WCA 083c Sa.sc. I \873 T '•>*; W > *■■ ■' i y-«4 ;sm >» *' THflB B NLfl DD10171S 2 NLM001017152 wasy > • < ^Mm ' war /-\ Tfitf/ i rear / * \ isc inoiqiw jo Aavaan ivnoiivn indiojw jo Aavaan ivnoiivn jnoiojw jo Aavaan ivno h?\ } i NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAl LIBRARY OF MEDM «? . ^ = VX inoioiw jo Aavaan ivnoiivn jnoiojw jo Aavaan ivnoiivn iNOiaiw jo Aivaan tvnoi lATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAl LIBRARY OF MEDIC 7 7 1 VXj- nijioiw jo Aavaan ivnoiivn indiojw jo Aavaan ivnoiivn in ATIONAL LIBRARY OF MEDICINE NATIONAl LIBRARY OF MEDICINE NATIONAL V * niDiaaw jo Aavaan ivnoiivn jnisiqjw jo Aavaan ivnoiivn sn LIBRARY OF MEDICI %H S r nJ 3-ent F. N OTIS' 11 in effecting this, and in promoting the necessary subsequent absorption and elimination, is Mercury; hence the internal administration of some mercurial preparation is essential in all well determined Initial Lesions. The Proto-iodide of Mercury, in pill \ grain to one grain, three times a day. The Bin-iodide, in 1-20 to 1-12. The Bi-chloride, in doses of from 1-20 to 1-12 grains. The Mass. Hydrargyrum, from two to four grains, three times a day, until the constitutional influence of the drug is manifested by a spongy, and sensitive condition of the gums, or a slight mercurial odor in the breath. The mercurial impression should be maintained as nearly as pos- sible at this point, until complete absorption of the local neoplasm has been effected. Its further employment wiU be considered in the Lesson on treatment of General or Constitutional Syphilis. Cleanliness;—freedom from friction, and irritation from all other causes:—simple diet, and abstinence from Alcoholic Stimuli, are necessary to the most favorable results in treatment of the Initial Lesion, as well as all other forms of Syphilis. In regard to the modifications of the Initial Lesion of* Syphilis. THE MUCOID FORM requires in addition to the constitutional treatment, previously des- cribed, the application of the solid Argentum Nitratis, (or some other caustic) sufficient only to destroy and subsequently to repress the exhuberant granulations. THE INFLAMED OR SUPPURATING INITIAL LESION requires rest and opiate or sedative dressing, as, the Lotio Plumbi et opii, in the proportion of grs. 5. each, to the ounce of water; or the powdered Iodoform, simple, or with an equal part of Tannic Acid, which seems to deodorise, and, possibly, increases the efficiency of the Iodoform. 12 CLASS ROOM LESSONS. IN THE GANGRENOUS FORM, the powdered Iodoform is efficient as an anti-septic. Poultices of powdered charcoal are also of value: but the internal administration of Mercury, must not be neglected while the gangren- ous action is limited to the induration. Occurring in debilitated or highly scrofulous subjects, as is usually the case, attention should be given to general support, by generous diet, Quinine and Iron. The Potassio-tartrate of Iron in 15 to 20 grain doses, (as recommended by Ricord) seems to exert a specific influence over gangrenous conditions. It must not be forgotten that healing and apparent cure of the Initial Lesion, does not mean cure of Syphilis. After disappearance more or less complete, the induration may return. Not unfrequently, it may be observed to increase or diminish in apparant sympathy with the progress or abatement of the constitutional disease. From this fact the local induration has come to be considered by some, as a reliable barometer, by which the effect of general treatment may be appreciated. The duration of the Initial Lesion varies greatly in different cases, sometimes disappearing within a few weeks, and with it, every trace of induration; at others, it continues as an induration, more or less distinctly marked, throughout the active stage of the constitutional infection. Enlargement and induration of the lympha- tic glands, nearest in connection with the Initial Lesion, constitute the first positive evidence of the progress of constitutional infection. Concealed Initial Lesions; (as within the meatus urinarius or the anus) may be treated with bougies, or suppositories, medicated with opium, salicylic acid, or iodoform. New York, December 13th, 1877. CLASS ROOM LESSONS. 13 No. 4. CONTAGION OF SYPHILIS. Recent investigations in regard to the disease germs of Contag- ious diseases, warrant the assumption of Dr. Lionel Beale (Disease Germs, their Nature and Origin, London, 1872, Page 143, 21 seq.) that they are degraded cells, (bioplasts,) originally derived from the healthy elements of the human organism. Having lost, by degradation, the capacity for development into useful tissue, they still retain the power of amoeboid movement, proliferation, and vital sustenance. This view affords a starting point for the rational explanation of Syphilitic Disease, which, so far as known, is confined to the human germinal elements. It is distinctly appreciable only in the lymphatic organs and channels, and in lesions which can be directly traced to disturbances of structure or function in the lymphatic system. In complete accord with all that is known in regard to Syphilis, we may assume, that contact of normal germinal cells, (white blood corpuscles) with those which have been degraded through the Syphilitic influence, brings about a similar degradation in them: and these again, in the same way, acquire the power to degrade other normal germinal cells with which they may be brought into contact, whether in the same or in another person. Thus the Syphilitic influence, at the point of original inocula- tion, in varying intensity, is transferred from cell, to cell, until its vitiating power is lost, by attenuation, or dilution, or until the entire organism is profoundly affected. Thus it is that we shall meet with Syphihs, in varying degrees of severity: from that where the subject passes through it with scarcely a single characteristic manifestation, to one, who, in its various periods, will present a classical picture of every phase of the disease. Germinal cells from one source or organism, cannot come in con- tact with those of an independent organism, without a breach of tissue. 