on the labium of a girl, after she had been confined in St. Lazare prison seventy-two days. If there is no error in this case, it is the longest yet recorded. There is no reason to suppose the incubation varies according to the source of the poison. More probably, within certain limits, it is determined by some peculiarity of the patient. In corroboration of this view, it should be recollected that the incubation of small-pox and vaccination, allied diseases, is not always the same to a day. Alfred Fournier,1 besides giving a long list of cases of accidental syphilis, where the period was noted, discusses this question carefully, and his essay may be read with great profit. Some excellent examples are also related by Bumstead and Clerc;3 the latter recites seven observations where opportunity occurred for marking the incubation. These gave an average of twenty-one days. To cite many instances of the length of the incubation period in accidental inoculations is unnecessary. I shall confine myself to the following, which came under my own observation.—A physician attended in her confinement a lady with a mucous patch on the vulva; he himself had also an abrasion on the finger. For a few days, the abrasion showed a little irritation, and then subsided until the thirty-fourth day after contagion. Irritation then began again, a papule formed, and constitutional disease followed. A second case is that of J., related at page 45, the man whose cheek was cut and then sucked by a man with syphilitic secondary sore on his mouth, a fortnight before Christmas, 1863. The wound healed, and remained quiet till the latter end of January, when papules formed, and constitutional syphilis followed. The initial manifestation.—The morbid changes which occur at the site of inoculation vary in their aspect to a certain extent, even when solely due to the awakening activity of the virus; but as they are often diversified through irritation of different kinds, the resulting affections have received various names, such as, infecting chancre-nonsuppurating chancre-indurated chancre-primary, or primitive syphilis. Perhaps the term initial manifestation is the least objectionable, because it comprises all the various phases in which the disease reveals its presence, without describing them, or attempting to distinguish one from another. As these initial manifestations are often slight, and of short duration, it has been maintained that they may be completely absent, and that the disease may run its course without any indication at the point of inoculation. This is erroneous, some change always takes place at the point of inoculation. In 1856, 826 patients with constitutional disease were treated at the Midi Hospital; in 815 of these, the initial lesion could be clearly traced; in only eleven could its presence not be unquestionably proved, but it was extremely probable that it had appeared in every one.1 Varieties of the initial manifestations of the awakened activity of the virus.-These differ from each other in degree of development, not in essential diversity of structure—they are three a. The elevated desquamating papule; b. The superficial ulcer; c. The indolent ulcer with a hard base. All are quite independent of any change produced by the admixture of irritating matter to the vehicle of the virus, to wit, that from suppurating chancre, or inflamed ulcers, which materially affect them. When irritating matter is inserted with the virus, the changes at the point of inoculation are either those set in action by these latter affections, or a 1 Fournier: Ricord, Leçons sur le Chancre, p. 325. compound of them with those proper to syphilis; the chief of which is induration of the tissue around the inoculated point. The changes observed to take place when immediate irritation at the point of inoculation has been prevented will first be described; next, the aberrations from these typical changes that local irritation of different kinds produces. Too much weight must not be attached to the differences of these sores for the purpose of diagnosing the absence or presence of syphilis in any given venereal ulcer. This can be done readily in most cases, but it is quite impossible to do so in some, where the amount of irritation masks or destroys any character that is peculiar to syphilis, and not shared by ordinary ulcerative inflammation. 1. The desquamating papule begins by forming a small solid elevation at the point of inoculation; this, at first the size of a pin's head, extends until it may reach that of a sixpence or a shilling. The skin around retains its natural aspect, and no inconvenience, except now and then a little itching, is felt. The colour is reddish coppery, or reddish purple, like raw ham. The surface, slightly raised above the skin, is flat and smooth, being covered by a few thin scales of dry epithelium. Not unfrequently the papule undergoes no further change, but after five or six weeks grows pale and subsides, leaving no trace of its presence. When the site of inoculation is the scar of a previous chancre, the cicatrix is thickened by this new deposit, which then frequently assumes an irregular form; instead of round or oval, it becomes angular, or linear; in these cases the coppery tint is often altogether absent, and the surface retains then the same hue as that of the surrounding skin. This form is most common on the skin in situations which are kept dry and not chafed. 2. The superficial erosion comes between the dry scaling papule and the well-marked ulcerating papule; common F localities for it are the under surface of the foreskin, or in women the opposed surfaces of the nymphæ, where the parts are constantly moist. For its production the surface of the elevated papule becomes red, secretes a plentiful fluid, usually thin and serous, but occasionally puriform. These eroded surfaces are similar in appearance to the mucous patches of the general eruption, which like these, owe their character entirely to the constant moisture. Sometimes on the skin or sheath of the penis the induration is very scanty, the surface consequently is only slightly raised; and it usually secretes a little viscid discharge, but has no tendency to extend, nor, unless irritated by dirt, to suppurate. Its edges are clearly defined, which peculiarity, with the absence of induration, causes it to slightly resemble the simple contagious chancre. 3. The indurated ulcer begins exactly in the same manner as the papule; but the surface instead of stopping short at desquamation, ulcerates. The ulceration begins at the centre and spreads outwards through the indurated papule, but does not extend beyond the papule, whence the cicatrix is very small when the ulcer heals, and often imperceptible. The fully developed sore has the typical appearance of an indurated chancre. The base is hard and resisting, feeling between the finger and thumb like a cup of gristle set in the skin; its surface is covered by a scanty adhesive yellow discharge, the edges are sloping, rounded, and the induration extends a little beyond the extent of the ulcer. The progress is always slow and, if the sore is kept clean and free from irritation, terminates by cessation of the ulceration, cicatrisation of the surface, and absorption of the indurated deposit. The period of existence of the initial manifestation varies from three or four weeks to, in rare cases, a duration of several months, if not shortened by treatment. Effects of local irritation on the initial manifestation.When pus of a soft chancre, or even pus of any kind is inoculated with the syphilitic virus, irritation and inflammatory action set in without delay at the breach of surface to which the matter has been applied. Vidal1 applied the discharge of syphilitic ecthyma to the arm of a medical student. The irritation of the pus produced a pustule in three days, which, however, healed in fifteen days; the remainder of the incubation was passed in tranquillity until the thirty-fifth day, when the initial manifestation began with the production of two papules which ulcerated after they had formed, and were the prelude to general eruption. The immediate irritation in this case was exactly similar to what the same matter produced when Vidal' inoculated it on the syphilitic patient whence he obtained it, though in him, of course, this immediate irritation was the sole result of the inoculation. A parallel change takes place, if the syphilitic poison be mixed with that of the suppurating chancre; irritation begins immediately, producing a soft chancre with purulent discharge in two or three days, which runs its course, irrespective of the incubation of the syphilitic virus. If the sore is still open when the incubation ends, it acquires an indurated base. The double cause of the affection is shown by the immediate inflammation and ulceration that takes place immediately after contagion, and the induration that is developed some weeks later. Sometimes, an ulcerating papule, which does not form till after the lapse of incubation, will suppurate if accidentally irritated, and the ulcer closely resembles one in which irritation has been excited at the outset. 1 Vidal: Maladies Vénériennes, p. 358. 1853. |