, no great reason why it should bet
happen" (p. 274.) From these observations it is quite clear that HUNTER's mind was not satisfied upon this point.
RICORD has also inquired into this subject, and observes :-" If, however, it be true that after suspicious sexual connexion, the enlargements of the neighbouring ganglions of the generative organs become rarely primarily affected, there are, however, circumstances in which it is impossible to find any suspicious antecedent or concomitant, and then we are forced to admit a primary bubo (bubo d'emblée.) When these enlargements are carefully examined without our being led into error by those which may resemble them, we find that they most commonly appear in the deep ganglions, and as frequently, even in those of the iliac fossa, or at least in the sub-aponeurotic ones of the thigh; that their course is often chronic; that they are long indolent, and have little disposition to suppurate; but it is very remarkable, that when they do suppurate, the pus they produce will not inoculate: never as yet have I found a bubo embracing all the positive signs of an immediate bubo which produced inoculable pus. If to this important observation be added, that after the exact researches which I have made, I have never found that immediate buboes, in the strict sense of the word, have been followed by general symptoms of pox, the importance of inoculation in this case will be evident.” Hence he concludes, that " a virulent bubo, or that from the absorption of the pus of chancre, is a symptom in every respect analogous to chancre as to its nature, and only differs in its seat; that virulent bubo is the only one which will inoculate; that the signs indicated by authors for distinguishing virulent bubo from the enlargements with which they are confounded, without exception, in the greater number of cases, serve only to establish a rational or probable diagnosis, and that inoculation alone can be considered as the indisputable and pathognomic sign; and that if in a greater number of cases the precise diagnosis of a bubo were not absolutely necessary to direct the treatment and to form a prognosis of the coming chances to the patient, when there is question of a bubo being immediate, we should never neglect when suppuration has taken place, to examine it at every stage of its course, careful examination, close observation having proved that buboes which do not inoculate (when the experiments are properly made) are never followed by secondary symptoms, and that they also are not syphilitic; whilst from other causes which often escape us, and without needing the pox, may give rise to enlargements of the lymphatic system of one region of the body as well as another; and that it would therefore be absurd to conclude that a bubo is necessarily syphilitić because it had appeared a short time after connexion.” (p. 67-9; Fr. Edit., p. 148–51.)]
819. If the disease be general, it attacks especially either the skin, mucous membranes, or bones. The length of time from the origin of the local syphilitic symptoms to the outbreak of the general venereal disease is different. Usually it occurs six weeks after the primary syphilitic affection; a longer as well as a shorter space of time may, however, be observed. The attack of the masked syphilis (lues larvata) can only be properly applied to this period, when, with a seeming cure of the primitive syphilitic affection, up to the outbreak of the general disease, no decided symptoms are manifest. The appearance of the general syphilis is mostly accompanied with slight fever and with burning heat in the palms of the hands.
[“ The venereal matter," observes John HUNTER, “ when taken into the constitution produces an irritation which is capable of being continued independent of a continuance of absorption; and the constitution has no power of relief; therefore a lues venerea continues to increase. This circumstance is perhaps one of the best distinguishing marks of the lues venerea ; for in its ulcers and blotches, it is often imitated by other diseases which, not having this property, will therefore heal and break out again in some other part; diseases in which this happens show themselves not to be venereal ; however, we are not to conclude because they do not heal of themselves, and give way only to mercury, that therefore they are venereal, although this circumstance, joined to others, gives a strong presumption of their being such.” (p. 320.)]
820. An Inflammation in the Mucous Membrane of the Throat most commonly shows itself as a seeming catarrhal affection, with stoppage in the nose, difficulty in swallowing, hoarseness, snuffling speech, and tears in the eyes. On internal examination of the throat, the mucous membrane is found reddened, the tonsils and urula swollen; the redoess, specially fixed on certain spots, is on others pale and discoloured. These places break up and run into ulcers, which are sufficiently characterized by their peculiar appearance. Vesicles often arise on the inside of the cheeks or at the corners of the mouth, which sometimes run into ulcers. These sores spread quickly, destroy the pendulous palate, attack the bones of the nose, produce a stinking secretion from it, (Ozana syphilitica,) caries, and destruction of the nose-bones.
821. On the external skin syphilis appears as blotches, (Macule, Lat; Flecken, Germ. ; Taches, Fr.,) vesicles, (Vesicula, Lat. ; Blättereken, Germ ; Vésicules, Fr..) or pustules, (Pustula, Lat. ; Pusteln, Germ.;
Pustules, Fr.,) which are especially common on the face and forehead, (corona Veneris,) and at first have a pale but subsequently a copper-coloured redness. The pustules are surrounded with a reddish brown edge, are sometimes single, sometimes collected in groups ; they often produce consi. derable burning, especially at night, and frequently run into ulcers which have purple edges, and secrete an ill-conditioned ichor; they usually increase only in breadth, though often in depth, and even attack the bones. If pustules occur on hairy parts, the hairs fall off; if beneath the nails, these fall off also, or are loosened by the ulcers, and the fresh growing nail is misshapen. These pustules often appear in form of small boils, which do not suppurate, but merely trickle.
[I ANRENCE describes four forms of cutaneous syphilitic eruptions : « Ist, The scaly eruption is one of the most common. The skin before the eruption appears exhibits a kind of mottled or marbled appearance all over the body. If you strip the patient, though the skin is seen in the natural state, yet there is a streaked or mottled appear ance underneath ; there are little patches of red appearing through the cuticle, which give it that appearance. Very soon you observe spots of a reddish brown, or what would be called a coppery colour on the skin; and this has always been the marked character of venereal eruption. These reddish-brown superficial discolorations of the skin soon become more deeply coloured. The cuticle covering them desquamates a little, becomes scaly, and the cuticle separates. The spots increase in size; they often run together, so that you have considerable patches of the skin in various parts of the body assuming this colour. In the end these discolorations generally are large in size and particularly vivid. They have a bright coppery-red colour, and the cuticle ore them becomes very scaly. They are very strongly marked when they occur in the palms of the hands and soles of the feet; then the contrast of the colour of the diseased with the healthy skin is very strong; and the cuticle being thick, cracks and assumes a whitish appearance, and what would have come under the description of that which WILLAN and BATEMAN call syphilitic lepra or syphilitic psoriasis. 2nd. Very frequently syphilitic eruption exhibits itself in the tubercular form. In the scaly form just mentioned, the discoloration is superficial, and the coppery red spots do not rise above the level of the surrounding sound skin, but in the tubercular eruption you have a small kind of eruption with the point more raised, and as that proceeds, the cuticle goes into the scaly state, so that that is in fact a scaly eruption, although there is a tubercular elevation of the cuticle in the first instance. 3rd. In other cases there is a more acute action of the skin-active inflammation, with the formation of inflamed pimples, or of papulæ, as they are technically termed. These arise in clusters and patches in various parts of the body; after remaining for a time, they resicate and sup purate, and that suppuration dries up. and they go into a scaly state, and you have a succession of those jimples forming over various parts of the body; this is called papular venereal eruption. 4th. There is another form in which you see it, where pustules, that is, inflammation of the skin, takes place, effusion occurs, and the caticle is elevated into inflamed pustules; these proceed and form venereal ulcers, that is, the pustular venereal eruption. These are the principal forms of eruption, observed as secondary symptoms of syphilis ; a scaly eruption which may be called syphilitic lepra or syphilitic psoriasis, a tubercular eruption, a papular eruption, and a pustular eruption proceeding to ulceration. Now you do not find these eruptions always distinct; fre