14 F. N. OTIS' Experiments by inoculation of Syphilitic blood, and of the un- mixed secretions of unirritated Syphilitic Lesions, have demonstrated the complete absence of any erosive property in the so called virus of Syphilis. In the wounds of such inoculations, healing was as rapid, and perfect, as in similar wounds where no inoculation had been made. All the secretions of syphilitic lesions, and of the blood, during the active stage of Syphilis, (usually from one to Wo years) contain degraded germinal cells or disease germs, and are thus capable of communicating Syphihs. The modes of transferance of Syphihs, from the diseased to the healthy, are three:— 1st. By Direct Contact of the diseased surface with an abrasion, or other breach of tissue, on a healthy person. 2d. By Mediate Contagion. 3d. By Hereditary Transmission. Communication of Syphilis by Direct Contact, (as under the circumstances peculiar to the venereal act,) is the most frequent mode of the acquirement of Syphihs. In the Female, Initial Lesions, from this source, are most common in the vicinity of the ostium vaginae; es- pecially so in the folds of mucous membrane about the fourchette; be- tween the greater and lesser labiae: under the sheath of the clittoris: upon, and even within, the meatus urinarius. They are also found to occur, not unfrequently, about the anus: They are rarely found on the os uteri, and still more rarely on the vaginal rugae. In the Male, the most frequent sites, are upon the glans penis and prepuce: occurring with especial frequency in the sulci by the side of the frenum: at the meatus urinarius, and in the fossae qlandis and occasionally on the integument of the penis In both sexes the Initial Lesion is sometimes found upon either lip, in the angles of the mouth, or even within it, and also near or CLASS ROOM LESSONS. 15 within, the anus; all as a result of direct contagion. Communication of Syphlis, by direct contact, through the act of kissing, is an accident of occasional occurrence. In this case, the inoculating secretion may be furnished, either by an Initial Lesion, or, by one of the common manifestations of active Syphilis, known as the Mucous Patch. Initial Lesions are also found in various other localities, as solu- tions of continuity, at any point, may become the accidental recipients of the Syphilitic contagium. Usually, they are rare in proportion to their distance from the genitalia. Surgeons, Accoucheurs, and Gyne- cologists, are especially exposed to the peril of an innocent inoculation of Syphilis, by direct contact. Within the circle of my city acquaint- ance, at the present time, are three medical gentlemen who acquired Syphihs through an Initial Lesion on the right forefinger. In another case, a surgeon, also an acquaintance, received the Syphilitic inoculation in end of his right forefinger, through accidental punc- ture, by a spicula of bone, while amputating the leg of a Syphilitic subject. Inoculation of Syphilis Through Mediate Contagion. Cells dis- eased by the Syphilitic influence, (or what is usually termed the Syphilitic virus,) may cling to substances with which they are brought into contact. All degraded animal cells, or disease germs, have the power of maintaining their vitality, for some, time after removal from the organism in which they have been developed. (Beale.) Any ma- terial, therefore, which has been in contact with the secretions of Syphilitic Lesions, or the blood of a Syphilitic, during the active stage of Syphilis, may prove the medium of communication of Syphilis to a healthy person, provided only, that the substance so contaminated, is brought into contact with a lesion, however slight, of the skin or mucous membrane. The most common source of the contagium, in cases of Mediate Contagion, is the Mucous Patch, a constitutional Syphilitic Lesion, fre- quent upon the mucous membrane of the lips, mouth, and faucial 16 F. N. OTIS' region, in persons passing through the active stages of Syphilis. The Saliva is thus impregnated with 'the Syphilitic disease germs, and, through it, a variety of domestic utensils, have been the known med- ium of Syphilitic inoculation, by contact with abrasions upon the lips of healthy persons, without regard to age or sex. In the same way, pipes,passed from Syphilitic mouths,cigars from Syphilitic cigar makers: canes, pencils, and even sticks of candy, contaminated by Syphilitic saliva, have effected a Syphilitic inoculation. Within the last 18 months, I have met with four cases, where there was undoubted proof of the acquirement of Syphilis through Mediate Contagion. One, of a young lady, with the Initial Lesion on the lower lip, acquired from her lover's kiss. The second, a physician, with the Initial Lesion just within the angle, (on the right side) of the mouth; from a Syphilitic friend's pipe. The third, in the same locality, appearing character- istically, about three weeks after a morning spent in a dentist's chair. The fourth, a worthy merchant, with his Initial Lesion, (well marked,) on his lower hp, with mucous patches in his mouth, and an accompanying Syphilitic Iritis. In this latter case, the only clue to the mode of acquirement of Syphilis, was the habit of passing among numerous clerks, and, occasionally, transferring a lead pencil from their desks to his mouth. Well marked constitutional Syphihs, with complete absence of any genital lesion, was present in each case cited. CoLLEciK of Physicians and Surgeons., New York, Jan. 17th, 1878. CLASS ROOM LESSONS. 