266

LECTURE XIV.

CONSTITUTIONAL SYPHILIS.*

THE presence of the syphilitic poison, when received for the first time into a patient's system, is usually marked by a certain amount of general disturbance. The patient feels feverish and uncomfortable; the skin becomes dry, and the tongue perhaps coated. It occasionally, however, happens that the secondary or constitutional symptoms show themselves without the patient feeling any general inconvenience.

Lassitude, weariness, and pain in different parts, frequently mark the progress of the disease. The skin loses its fresh and healthy colour, and assumes often a sallow hue.

When the general system is thus affected by the syphilitic poison, it is probable that the nutrition of every part of the body may be thereby influenced. The same tendency to the separation of lymph from the other elements of blood may be manifested in any part

*The description of secondary syphilis in this and the following Lecture does not differ in any essential particulars from that which has already been published in the first volume of Holmes's Surgery.

of the body as in the original seat of the disease. These effusions are more or less organized, and take their characters from the structures in which they are formed. Thus, in the skin, the papillæ become inordinately developed; and if several of these unite together, tubercles are formed. On the iris, the lymph effused forms fibrous bands, which unite it to adjacent parts and prevent its actions. If the periosteum of a bone be affected, the effused material ultimately becomes converted into new bone; and this process, from the unyielding nature of the parts, is attended with much pain, experienced chiefly at night, which has been supposed to be the period of growth. According to the constitution of the patient, the part affected may take on the adhesive, the suppurative, or the ulcerative form of inflammation; or any of these may terminate gangrene, molecular or of the whole surface. Hence a syphilitic affection which commences as a pimple, may at a subsequent period suppurate, or ulcerate, or a portion of its surface may be thrown off, as a small slough. Different names have been given to these different forms of disease; but it is obvious that as long as they are liable to pass one into another, no very accurate divisions can be made. Again; a division has been made with regard to the time at which different parts of the animal economy are affected. The skin, the throat, the eye, and the absorbent glands, are those in which the disease generally appears in the earlier stages of the complaint; and diseases of these parts have been called secondary symptoms: whereas the fibrous and osseous tissues and the deeper struc

in

tures are, as a rule, affected later, and have been called tertiary symptoms. This distinction will be adopted for convenience of description, but it must not thence be inferred that there is any well-marked natural division; and, in fact, the so-called tertiary symptoms sometimes appear before the secondary, and the parts belonging to these respective classes are constantly found affected at the same time.

SECONDARY SYMPTOMS.

The specific induration around the infecting sore has been regarded as the first of the secondary affections. This is, however, not attended with any of the constitutional symptoms above referred to. At an uncertain date, but generally from four to seven weeks from the first appearance of this induration, the syphilitic fever, often very slightly marked, will occur; and in a great majority of instances this will be followed by an exanthematous eruption of the skin, often accompanied by sore throat. At the time that this occurs, a change may frequently be observed in the character of the original sore; a fresh effusion of lymph may take place in its neighbourhood, or the sore itself may ulcerate in a way that it did not before. The nature of the sore will now become altered-a free secretion of pus will often take place from its surface. It no longer presents the characters of the adhesive inflammation only. It has, in fact, become one of the secondary symptoms of the disease. The inguinal glands, in like manner, which up to this period were indurated and enlarged only, will now sometimes show

signs of increased morbid action. They may become tender to the touch. The thickening, originally confined to the glands themselves, may involve the surrounding cellular tissue; and it not unfrequently happens that an abscess will form either in one of the glands themselves, or in the surrounding structure. These suppurating buboes are to be regarded as a part of the secondary symptoms; and their occurrence in no way invalidates the fact dwelt upon in Lecture IV., viz. that the sores which produce syphilitic infection of the constitution do not produce suppurating buboes, excepting from some accidental cause.

SYPHILITIC ERUPTIONS.

Roseola, the eruption which generally first succeeds the syphilitic fever, is of a rose-red colour, not raised above the surface of the skin; disappearing upon pressure, and returning as soon as the pressure is removed. It appears in more or less rounded patches, giving a mottled appearance to the skin; when examined closely, each patch appears made up of a cluster of papillæ, more injected than natural. This eruption will sometimes disappear within a few days. If it persists, the papillæ forming each patch will generally become visibly enlarged, and the colour of the eruption will gradually change to a copper colour. This colour is a common characteristic of all syphilitic eruptions which remain for any length of time without suppuration or ulceration.

The syphilitic eruptions which follow this first

efflorescence on the skin present a variety of appear

ances.

Lichen. The papillæ of the skin frequently are enlarged separately and scattered irregularly over the body. They form small hard elevations of a coppercolour, which terminate by desquamation or resolution. The enlarged papillæ are sometimes formed into groups, and then, occasionally, one much larger than the rest appears as a tubercle in the centre. This form of eruption has been described separately as central tubercle.

Syphilitic tubercle. The same tendency, which has been traced throughout, to the exudation of a fibrinous and albuminous material from the diseased blood, manifests itself particularly in this form of disease. The effusion takes place by a slow, gradual, and uninterrupted process, and becomes perfectly organized as in the papular eruption; each tubercle appears as a small, full, and tense conical eminence, covered with a red and shining cuticle, gradually, like other syphilitic eruptions, assuming a copper colour. The tubercles may be scattered singly over the surface, or they may be seen in groups.

The syphilitic tubercle may assume any size from a large pimple to a split pea or bean. Their shape is generally round, but often they are irregularly oval. The cuticle thrown off from the surface of syphilitic tubercles is peculiarly thin, white, and shining. It resembles small broken pieces of silver-paper. When syphilitic tubercles appear on mucous membranes, they are generally irregular in shape, flattened, and but