vessels of a part, without giving rise to any local affection; and ever since his time there have been original observers who have held the same doctrine. Thus Mr. Lane, one of the present consulting surgeons of the Lock Hospital, has shown, by inoculation, that a bubo was of a specific character, when no primary lesion could be found upon the most minute examination; and Dr. Marston, of the Royal Artillery, has lately recorded cases in the Transactions of the Medical and Chirurgical Society, in which constitutional syphilis occurred without any previous primary symptom. Satisfactory demonstration upon the point is extremely difficult. With regard to the existence of a suppurating bubo without any accompanying sore, it might be said that a sore had really existed before the occurrence of the bubo, and had healed before the examination took place; and with regard to syphilitic infection, although it may be shown to occur without the existence of any chancre, as usually recognized, it would be extremely difficult to prove that the first or second form of primary syphilitic infection, described in Lecture II, had not existed in any individual case.

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LECTURE V.

DESTRUCTIVE SYPHILITIC INFLAMMATION: ACTION OF CAUSTICS: SERPIGINOUS SORES: TREATMENT OF

SUPPURATING SYPHILITIC SORES.

DESTRUCTIVE SYPHILITIC INFLAMMATION.

It is a very remarkable fact that some of the most vascular parts of the body, and those the best supplied with nerves, are, under certain circumstances, the most

prone to mortification. The parts of generation, amply supplied with nerves and blood-vessels, will, under the influence of the syphilitic poison, occasionally become intensely inflamed, and that inflammation will speedily terminate in gangrene. If the gangrene so produced occurs within a short time after the application of the syphilitic poison, the death of the part involves the destruction of the poison. They together cease to exist; and, when the slough separates, an ordinary sore alone remains, requiring no specific

treatment.

Mortification of some part of the organs of generation sometimes appears to depend upon a diseased state of the blood, independent of any local cause.

The blood will stagnate in the capillaries of the skin here as elsewhere; and the tendency to mortification will first show itself in the most vascular parts. The skin will be affected before the areolar tissue, and the areolar tissue before the fibrous and membranous parts.

ance.

I. The mortification, which involves the whole of the infected tissues, will sometimes be of the dry kind, but generally it will be of the moist variety. In the first there will be little pain or swelling, but in the second there will be much effusion, with great pain and a considerable amount of constitutional disturbBoth these varieties of mortification may occur where there is no evidence of the disease having arisen from the application of any poison; and on the other hand, they will occasionally as evidently appear to depend upon direct contagion. Patients in apparent health will sometimes, within three or four days after exposure, find some part of the organs red, swollen, and extremely painful. In the centre of the inflamed part a dusky spot will indicate that the blood has already begun to stagnate in the vessels. The nutrition of the parts is no longer maintained; irregular excavations are made by small portions of the tissues being thrown off in the sanious discharge. The whole part affected becomes of a darker hue, and ultimately presents the ordinary appearance of gangrene. After a time a line of demarcation is established, the slough is thrown off, and the wound generally cicatrizes without difficulty. This process, effected by nature, is very similar to that which is artificially produced

by the application of caustic to a syphilitic sore. In both cases, if the mortification has reached all the parts which have imbibed the poison, the destruction of the poison will take place in that of the tissues which contained it.

In this first practical division of mortification, viz. : that in which the whole of the infected tissues perishes, as it occurs naturally, there is very seldom indeed any subsequent affection of the patient's system, even supposing he has been in a position to contract an infecting sore; and the reason of this doubtless is, that the action which terminates in mortification commences at the same time as, or very soon after, the application of the poison. In cases where the mortification has been artificially produced, on the contrary, a period of incubation may have existed, of some days or weeks, before the disease has shown itself, and consequently before the caustic is applied ; and during this time the tissues will have imbibed the poison, to a greater extent than the caustic can reach.

The morbid action, which we are now considering, appears to be communicable by contact, although this cannot be so closely traced as in the other forms of syphilitic inoculation. In patients, for instance, in whom the general health has not been impaired, parts which have no direct connexion, either by bloodvessels or nerves, will appear to infect each other. Thus the glans and the prepuce, the opposed surfaces of the labia or of the nates, will sometimes become affected in a similar manner and exactly to the same extent; and

when lymphatic absorption accompanies the gangrenous inflammation, the destructive action is tolerably sure to be communicated from the primary sore to the corresponding inguinal gland, and from it to the surrounding areolar tissue and skin.

II. The second form of destructive inflammation is by far more common, and ordinarily of much longer duration. In it the infected tissue dies slowly, bit by bit, by a kind of molecular necrosis; and, in consequence of this tardy action, the whole of the infecting portions never perish at the same time. A part is always left as a focus of contagion, and this involves fresh portions, which, in their turn, are thrown off, but not before they have communicated the disease to parts beyond. This action constitutes the phagedanic syphilitic sore. It may appear as an original disease, or it may supervene upon any of the forms already described. It is inoculable, and generally arises from the direct result of the application of the syphilitic poison; but secondary forms of syphilitic disease may assume precisely the same characters. These, however, cannot readily be inoculated upon the patient, whereas the primary phagedænic ulcer can.*

The phagedænic ulcer spreads irregularly in different directions, is accompanied often by much pain, and yields a profuse discharge. This consists of an ill

The experiment of inoculating this form of disease should be carefully avoided; for a surgeon can never tell when the artificial inoculation which he produces will heal, and he will have the credit of having prolonged the disease if the original sore should heal before the inoculation.

H