17 The foregoing typical cases, illustrative of the modes, through which Syphilis may be contracted by Mediate Contagion, (with the exception of the last,) were seen in consultation with Physicians from neighboring States. Such accidents however, are of more likely occur- rence in great cities, where moral restraint is least stringent, and oppor- tunity for acquiring Venereal Diseases most favorable. It becomes necessary therefore, in connection with cases of obscure disease, sim- ulating Syphihs, to make a searching scrutiny of all incidents, condi- tions, and exposures, which may, in the light of possible accidents, point to opportunity of Syphilitc infection, through Mediate Con- tagion. The third case cited is of especial value, as conveying a les- son on the necessity of scrupulous care of instruments, used in opera- tions about the mouth. So simple a procedure as the depression of a patient's tongue, with a spatula, in examinations of the mouth and throat, may easily become the means of carrying the Syphilitic disease germ, to an abraded surface in a healthy person. In all cases, therefore, where the same instruments are in use for different persons, after thorough cleansing, their passage through the flame of an alcohol lamp, should be systematically practised after evtry operation. The same procedure is equally indicated, in regard to instruments used upon other mucous membranes, as those lining the urethra, the bladder, the rectum, the eye. It is also essential, in all instruments used in cutting operations, at any point. Not the least important among the modes of conveying Syphilis, by Mediate Con- tagion, is that by Vaccination. Numerous well authenicattd cases of this disaster, may be found recorded in any modern, systematic, work on Syphilis. Inoculation of Syphilis by Vaccination, may be effected either by an impure virus, or an unclean knife. Use of the Bovine virus, by means of a clean instrument, relieves this beneficent operation from the stigma of'being considered a possible means of communica- ting Syphilis. 18 F. N. OTIS' No. s- SYPHILIS BY HEREDITARY TRANSMISSION. Heretofore in considering the modes of transmission of Syphilis, we have accepted the probable fact, that this disease is communicated by contact of a diseased, with a healthy, human germinal cell. We have now to consider, how diseased cells, in the adult, male or female, suffering with Syphilis, may be brought in contact with those of the embryo, or of the foetal organism. It is claimed that the foetus, through the natural processes of growth and development, may be built up from a Syphilitic seminal animalcule, (spermatozoon,) furnish- ed by the male, in conjunction with an ovum furnished by a healthy, or even by a Syphilitic female, and may thus come to comparative maturity. Much clinical material has been adduced to prove this. On the other hand it is claimed, with equal proof of a similar charac- ter, that this is never the case; but that the Syphilitic influence, is always furnished by the female; presumedly communicated to the embryo or foetus, through contact with the nutritive elements, fur- nished by a mother, in whose organism, the degraded cells or disease germs of Syphilis are present. Like most important questions in which Syphilis is involved, a solution of the foregoing, based on chnical evidence alone, is most difficult. The best proof of this statement is, that on either side of all such questions, the most experienced and competent observers, are ranged in nearly equal force. To constitute Hereditary Syphilis, either the embryo, or the foetus, must be infected. All infection dur- ing, or subsequent to birth, must be classed with one or other of the modes of transmission of Syphilis previously considered. If we accept the Syphilitic influence to be, as previously claimed, a degraded formative cell, we may also accept, as a legitimate sequence, that, through this degradation, there is a loss of formative power; an inability to develope into any useful tissue. CLASS ROOM LESSONS. 19 The Contagion of Syphilis, as claimed, is always effected by con- tact of a degraded, with a healthy germinal cell. In a strict sense, therefore it is always localized. Cells, thus degraded, are practically emasculated; their capacity for usefulness is lost. Of necessity, then, growth of living tissue occurring, must take place through the normal cell elements, that is in those which have escaped this degradation. It is thus plain, that only a portion of the germinal material of a living organism can be affected by Syphilis. Sufficient germinal material, to carry on the processes of life and growth, must escape, or growth would be at once arrested, and life would cease. The possibihty of involving, in the Syphilitic dyscrasia, so infinitesimal a fraction of a spermatic organism, as would still enable it, in conjunction with the ovum, to play an efficient part in the growth and development of the human embryo, is scarcely conceivable. Especially difficult, shall we find it to accept such a view, when we consider, that, once in connec- tion with the ovum, the Syphilitic influence would be rapidly impart- ed to the germinal elements furnished by it. We may then, consis- tently, throw the great improbability of continued growth, (or indeed of any growth,) under such an unfavorable influence, into the scale with the clinical claims of those who deny the possibility of the embryo, or foetus, being infected with Syphilis, by the spermatazoa. With this view of the subject, the onus of Hereditary Transmission of Syphilis, is necessarily thrown upon the Mother, under all, even under appar- ently contradictory, clinical circumstances. Hence, when an embryo or foetus, is the subject of Syphilitic infection, we may conclude that it is the result of contact of its normal formative or germinal cells, with cells degraded through the Syphilitic influence, furnished by the nutritive fluids of the Mother; either directly through the circu- lation, or through degraded cells from her organism, gaining access to that of the embryo or foetus by their amoeboid power. Hence, to make the Syphilitic infection of an embryo or a foetus possible, the organism of the Mother must first be infected with 20 F. N. OTIS'________ Syphilis. The previous acquirement of Syphilis, by the Mother, from the Father: or through the secretion- of a Syphilitic lesion, or from the blood of one suffering from active Syphilis, (by direct or Mediate Contagion) is necessary to the Syphilitic infection of a foetus or an embryo. It is only during the active stages of Syphilis, (primary and secondary pariods) that the contagious element of the different lesions of Syphilis and of the blood, is present; Therefore; Hereditary transmission of this disease is only possible during this time, (usually from one to two years). The Sequelae of Syphilis (tertiary and quar- ternary periods) contain no discovered