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quently they are so, but sometimes the different characters of the eruptions are united; that is, you will find an eruption partly pustular and partly scaly. * * * The pustular eruption spreads into ulcerations; the cuticle, which has been elevated by lymph or pus, gives way, and the fluid which is discharged incrusts upon the surface. The skin ulcerates under that incrustation; a greater discharge of matter takes place, and the incrustation is increased. If the parts be kept moist, an ulcer is seen; but if less exposed to the air, the matter concretes, and the part is covered with incrustations more or less thick. The ulcerations thus formed are superficial sores, generally of a circular shape and rapidly healing. In other instances they degenerate into very foul and intractable ulcerations of a phagedenic character. Very generally they retain the circular form and heal up in the centre but not towards the edges ; there is a healing up in the centre and a very foul or tawny margin by which the ulceration extends. Frequently the sores are of a crescent shape, that is, they have a convex edge by which they extend, whilst they heal up at the concavity. Sometimes the phagedenic edge is simply of a tawny colour; at other times it is considerably elevated and almost sloughy, with a very red, angry, and fiery state of the neighbouring skin. There is a considerable variety in the characters of these syphilitic ulcerations of the skin, all of which originate, in the first instance, from a vesicle or pustule.” (pp. 773, 74.)]
822. Syphilis often produces on the skin a more herpes-like eruption, which exfoliates like scales, especially in the hollows of the hands, (Rhagades,). on the thighs, in the neighbourhood of the generative organs, on the buttocks. The skin also frequently has cracks, with copper-coloured, callous, painful edges, from which an ill-coloured acrid fuid is poured out. Or there arise, most commonly on the generative organs and the rump, Growths, which, according to their different form and consistence, have various names, as Warts, (Verrucæ,) Fig Warts, (Condylomata, Fici, Mariscæ, &c.,) with which are frequently connected ulcers on the generative organs, discharge of mucus from the urethra, vagina, and so on (a).
[JOHN HUNTER first noticed the difference between the pus from a primary and that from a secondary syphilitic sore, and not admitting that though mercury cure both kinds, both were necessarily the same in their nature, “as mercury cures many diseases besides the venereal. On the other hand there are many strong reasons for believing that the matter is not venereal. There is one curious fact which shows it is either not venereal, or if it be, that it is not capable of acting in some respects on the same body, or on the same state of constitution, as that matter does which is produced from chancre or gonorrhæa. The pus from these latter, when absorbed generally, produces a bubo, but we never find a bubo from the absorption of matter from a pocky sore; for instance, where there is a venereal ulcer in the throat, we have not buboes in the glands of the neck; when there are venereal sores on the arms, or even suppurating nodes on the uloa, there are no swellings of the glands of the arm-pit; although such will take place if fresh venereal matter is applied to a common sore on the arm, hand, or fingers. No swelling takes place in the glands of the groin from either nodes or blotches on the legs and thighs. It may be supposed that there is no absorption going on from such sores; but I think we have no grounds for such supposition. Its mode of irritation, or the action of the parts affected, is very different from what happens in chancre, gonorrhæa, or babo, being hardly attended with inflammation, which in them is generally violent." (p. 512.) He then mentions some experiments made with the matter of secondary syphilitic sores on the skin, and on the tonsils, but from neither was any chancrous sore produced.
The truth of HUNTER's opinions and observations on this interesting question has been of late fully confirmed by the experiments of RICORD, who says that he has thus arrived at the conclusion “that all reputed secondary phenomena are far from being specific; that infection by the venereal virus may excite in the economy disorders, lesions, the development of morbid symptoms analogous to those produced by any nonspecific cause ; but that independent of these, perhaps most common symptoms, and which afford a deceptive support to the doctrine of non-specificity of pox, or of the
(a) ALDERS, Ueber die Erkentniss und Heilung MARTINS, Mémoires sur les causes generales des der syphilitischen Hautkrankheiten. Bonn, 1832. Syphilides (extr. de la Révue Médicale, vol. i.
