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The reader is referred to the chapter on Syphilisation, for explanation of the results of inoculating the secretions of these ulcerating surfaces. It suffices here to remark, that mixture with the matter of a soft venereal ulcer, is not the only way to make the syphilitic ulcer furnish a contagious pus, which, when inoculated, produces a succession of pustules where the matter is inserted. Mechanical irritation has been employed for this purpose by Lee,1 Bidenkap,2 and myself. This question is more fully discussed in the chapter on Syphilisation; here only the different ways the local ulcer may be altered from typical characters are described.

The suppurating ulcer, with an indurated base and an inoculable discharge, is called by Rollet3 the mixed chancre. This term denotes that both contagious principles are present in the sore. This explanation appears to me to be satisfactory, as there is no theoretical reason why the two should not be present, and Rollet, Laroyenne, Sigmund, and others, have succeeded in making indolent hard ulcers inoculable on their bearers by touching them with pus from soft chancres. Indeed the advocates of syphilisation (Boeck and Bidenkap) prefer a suppurating indurated ulcer for the source of their inoculating pus.

The disease begins its course in these various ways; all the varieties, when uncomplicated with local irritation, are mild affections, disturbing the system very little, and, therefore, in many persons altogether overlooked.

Acute inflammation, violent suppuration with sloughing, and abscess in the lymphatic glands, occasionally attack the initial manifestation in the early stages of syphilis.

1 Syphilitic Inoculation. 1865.

2 Wiener Med. Wochenschrift, 1865, No. 34; Auspitz, Die Lehre vom Syphilitischen Contagium, p. 322. 1866.

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These are only present when the patient has, in addition to the infection of syphilis, some local irritation not part of syphilis. Inflammation and phagedena are generally consequences of irritating matter acting on an exhausted or debilitated constitution quite independently of syphilis. Recently, I had among the out-patients of University College Hospital, a man who lost by sloughing chancre of the frenum a considerable part of the under side of the glans, the urethra being laid open for a short distance; the chancre healed, and while healing indurated very widely. The inguinal glands enlarged, scaly and pustular eruptions of the arms and trunk followed closely on the induration, and formed part of a very severe attack of syphilis.

Number.-The initial manifestation is usually single. Now and then several are met with on the same person. Chance favours absorption at one point rather than at many; still, if the virus happens to be applied to several breaches of surface at the same time, several papules subsequently appear at these points of contagion. When the patient has had herpes preputialis at the time of infection, by which a wide surface of the foreskin was denuded, the prepuce often assumes a leathery consistence. Their singleness is a very characteristic distinction of syphilitic sores from soft chancres, which are usually multiple, because the acrid condition of their discharge enables them to repeat themselves wherever a breach of surface may chance to

occur.

Seat.-The initial lesion has been found on every part of the surface of the body, least frequently, of course, in parts seldom brought in close contact with other individuals, and also best protected by thick epithelium. Within the body1

1 Fournier: Leçons sur le Chancre, p. 364.

it has been seen in the mouth as far as the tonsils, and in the last two inches of the rectum it is occasionally met with. Along the urethra it penetrates a short distance, the furthest I have observed being an inch and one eighth from the meatus. Fournier relates a post-mortem examination of one in the fossa navicularis. They are not uncommon at the meatus, where the induration of both sides gives the meatus a pouting funnel-like shape. The lips, being easily excoriated and frequently exposed by contact, are common points for the contagion to enter by. The nipple, too, in women suckling syphilitic children is often the seat of inoculation, while, in accoucheurs, the finger is sometimes the point of infection. The genitals, of course, far precede all other parts of the body in frequency of inoculation. Of 472 cases of syphilitic inoculation in men, Fournier1 found 314 on the prepuce and glans; 60 on the sheath of the penis; 32 on the meatus; and 17 within the urethra; 12 on the lips; 6 on the arms; and the remainder on other parts of the body. Clerc, also, of 403 local manifestations with general disease, found 234 on the inner aspect of the prepuce and furrow behind the glans; 58 on the sheath of the penis; 33 at the meatus; and the remainder on various parts of the body. Besides these 403 cases, Clerc had in the same period (two years and a half) nine other cases of early syphilis, in which the situation of the primary manifestation could not be traced. The eyelid, nostril, and navel are among the extremely rare situations which are noted by Fournier as points of inoculation.

3

Of the situations frequently inoculated in women, Clerc 3 gives 113 cases in which it was noted: 29 were on the nymphæ; 25 on the labia majora; 16 on the fourchette;

1 Leçons sur le Chancre, p. 364.

2 Clerc Maladies Vénériennes, p. 97. Paris, 1866.

3 Loc. cit. p 100.

and the remainder scattered about all parts of the body. In women the local manifestation so frequently escapes notice, that Clerc has failed to find it in a fifth of the women admitted with recent syphilis. At the Lock Hospital it is extremely unusual to find the point where the disease entered. Probably the initial manifestation is, in many cases, situated on the vagina, and is cleared away before any examination is made. Indurated ulcer of the vaginal portion of the uterus is extremely rare; when present it renders the latter tough and hard; if the surface is lightly pressed, the colour is said by Zeissl1 to resemble motherof-pearl.

Induration. The hardening of the area immediately around the point of infection varies much according to its situation, and according to the individual, but is very rarely, if ever, wholly absent. It is best developed in the skin, not so well in the mucous membranes. It is sometimes illmarked on the glans penis and the nymphæ, but even there it may be abundantly developed. It takes the form usually of a circumscribed nodule set in the tissue, varying in size from a pin's head to a large bean, and feeling between the thumb and finger hard and elastic like a cup of cartilage. Sometimes, on the inner aspect of the foreskin, instead of being developed in a mass, it is spread in a thin layer over the surface as large as a sixpence or a shilling; this form is called by Ricord "Parchment induration." A prepuce so thickened has a peculiar appearance as it is turned backward. Now and then the induration is confined to one or two sebaceous follicles, which then feel like small beads set in the deeper part of the skin. The blanching all the varieties of syphilitic induration undergo, if pressed, is very characteristic: the indurated skin loses

1 Zeissl: Constitutionelle Syphilis, S. 39.

its colour much more readily than the healthy tissue round it.

When the induration has developed to a certain extent, it disintegrates by degeneration of its component parts; this slow process, when free from irritation and congestion, forms the ulceration which sometimes takes place on the surface of the papule.

The course of the initial manifestation is slow. After an interval of desquamation or ulceration, the tubercle subsides, shrivels, and disappears, leaving sometimes a cicatrix, generally no more than a stain in the skin which, also, after a while, is wholly lost. A common time for it to subside is the appearance of the macular eruption, &c. Zeissl1 and Clerc believe that a papule may reform, and even ulcerate again after having subsided, this is a distinction between this and the simple chancre hitherto overlooked.

The duration of the induration in Zeissl's cases was never less than ninety days, counting from the moment of its first detection, and the hardness often continued eight or nine months. Puche says from sixty to eighty or a hundred days is almost the rule, and mentions a case where even after nine years the induration could be detected. Clerc says the duration depends greatly on the amount and form of the thickening; when considerable, or peashaped, it often continues six or eight months after its formation. On the other hand, when the induration is but small, it soon disappears. He once lost all trace of an indurated papule in twelve days after it first appeared.

The anatomical characters of induration-tissue have been carefully described by Virchow, Robin, and others. The

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