elements of contagion. The most careful microscopical examinations have failed to discover in the products of Tertiary Syphilis (various forms of gummata, including eruptions) any thing besides the debris of normal germinal elements. Repeated inoculations of these products, have failed to disclose any contagious principle. Without contagion there is no Syphilis. Hence, we may reasonably conclude that Hereditary Syphihs, is only acquired during the active periods of the disease, and that in order to effect Syphilitic contamination of the embryo or foetus, the female organism must first be infected. With this view of the maternal influence in Syphilitic infection of the foetus or embryo, cases reported, claiming such infection to have occured through the sole agency of the Father suffering with Syphilis, (the mother, up to this time, free from the disease) must be classed either among those instances referred to on page 12, where the characteristic features of the disease are absent, or so imperfectly developed as to have escaped detection. The difficulty of instituting a thorough examination, under cir- cumstances where it is necessary to avoid suspicion of its object; the want of tact, care, and experience, in detecting obscure evidences of this disease, have, without doubt, too often led to the acceptance of Syphilis acquired, through the paternal influence, where, under CLASS ROOM LESSONS. 21 other conditions, and in other hands, infection of the mother would have been recognized. The following case will serve to indicate some of the various ways in which Syphilis may be overlooked, and further, to show important variations in time and manner of development of Syphilis from a similar source. Some three months since, Dr. W., a naval Surgeon, consulted me in regard to a small nodule on the frenum preptutialis. An abrasion was discovered, after a suspicious exposure, some four weeks previous. This healed at once, as if simple, and nothing farther was noticed, until the nodule, about the size .of a kernel of pearl-barley, was observed. Its surface was abraded, prob- ably during a recent connection. Its scanty secretion was found under the microscope to consist chiefly of laminated epithehal scales. On account of the obesity of the patient, a satisfactory examination of the inguinal glands was impracticable. No enlargement could be felt. I advised excision of the neoplasm. This was c'one at once, and healing by first intention was complete within 48 hours. A few days since (Dec. 15th) the Doctor called to say that the operation had evidently been efficacious in saving him from a general Syphilitic infection: That, he had positive proof of having, himself, communicated Syphilis, to a young lady, the night previous to the ex- cision. In her case, an Initial Lesion followed, in due time after the con- nection, accompanied by inguinal gland enlargement and followed by general gland hyperplasias. She now had, in addition, a characteris- tic papular syphilide, and yet he claimed to be absolutely free from the least evidence of Syphilis. A cursory examination appeared to confirm the Doctor's state- ment. This, however, appeared so improbable, that I at once insti- tuted a more thorough examination, which resulted in the discovery, under a deep layer of adipose, of small, but characteristic gland enlarge- ments, in connection with the Initial Lesion. The cicatrix on its former site was slightly indurated. Glands at a distance—epitrochlean 22 F. N OTIS' and post cervical regions, preceptably enlarged. Slight, but pos- itive congestion of the fauces and a narrow, but characteristic, mucous patch hidden behind the anterior pillar on either side. These proofs of Syphilitic infection had escaped the anxious search and skill of the patient, also of a professional associate, who was a competent and experienced general surgeon. Through evidence furnished by clinical cases, it has been claimed that Syphilis once acquired is never fully eliminated from the system, but that it exists as a possible infecting agent, after the stages which furnish known contagious elements are past. During more than twenty years of observation, and especial interest in regard to this point, I had been unable to find a single undoubted instance, where a person in the known Tertiary period of Syphilis, (and so demons- trated by the absence of the glandular enlargements characteristic of the active stages of the disease,) had been the proven carrier of Syphilis to a healthy person. I came to believe fully, that persons who had passed successfully through the so called primary and secondary periods, and so proven by complete absence oijjrimary and secondary hyperplasias, that treatment was no longer necessary : that such persons might, if desirable, even, be permitted to marry, with the assurance that, through them, transmission of Syphilis to wife or child was impossible. This doctrine I had taught and practiced for a very long period, when a case came under my observation which, but for a mere chance, had unsettled me on this vital point forever. The important lesson, which it enforced, viz : to distrust the value of purely clinical evidence, may be profitably transmitted by the brief extract from my note book, which follows: " Mr. Q., a young lawyer, age 25 years, acquired a well marked Initial ksion of Syphdis on the glans penis. His gland enlaroements in the epitrochlean, cervical, and post cervical regions were character- istic—his roseola escaped (>bservation, but a classical papular Svphil- ide appeared about the fourth month, anil continued for several weeks. Ulcerations of the tonsils and mucous patches on the soft CLASS ROOM LESSONS. 