HUMBERT, Manuel pratique des Maladies de la 1838.) Paris, 1838. Peau appellées Syphilides. 'Paris, 1833.
non-existence of the virus, there are certain regular characteristie symptoms occurring as necessary and sure consequences after the primary infection, and which are the rë sult of chancre, under one of the forms already mentioned, or the product of inheritance, which military Surgeons can only deny from want of a proper field of observa tion. When we have followed the pus of a chancre, in its penetration into the economy, if I may be so allowed to express it, we have seen that whether it was merely by inbibition of the cellular tissue, to whatever depth it might reach, it still preserved its characteristic property, the capability of inoculating: that it was the same with the afferent lymphatics, from the chancre to the first ganglion, in which they terminated, and that beyond this point, where first began the mixture with the circulation and other organic matters by this kind of ganglionary digestion, which takes place in the lymphatic system, the pus underwent a transformation which, without depriving it of its specificity as regards the symptoms it produces in the economy, takes from it the power of inoculating: that it was only by virtue of this modification that this syphilitic temperament could be established, to give place more slowly to the diathesis for the development of secondary symptoms: that without traversing the lymphatic system this result was the strict consequence of venous absorption; the symptoms of constitutional pox not requiring for their manifestation, the passage of the virus by the lymphatics and the previous production, in all cases, of buboes." And hence he rives at the conclusions, “ First, That though one symptom does not inoculate, it is not therefore to be said that it is not syphilitic, because the virus modified by venous absorption and susceptible of poisoning the economy, loses this property whilst it pro serves alone that of propagating by inheritance. Secondly, That whenever a symptom, whatever its seat and apparent form, inoculates, it is necessarily the product of direct contagion and not the result of general infection depending on absorption from one to another part, and does not actually indicate the venereal temperament or in common terms constitutional pox.” (p. 74-7; Fr. Edit., p. 162-67.)]
823. The Syphilitic Affection of the Bony System is manifested by nightly pains, which are boring and gnawing, and situated, especially in tubular bones, and in such bones as are covered with least soft parts, as the shin-, arm-, breast-, collar., and skull-bones. These bones, especially those of the shin and skull, swell up, in which latter case the bony swellings usually precede or are accompanied with severe head-ache. The bony swellings are often soft, and formed by a jelly-like mass poured out beneath the periosteum, (Gummata,) often hard and immovable, (Nodi, Topki, Ecostoses,) and frequently contain a chalky substance. Not unfrequently the bones swell very considerably ; inflammation often takes place, and expansion of the medullary cavity of the tubular bones, (Spina tentosa. If these bony swellings inflame and run on to ulceration, dangerous eating away of the bone (Caries syphilitica, Lat. ; Knochenfrass, Germ.) occurs. But commonly by the destruction of the soft parts and of the periosteum the bones are laid bare to a great extent, killed, (Necrosis,) and thrown off in larger or smaller pieces (Exfoliates.) Very frequently also in general Lues inflammation of the joints and its consequences take place.
824. If the Lues have advanced considerably, hectic fever, complete disorder of the digestion, exhaustion, and death, may be produced by the tormenting pain, and by the great loss of the juices from the suppurating parts.
825. Syphilitic symptoms are subject to various modifications, which do not depend on a variety of the syphilitic poison, but on the constitution and age of the patient, on the mode of its reception into the body, on climate and other circumstances, on the existence of other diseases, but perhaps also on a qualitative change of the poison, which it suffers in insufficient treatment. The stronger and more powerful the person is, so much the more speedy in its course and destructive is the syphilis. In warm climates the general symptoms of syphilis are milder, it attacks rather the skin and its processes and the cellular tissue; in cold climates.
on the contrary, it attacks rather the bony system ; in warm climates, however, there may be noticed great severity of the primary symptoms, in which case severe inflammation follows, and runs into mortification. This disposition to erysipelatous inflammation and mortification in primary syphilitic ulcers is observed frequently in bad, tainted, and marshy air. The scurvy, or a similar affection, after too frequent use of mercury, scrofula, gout, and rheumatic affections, may produce different variations of syphilis from its usual course, and thereby render diagnosis difficult.