23 palate and inner surface of the cheeks followed, but yeilded satisfac- torily to treatment. The gentle but persistent use of mercury internally and by in- unction had been pursued irom the first and through a period of 12 months, occassionally combined with the iodide of potassium. At this time, all glandular enlargements had disappeared, except a small one, the size of a pea, in the right post cervical, region. Treat- ment suspended for three months, when a thin dipthenc patch appeared on the right side of the tongue, with slight induration. Treatment resumed, mercury, with iodide of potash. Patch < n the tongue faded slowly out in about a month, but was replaced by an- other, on the opposite side, which continued about the same time, cervical gland not preceptably changed. A series of mecurial baths, and a course of Zittman's decoction, covering neary three months longer: gland now scarcely felt. Patient very anxious to marry, but was advised to wait a full year. The next six months passed without any new develojnnent. Gland very small, but stdl recognizable, when the patient, now in good general health, married on his own responsibility. One year after marriage the wife gave birth to a fine healthy look- ing boy. During the 5th month of lactation, the wife had Scrofulous abcess of the neck (inherited tendency) which alarmed the husband (fearing Syphilis) exceedingly. She recovered under simple treat- ment, and relief from nursing. Child healthy up to third year, when it died from tubercular meningitis, following scarlet fever. No salient evidences of Syphilitic taint. Fear that his old trouble had been in some way connected with his child's death made the husband very un- happy, and he frequently expressed the fear that he had, or might yet, contaminate his wife, to whom he was tenderly attached. In Nov. 1870, Mr. Q. camplained of some swelling and soreness over the right tibia. A gummy tumor was found presenting, the size of a horse chestnut. Explained the nature of it, and put him on a mild mercurial, with large doses of iodid. potass., which resulted in its entire disappearance within a month. Both husband and wife con- tinued healthy up to Oct. 1871, when one morning he called, in great distress, to sayr that his wife had some sores in her mouth, that resembled those of his early Syphilitic trouble. 1 did not hesitate to assure him that this was simply impossible; that his disease, if any trace of it remained, was beyond the fear of contagion. The spotless character and chaste deportment of his wife made me ture there could be no other danger, and I comforted him accordingly. What was my surprise, on seeing her, to find, not only several characteristic mucous patches in her mouth, but on further ex* mina- tion, to discover four or five mucous tubercles: one on the inner bor- 24 F. N. OTIS' der of the thiSh, and the others on the right labium. I was forced to acknowledge to the wretched husband, that he was rignt, ana we could only conclude that, contrary to all my assurance and Deiiet, that his old taint had been the cause. .. Here was a dilemma. I could not suspect the wife. I couhi not accept the contagion from a source which stultified all my conclu- sions, teaching and experience. I was wretched. Husband was wretched, but resigned, so only, if not necessary to her recovery, that I could keep the secret from his wife. She was serene—after a few weeks medication and not unfrequent painful application* of caustic to the mucous tubercles, I thought she was too serene. I asked and received permission from the husband to tell his wife what her trouble was, if I thought it best. I changed my manner to her, and from being sympathetic and considerate, I became brusque and reserved—an explanation was finally demanded. I evaded the issue. After a little dexterous fencing, the source of her troubles was flatly demanded. Ignorance of my meaning was feigned. I explained the only causes of her disease, and said she had been married too long to suspect her husband. She promptly re- plied that he was "as pure as the sun." I then told her if she would give me her confidence, I would protect her—if not, would lay the matter before her husband, (who was not supposed to be aware of this nature of the disease.) Then came tears—reproaches—and finally, in a tempest of womanly indignation she bade me leave, for- ever. I left, disheartened and in disgrace—but before I was well on my way down stairs, I was recalled and amid tears and sobs: she confessed. A yachting excursion—an unexpected night at sea; ex- posure with an old lover and all this about three months before. If this were not sufficient, a letter subquently rceived from him—full of regret that he had discovered himself Syphilitic and inquiring if he had been so unfortunate as to have communicated the disease to her." The subsequent progress of this instructive case wrasnot peculiar. The lady made an apparently complete recovery in about a year. After another year, she again became pregnant—was delivered of a healthy child, now living, but died of puerperal fever, the third week after her confinement. In carefully reviewing th's history, it will be observed that while it is no exception to the rule that tertiary lesions are not contagious —it will show how easily they may achieve the credit due to the active manifestations of Syphilis. College of Fhysicians and Surgeons, New Yokk, Jan. 24th, 1878 CLASS ROOM LESSONS. 25 No. 6. EARLY DIFFERENTIAL DIAGNOSIS. The characteristic, and only constant feature of all lesions, during the active stages of Syphilis, is shown, by microscopic examination, to consist in a localized cell accumulation. Consideration e>f the nature and behavior e)f this material, will afford intelligent aid, in a differential diagnosis, between the Initial Lesion of Syphilis, in its early period, and solutions of continuity from other causes. As far as known, Syphilis is primarily a process of cell growth, and accumulation, so rapid that it interferes with healthy tissue growth, by obstructing the processes of nutrition and development. Not of necessity interfering to the extent of causing death of tissue, but of impairing its vitality, and thus causing it to break down, more rapidly, under influences which favor solutions of continuity. Hence we have presenting, as characteristic Initial Lesions of Syphihs; either a neoplasm, dense, insensitive, and cov- ered with unbroken, and apparently normal, cuticle or mucous mem- brane, or, from the causes above mentioned, some one of the various characteristic solutions of continuity described in Lesson 1st. In addition to the foregoing characteristic lesions, we may also find early local disturbance, in various forms and from various causes, associated with the beginnings of Syphilitic cell accumulation, but pre- senting no features characteristic of Syphilitic inoculation. The known fact, however, that Syphilitic infection, not unirequent- ly follows a wound of inoculation, which heals promptly, and with no subsequent solution of continuity, is sufficient to prove that neither In- flammation nor Ulceration are essential features in a Syphilitic inocula- tion. Thus: wounds, abrasions, broken vesicles, pustules, or ulcers, may receive a Syphilitic inoculation, and progress or heal, as if no such inoculation had taken place. It is then evident, that no positive differential diagnosis can be 26 F. N. OTIS' m ide at once, between lesions which will be followed by Syphilitic infection, and those which will not. A positive decision cannot be ren- dered until after such interval, from latest exposure, as may be requir- eel to develope some characteristic cell accumulation: either on the site of the lesion or in the adjacent lymphatic channels and glands. This interval is recognized by all authorities as a clinical fact and is characterized as " The Period of Incubation of Syphilis." The term was invented in accordance with a belief, (formerly pre- valent) that the virus of Syphilis was a mysterious imp lpable influ- ence. That this, having entered the System at a given point, instant- ly permeated the fluids and solids e>f the entire organism. It then accumulated by 'a kind of germination" until the point of "satura- tion" c;r extreme limit of tolerance, was reacheel. This event was announced by a peculiar and characteristic action, at the po.nt of entrance of the vims, which was termed the Chancre. It is plain, however, that such a view of Syphilitic infection, can have no support, if we accept the view of a cell degradation, and a systemic Syphilitic infection, in accordance with known histological physiological, and pathological laws. It is then to the local conditions, at the point of inoculation, that we must look for the earliest evidences of Syphilitic action. This is afforded, at first, through the microseop;>,by discovery of a densely packed non-inflammatory cell accumulation, which steadily increases, until it is appreciable to the ordinary touch. The same cell accumu- lation is also seen to occur in the lymphatic vessels connecting the Initial Lesion with the adjacent lymphatic glands. These vessels are not unfrequently found obstructed and indurated, and, like knotted cords, the size of a crow's quill, or larger, often easily traceable to their gland termination. The associated blood vessels are never narrowed or interrupted from this cause. Note.— The only recognizable cell accumulation in Syphilis, is confined to the lymphatic svs- tem. If, during the period of so called incubation, the Syphilitic influence has found access to the general circulation, no evidence of it has ever been discovered, in the condition of blood vessels or of the blood, or in the conditions or sensations of the person so affected. CLASS ROOM LESSONS. 27 The local induration of a suspected lesion, however is not posi- tive evidence of Syphilitic action. Cell accumulation sufficient in degree to produce well pronounced induration, may result from irritation of a simple lesion. Thus, an herpetic vesicle, or pustule, even a simple abrasion, through friction from clothes, or from appli- cations of caustics, or astringents, may become indurated sufficiently to raise grave suspicions of Syphilis. Induration, in such cases, is always the result of inflammatory action. The induration of Syphilis is essentially, non-inflammatory. The differential diagnosis is aided by means used to combat the in- flammatory condition. Under the influence of rest, and local sedatives, the incidental induration, is promptly dissipated; in the Initial Lesion of Syphilis the induration is made more salient. Sometimes, though rarely, the induration is quite obscured by a slight localized serous effusion, which gives it a bluish appearance. This, I have observed in two cases, where the lesion was on a finger. The same condition, quite frequently, succeeds well marked indura- tions, near the fossa glandis, and is so persistent as to become a valu- able diagnostic mark. The induration may be said to be characteristic, when insensitive, dense, and resistant, like cartilage. If pressed between the thumb and finger, it becomes exsanguinated, and like in appearance to the tarsal cartilage, when the eyelid is turned back. Even this most positive evidence of Syphilis, cannot be accepted as conclusive. The induration of a commencing epithelioma simu- lates it very perfectly and, if an open lesion, its secretion under the microscope presents appearances almost identical. In summing up the whole matter, we are forced to confess that a final decision in any given case, is not warranted, until some other evidence, is present besides the appearance and character of the local lesion. 28 F. N. OTIS' In all cases, where possible, the person from whom Syphilis may have been acquired, should be carefully examined. In making such examination, search not only for the initial lesion, but for each of the possible secondary manifestations. Even when such are found, it must be borne in minel that, a breach of surface on the person exposed, is essential to the acquirement of Syphilis, and that this surface must be brought into contact with the Syphilitic secre- tion, either directly or mediately. So that while the presumptive evi- dence furnished by confrontation is often strong, it is not neces- sarily conclusive. The following cases will serve to illustrate the importance of cau- tion in arriving at conclusions, in regard to the true nature of ven- ereal lesions: Case 1st.