Primary syphilitic ulcers have especially no decided external character; they have a very varied appearance, and cannot, at a mere glance, be distinguished from such ulcers as are of a more common or totally different nature.
[“ It cannot, I think, on due consideration of the subject, be denied," says ABERNETHY (a)," that many sores are induced on the genitals, by sexual intercourse, which are not the effects of the venereal poison, and that many of them infect the constitution, and produce secondary symptoms resembling those of that disorder. It may be asked, however, if these diseases be not venereal, what are they? As they are all the consequence of sexual intercourse, they may, in one sense of the word, be said to be venereal. To avoid ambiguity, therefore, I shall denominate that disease which broke out at the siege at Naples, and which Mr. HUNTER has described as the venereal disease by the Dame given to it by nosological writers, that is, syphilis; and I shall call those diseases, which differ from it in their progress and mode of becoming well, though they strikingly resemble it in appearance, by a name importing these circumstances, that is, pseudosyphilitic diseases." (pp. 2, 3.) He then proceeds to some observations on the probable origin of the latter complaints, and mentions that " CELSUS describes eight species of sores with which the genitals were affected in consequence of sexual intercourse ; and as this was long before syphilis was known, it follows that there must be other causes producing them. Some of the sores described by Celsus are not unfrequently met with at present, and they are not syphilitic. Sores also frequently form upon the genitals of females, in consequence of that irritation which accompanies diseased secretions from the vagina. Sores, for instance, very frequently succeed to gonorrhæa in the lower class of females, who pay little attention to cleanliness, and do not abstain from sexual intercourse. Sores frequently break out on the prepuce and glans of the male, in consequence of the irritation which gonorrhæa, or other diseases of the urethra produce in these parts. These sores generally heal without mercury, frequently without inducing any constitutional disease; and when they do affect the constitution, the disease oc. casioned by them is not syphilitic. I merely mention these circumstances at present to show that it is possible for ulcers to form which may not be syphilitic, and yet the discharges from them may prove morbific, and produce disease in others. Even discharges from the genitals of one person, where no ulcers exist, are capable of exciting ulcers in another.” (pp. 4, 5.) He further observes, that “the primary infected sores, which are capable of producing secondary symptoms, strikingly resembling those of syphilis, do not themselves possess any uniform characters” (p. 40). And he thinks “it is probable that the morbific poisons which produce pseudo-syphilis, may be absorbed without any evident ulcer, or from a trivial ulcer, which may heal spontaneously, much more frequently than the syphilitic poison.” (p. 41.)
As regards the mode of distinguishing the false from the true disease, ABERNETHY says :-"I have not been able to discover any (appropriate characters); the fictitious dissease, in appearance, so exactly resembles syphilis, that no observation, however acute, seems to be capable of deciding upon its nature. Although the ulcers in these ambiguous cases generally spread more extensively along the surface of the part which they affect, yet this does not constantly happen. * * * It must also be remarked that true syphilitic spots and ulcers sometimes assume the appearance of other diseases, and do not possess their ordinary characteristics. Since then our senses fail us in our endeavours to discriminate between these two diseases, and since the most important circumstance is to distinguish whether the disease be syphilis or not, we may inquire whether there are any circumstances in the progress of these different diseases which will serve us in distinguishing one from the other. It appears to me that there are. * * A very · simple fact has enabled me in most cases to distinguish between the two diseases; yet simple as it is, if it be generally true, it is very important; and if it were universally true, it would be of the highest consequence. The fact alluded to is that the constitutional symptoms of syphilis are progressive, and never disappear unless medicine be esse ployed. It may be added too, they are as generally relieved under an adequate effect of mercury on the constitution." (p. 45–7.)