—Mr. T., aged 23, on the fourteenth day after his first and only connection, noticed a slight urethral discharge. Under the microscope this was found to be distinctly purulent. No pain on urination. Meatoscope showed the mucous lining of the urethra deeply congested for half an inch. Beyond this there was no puru- lent secretion; appearances normal. The difficulty was, evidently, not gonorrhceal. A Syphilitic inoculation was suspected. Exami- nation of the woman with whom he had connection showed her to be passing through the active stages of Syphilis. No Initial Lesion was found; but the inguinal, epitrochlean, and cervical glands were char- acteristically enlarged. Several mucous tubercles were discovered within the vulva; one in the cervical side us, and three on the os tincae. Besides these, was a double row around the anus, eroded and se- creting pus freely. In the presence of such evidences of Syphilis, it seemed impossible that the young man could have escaped infec- tion. The urethral discharge was probably caused bv a Syphilitic inoculation which had not yet produced a well defined initial Lesion. Inguinal glands of both sides slightly enlarged. Treatment for Syph- ilis deferred, (much against the patient's wish) until evidence of Syphilis should become more positive. The urethral discharge grad- ually declined and disappeared entirely in about a month. Up to the present time (4 years from date of exposure) patient has not had the shghtest evidence of Syphilitic trouble. Case 2d.—Mr. H., aged 30, had a suspicious connection in May last. On the third day following, he noticed several small pimples College of Physicians and Surgeons, New York, Feb. 14th, 1878. CLASS ROOM LESSONS. 29 on his prepuce. Fearing veneral disease, he consulted his family physician, who, at once, pronounced the trouble a simple herpes. A mild lotion was recommended. Under its use all evidences of dis- ease disappeared, within a few days, and the patient was assured, in the most positive manner, that he was free from disease. June 10th, four weeks after the suspicious connec ion, (and more than two after he had been pronounced free from disease), the patient was brought to me by his physician for an opinion in regard to a small hard, eroded nodule on the former site of the herpes. Inguinal glands on corresponeiing (right) side, characteristically enlarged. My belief that the nodule was an Initial lesion of Syphilis was strongly ex- pressed, and the gentleman was put upon a mercurial course. A month later, he called, presenting a well marked roseola, with the usual secondary gland enlargements. His wife, who accompanied him, had an indurated Initial lesion on the lower border of the meatus urinarius and well marked inguinal enlargement. Case 3d.—Mr. "W. V. No unusual trouble until 2| months ago when 10 days after a suspicious connection he noticed a small sore on the right side of the penis. He consulted a surgeon, by whom he was informed that he had a " Soft Chancre;" that he would quickly destroy it by application of niiric acid, and further, that there need be no fear of subsequent trouble. The cauterization was made, was re- peated several times, at intervals of three or four days; healing finally taking place in about three weeks. Patient had connection with his wife the night previous to receiving the surgeon's opinion that he had a soft chancre; no connection since. This gentleman called upon me to ascertain the cause of a papulo- pustular eruption which was confined to the face and neck. I at once recognized it as syphilitic; examined the cicatrix, of the so called soft chancre and found it distinctly indurated. Gland enlarge- ments of elbow and neck, all well pronounced and characteristic. In answer to an anxious enquiry, as to the possible infection of the wife, I was obliged to admit the possibility of. such a calamity. He assured me that she had been, and was then, perfectly well in every respect—" except that she had some little swellings in the right groin; not the least pain." An examination of the lady, on the following clay, dis- closed characteristic gland enlargements, not only in the groin, but in the arm and neck. No search was made for the Initial lesion. She was put upon constitutional treatment for "a form of leucocythemia," and remained in blissful ignorance as to the nature of her own and her husband's trouble. 30 F. N OTIS' No. 7. PROGRESS OF THE SYPHILITIC INFECTION. The term Contagion, has been used to designate the act by which, through cell contact, the Syphilitic influence is conveyed from a diseased to a healthy person. By means of the influence thus communicated, proliferation and accumulation of degraded cells, at the point of original contact (or inoculation) are claimed to result in the establishment of the Initial Lesion of Syphilis, or Chancre, in its various forms. The course of the disease beyond this point is indicated, a priori by the known fact* that all integumentary and cellular tissue are per- vaded by lymph spaces and channels, which lead, more or less directly, into lymphatic vessels; and that the lymph current is constantly flow- ing, from the tissues, toward the lymphatic vessels and the glands in which they terminate. Therefore a degraded germinal cell (Syphilitic) introduced into the tissues (as by an inoculation), unless carried directly into the in- terior of a blood vessel, must, (itself, or its vitiated descendents), of necessity sooner or later be carried along by the lymph current, to and into, the gland of connection^ All clinical observations confirm this view. First, in the discovery of indurated lymphatic vessels, lead- ing, from the point of inoculation, to the gland in connection. Second, by the subsequent enlargement and induration of such glands, Third their acceptance as a necessary sequence of the inoculation, and . as positive proof of the nature of the disease. The process through which the Syphilitic influence, thus grad- ually advances and finally invades the general system, is termed the process of Syphilitic Infection. ♦Strieker's Human and Comparative Histology, Sydenham Ed., Vol. 1. pp 307—et sequitur. tNoTE.-"The wandering red blood globules, mostly a^ain return into the circulation, through the lymphatics. The wandering white blood corpuscles probably return into the circulation in the Same way."—Wagner's Manual of General Patnology, Am. Ed., p 151. CLASS ROOM LESSONS. 