ABERNÉTHY further remarks, that "Mr. HUNTER thought that syphilitic poison might produce a sore which might be modified by the diseased propensities of the constitution and the part, and thus lose its distinctive characters.” And further :-“If, according to the opinion of Mr. HUNTER, the action of a syphilitic chancre may be so modified by the diseased propensities of the constitution or part, as to form an ulcer scarcely cogni. zable as a syphilitic one, it follows, &c.” (p. 59, 60.) Where this opinion of HINTER'S is to be found, I know not, for I cannot meet with it in his work on the Venereal Disease; and the only passage at all like it is the following :-“Chancres, as well as the gonorrhæa, are perhaps seldom or never wholly venereal, but are varied by certain peculiarities of the constitution at the time.” (p. 242). It must not, however, be omitted, that the last part of his work is occupied with observations “ of diseases resembling the lues venerea, which have been mistaken for it," and that he closes his book with the observation that undescribed diseases resembling the venereal are very numeross, and that what I have said is rather to be considered as hints for others to prosecute this inquiry further, than as a complete account of the subject "
CARMICHAEL objects to the use of those common but arbitrary terms syphilitie, syphiloidal and pseudo-syphilitic” (p. 48) diseases, which he regards as “an endeavour to cos ceal our ignorance by the adoption of plausible and delusive epithets and appellations." (p. 47.) And remarks, that as long as syphilis is the name attached to a certain form of venereal complaints, we shall never escape from the terms pseudo-syphilis, syphiloidal symptoms, and sequela of syphilis. The first is an arbitrary term applied to a congeries of symptoms upon the nature and extent of which scarcely two practitioners are agreed; and, therefore, when one person calls a complaint syphilitic, another disease altogether different may be presented to the mind of the person he addresses. Pseudo syphilis is equally objectionable, as it is too general a term for any useful purpose, inasmuch as it embraces not only all those venereal complaints which do not correspond to HUNTER's description of syphilis, but all those spontaneous disorders which have no pretension to a venereal origin, and are solely attributable to some derangement of the constitution. The term syphiloidal symptoms and sequelæ of syphilis imply that there is but one venereal poison, an opinion which I conceive to be absolutely refuted." (p. 66.) "Without, as seems to me, any very satisfactory reason, CARMICHAEL founds his arrangement of venereal complaints on the character of the eruption. He says: In arranging under distinct heads the numerous appearances and symptoms produced by venereal complaints, I would follow the same rule which has hitherto guided the judg ment of the profession in arranging and classifying all other morbid poisons attended with eruptions. In other words, I would regard the eruption as the most proper basis of the arrangement; and, without neglecting such auxiliary evidence as other attending symptoms may afford, consider them as of minor importance in determining the nature of the disease. By following this method, it is truly gratifying to find how easily the numerous symptoms, both primary and constitutional, of venereal diseases, which are so various as seemingly to bid defiance to any attempt at arrangement, can be disposed of in their appropriate places under the name of the eruption which belongs to their respective species. Next to the eruption the symptom most to be regarded is the primary ulcer, whose characteristics are in general found sufficiently distinct to enable us to foretel with tolerable certainty what the appearance of the eruption vill be." (pp. 62, 3.) Now, if such be the fact, as it most undoubtedly is, there does not seem good cause for taking the eruption, which is the second, and indeed not unfre quently the third form of the disease, and which frequently never appears at all, as the foundation of the arrangement of diseases which commonly do not, if properly tended, proceed beyond the primary sore, of which sore CARMICHAEL says, “ the characteristics are in general found sufficiently distinct,” which sore must always have occurred prio? to the appearance of the eruption, and is the condition of the peculiar eruption, although not necessarily followed by the outbreak of any eruption, as indeed CARMICHAEL admits : “On a loose computation, it may be regarded that nine out of ten of primary ulcers are not attended by constitutional symptoms; so that in a great majority of cases the disease has never arrived at the stage to which it is indebted for its name To this objection I reply, that the primary ulcers afford a less decisive means of determining the nature of the disease than the secondary; yet from their characters when unaltered by irritation or mercury, we may discriminate their nature with sufficient certainty to decide on the precise eruption they would produce in their secondary state." (p. 68.) These observations, on his own showing, seem to prove the needlessness of having recourse to the eruption as a nomenclator for his “division of venereal complaints into four distinct diseases;" but, as if to put the question beyond dispute, he immediately proceeds to give the following brief description of the several ulcers and their consequent eruptions:- First, the ulcer without callosity, raised edges, or phagedena, in fact without any very peculiar characters, and which may therefore be termed the simple venereal primary ulcer, produces the papular eruption, which ends in desquamation; and the same effect is produced by a patchy excoriation of the glans and prepuce in men and of the labia and vagina in women, and also by a gonorrhæa virulenta. Second, the ulcer with raised edges produces the pustules which terminate in small ulcers covered with thin crusts, and which heal from their margins. Third, the phagedenic and sloughing ulcers produce the spots and tubercles which terminate in ulcers covered with thick crusts, which are accompanied with phagedena, and heal in general from their centre. Fourth and lastly, the primary callous ulcer or chancre is attended with the well known scaly eruption-lepra or psoriasis.” (pp. 68, 9.) CARMICHAEL thus shows the grounds on which he had founded his opinion, that “the difference which was found to exist in the appearance and progress of certain groups of symptoms which usually went together, compelled him to presume the existence of a plurality of venereal poisons.” (p. 48.) But subsequently he observes :-" If any individual object to the division of venereal complaints into four distinct diseases, the difference between us is easily reconciled. Instead of four distinct diseases, let any one that pleases consider them as so many forms or modifications of the one disease, each requiring a peculiar mode of management, and under this view every practical object will be equally well obtained.” (p. 69.)
The following excellent observations of RICORD, whilst explaining the causes on which the varied appearances of chancre or primary syphilitic sore depend, at the same time negatives the much-disputed question of the plurality of venereal poisons, of which CARMICHAEL is the great supporter.
“ Chancre," says RICORD," the strict and inevitable consequence of the application of the syphilitic poison, either upon the skin or mucous membranes, in the condition requisite for inoculation, often presents such varieties, in its material aspect, that it then seems to constitute different diseases. These differences of chancre, badly understood or ill-appreciated, have afforded to some an argument against the identity of the venereal poison and its unity of action, and to others, the proof of the existence of a plurality of poison; but, if well studied in its cause, which always remains the same in its mode of development, and its consequences, in the ordinary and not complicated cases, the seeming differences are explained with ease, and all contradictions disappear; for whatever be the actual form of the chancre from whence the pus has been taken, provided it have reached that period which I have pointed out, a regular and characteristic pustule is, as I have said and proved, obtained, when the virulent pus is put beneath the epidermis or epithelium, a direct ulcer (ulcère d'emblée), when it is applied on naked tissues, or an abscess, when it is introduced into the cellular tissue, into a lymphatic or into a ganglion, always bearing in mind the difference arising from the seat and particular tissues affected, there is found in the ulcer, at its commencement, a regular and peculiar physiognomy, and that also whether it be consequence of the rupture of a pustule, of the opening of a virulent abscess of the cellular tissue or lymphatic passages, or whether it have been produced direct. The deviations or special forms neither occur nor are developed, but after and under the influence of condition foreign to the specific cause, such as the peculiar constitution of the patient, his previous or concomitant ailments, his health, the general or local treatment to which he has been subjected. Thus is it that persons are affected with phagedenic chancres, who have contracted their malady from persons who, seemingly, had only benignant ulcers, and that this vulgar potion, participated in by some physicians, who conceive that a severe disease had been contracted from a very foul person, is found absolutely false.” (pp. 60, 61; Fr. Edit. p. 134-36.)]
Ingenious as are these distinctions, yet are they by no means confirmed by experience; besides the circumstances already mentioned, on which the modifications of syphilis depend, there is still especially the proved fact against the admission of various syphilitic contagions, that frequently many persons are infected in different ways by one and the same person. But the principal ground of this (ABERNETHY's division) that the syphilitic affection is cured only with mercury, but the pseudo-syphilitic without it, has, on the contrary, lost all weight, inasmuch as it is perfectly well known that all syphilitic ulcers may be healed without mercury.
If it may also to this be added, that as the result of congress of the sexes, affections