31 The progress of the Syphilitic Infection, from the date of its genesis at the point of inoculation, to its characteristic appearance in the glands nearest the point of inoculation, (the glands of connec- tion,) varies in different persons, from causes not thoroughly settled, but which are indicated in note on page 8, lesson 2d. The degraded cell elements, then, effecting an entrance into the substance of the lymphatic gland, are here detained by the peculiar- ities of the gland structure, and perhaps by other inhibitory influences, (see Physiology of Syphilitic Infection, page ,) for a period varying in different instances from 20 to 60 days, (see Physiology of Syph- ilitic Infection, page ). This period is recognized by all clinical observers, and has been described as the seconel Incubation of Syph- ilis. It is certain, however, that no Syphilitic influence, has yet been discovered, in the general blood current, during this period, and there is sufficient reason to suppose that the diseased elements are confined te» the glands of connection, and those intervening more deeply between these and the thoracic duct.* The glands of connection become gradually enlarged, apparently through the proliferation and accumulation of cells in their interior. When the Initial Lesion is located upon the genital apparatus, on the glans, or on the body of the penis, in the male, or on the labiae or within the vulva in the female, the lymphatic glands of the groin be- come enlargeel.so that, as a rule, several may be elistinctly recognized by the touch; varying from the size of a small pea, to that of a large bean. Sometimes these enlargements are apparently confined to the side, ♦Note.__A similar inhibitory influence, exerted by the lymphatic glands, in cancerous'diseases is cited by Virchow, in his Cellular Pathology, Am. Ed., pp 221, with the following explanation. " We can account for this by no other supposition than that the gland collects the hurtful ingredients absorbed from the breast, and thereby for a time affords protection to the body." It has been suggested that if the disease were really so localized, prompt enucleation of the Initial Lesion and of the affected glands might prevent general infection. It must be remembered that the in- fective cells, each of which is potent to act as a starting point for systemic infection, are not only pres- ent in untold numbers at the point of inoculation, but that (as shown by Beisiadecki's microscopic re- searches,) the walls of the intervening lymphatic vessels, are lined if not packed with them. Hence any proposed surgical extirpation ot the disease must imply the entire removal of all the lymphatic con- 32 F. N. OTIS' corresponding with the Initial lesion—sometimes to the opposite side: usually however, the glands of both sides are more or less en- larged. Hard, nearly or quite painless, and moveable, their gradual accession within two or three weeks, after a suspicious venereal exposureM is strongly indicative of Syphilitic e>rigin, without regard to the char-1 acter of the local lesion. If this is present, and indurated, the Syph- ilitic character of the trouble is no longer doubtful. It must however be borne in mind that glands enlarged through the influence of Scrof- , ula, cannot be with certainty, distinguished from those of Syphilitic origin. They are found in the same locations, and though usually less positively indurated, are still sufficiently so to prevent certain diag- nosis. When the Initial Lesion is on the lips, or in the mouth, the submaxillary gland is affected. Wherever situated, it is always the glands of connection (i.e. those nearest to the seat of inoculation) which are involved. Such enlargements are called Syphilitic Buboes. The complete freedom from true inflammatory action, which has been shown to characterize the induration of the Initial Lesion of Syphilis, and the lymphatic vessels in connection with it, is equally characteristic of the enlargement and induration of the associated lymphatic glands. When attaining sufficient size to interfere with freedom of motion of a part, or where, from any cause, they are subject- ed to undue pressure; a degree of tenderness may result. From the same cause, inflammation, and even suppuration, may surpervenein highly scrofulous subjects. Such accidents, however, are exceptional, and do not materially lessen the diagnostic value which attaches to recent and painless enlargement of lymphatic glands. neclions of the Initial I.esion and the g'ands of connection. A procedure not only without sufficient promise ofbenefit at this stage of the infection,but even at the earliest date after inoculation, the neces- sary icnorance as to the degree of implication of the lymph spaces and vessels in the vicinity of the in- oculation, would in all probability render all such means of preventing the spread of the infective pro- cesses of uncertain value. Early excision of the Initial Lesion, may however, be found to modify the intensity of the subse- quent general Infection. My own experience in 9 cases of excision, during the past 8 years, would ' warrant this inference. CLASS ROOM LESSONS. 33 The progress of the Syphilitic Infection, which has been steady and persistant, from the moment of inoculation to the engagement of the nearest lymphatic glands, appears now to be arrested. Gradual increase in their size and density, alone inelicates the activity of the in- fective process, until, after aperioel (varying in different instances from 20 to 40 days) evidences of constitutional infection may appear. Access from the surface, to the general blooel current, through the lymphatic spaces and vessels, necessitates passage, 1st, through the gland in immediate connection; 2d, through any other glands or vessels which may intervene between them and the great lymph chan- nels; passage from thence into the general blood mass is immediate. Thus, the delay between appreciable implication of the glands of connection, and earliest evieleuces of constitutional Syphilis, is explain- ed in accordance with known histological and physiological laws. Hence, it is only after a time sufficient for the the passage of the dis- eased elements through the natural barriers, the lymphatic glands, to the general blood channels, that Systemic infection can take place. 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