II. SPECIAL CAUSES AND PERIODS OF MANIFESTATION OF SECONDARY PHENOMENA.
Secale 82. Chancres and gonorrhoea as causes.
The fact that secondary phenomena are the remote sequelae of an infection caused by a specific virus, is no longer doubted at the present time either by the former adherents of Broussais’ Physiological School in France, nor even by the adherents of the same school in Germany, where it still flourishes, even after it had been almost universally abandoned in the country of its nativity some ten or fifteen years ago. Whereas all modern practitioners agree that the symptoms of syphilis originate in some previous chancre or bubo, this unanimity disappears again when we are to decide whether the legion of secondary phenomena can only be superinduced by chancre and buboes, both being equally primary phenomena; likewise by simple gonorrhoea. A superficial glance at the annals of medicine would seem sufficient to at once decide the matter in favor of gonorrhoea, since in the Paris hospitals alone the secondary syphilis of fifty among every hundred patients is distinctly traceable to gonorrhoeal infection. However, upon examining these irrefutable and striking proofs more carefully, we shall stumble upon various circumstances that lead us to doubt the correctness of that evidence. In the first place who knows whether these patients who, when entering the hospital, were seemingly infected with nothing but gonorrhoea, had not contracted the syphilitic disease by some prior connection, but whose manifestation had been mistaken for a simple excoriation caused by the act of coition, and had been suppressed by an astringent wash? Who knows whether this suppression was not the real cause of the secondary phenomena, instead of the gonorrhoea which, happening to be the most recent and most ostensible infection, had the honor of having the secondary appearances attributed to it? Adding to this that the French, who have furnished the most circumstantial statistics, designate as blennorrhoea, more particularly among females, every infectious discharge from the vagina, no matter whether the discharge is idiopathic or symptomatic, caused by chancre or syphilitic ulcerations; and that, among the Germans, the terms blennorrhoea and gonorrhoea by no means refer to the same pathological condition; we may regard this as sufficient evidence that the French statistics are not applicable to what we Germans call simple gonorrhoea, which is indeed a venereal but not, any means, a syphilitic disease. It is indeed beyond doubt that syphilitic gonorrhoea, more specially when originating in sycosis, has power to superinduce secondary phenomena; but whether simple, non-syphilitic gonorrhoea can have the same effect, remains to this day a matter of great doubt, owing to the fact that a discriminating diagnosis of these two forms of gonorrhoea has been too sadly neglected. All that can be said on this subject is, that there is a kind of gonorrhoea that may cause secondary symptoms, and that there is another kind that will have no such effect; at any rate, this point is so far involved in the greatest doubt. In my own practice I have never yet had an opportunity of witnessing such a result.
Secale 83. Causative conditions.
Omitting for the present all considerations of the questions about simple and syphilitic gonorrhoea, and taking it for granted the secondary syphilitic phenomena always originate in some manifest or concealed chancre, or in something equivalent, such as buboes or mucous tubercles, as their remote cause, an equally important question will then arise. Under what conditions will primary syphilis be capable of causing secondary phenomena? It is an admitted fact that secondary phenomena always arise when the primary symptoms are either neglected or removed by external applications alone; another question is, whether secondary phenomena can develop themselves even after the primary infection had been apparently eradicated from the system by means of the most appropriate specific internal treatment, in consequence of which, all external manifestations of the internal disease had been completely removed and extinguished. Concerning this question we have no reliable records, for the reason that authors have not paid the least attention to the important distinction between a real chancre-cure effected by the internal administration of specific antidotes, and a mere cicatrization of the chancre by external applications; or for this additional reason that, even where the cure had been effected by internal means, the patient had taken such large quantities of Mercury that it would be difficult or even impossible to decide whether the secondary phenomena, manifesting themselves subsequently to the supposed cure, were really of a syphilitic character, or rather the result of excessive mercurial action. On this account I have only my own experience to refer to, and am enabled to assert that, among all the patients whom I have treated for the last thirty years for primary syphilis, I have never seen a single sign of the syphilitic disease manifesting itself even ten or twenty years after the internal use of specific antidotes; the only untoward symptom that may have occasionally shown itself was, perhaps, an evanescent manifestation of excessive mercurial action, which, owing to the smallness of the doses administered, soon passed away again forever. What I am able to assert of the cure of chancre while yet in the stage of primary ulceration. I am unfortunately not able to assert of the cure of chancre after it had passed into the stage of fungoid growth, or had become complicated with buboes, tubercles, or figwarts, and hence was on the point of entering into the secondary period. In such cases, even after the primary symptoms had been completely and apparently radically removed by the use of Mercurius sol., Nitri.ac., or Thuja, I have often, even after the lapse of three, eight, or even eighteen months, seen syphilitic phenomena still make their appearance, consisting almost without an exception of unimportant cutaneous affections that never assumed the form of extensive syphilidae, and yielded very speedily to proper treatment without ever returning; but, if neglected by the patient, became very obstinate and remained visible for a long period; all of which shows in the most indubitable manner that, if the primary symptoms have left their first stage of primary ulceration, their removal, even by the best internal treatment, may not constitute a perfectly complete cure of the syphilitic disease, and not all danger may as yet be obviated.
Secale 84. Period of Manifestation of the Secondary Phenomena.
Here two question arise: (1) What is the shortest period when they may manifest themselves subsequently to the breaking out of the primary, protopathic symptoms? and (2) What is the longest period when the danger of secondary symptoms breaking out may still exist, even after the primary disease seemed to have been thoroughly eradicated? As regards the first question, when secondary phenomena may arise in the shortest time, it is certain, not only according to my own observations, but likewise those of all other physicians who have had opportunities of observing the course of the syphilitic disease, that they not only arise after the disappearance of the primary protopathic phenomena, but likewise while these phenomena are still running their course. Whatever may be said of the protection which a chancre or a various bubo affords against the breaking out of constitutional syphilis, there is unimpeachable testimony that this protection does not always exist. It is positively certain that, even if secondary symptoms very seldom manifest themselves during the primary ulcerative stage of chancre, if a chancre, without being treated with external ointments or astringents, is left to itself for six or seven only four weeks, or up to the period when it passes from the stage of primary ulceration into the state of fungoid growth, this transition period is simultaneously ushered in by the appearance of some cutaneous eruption, most generally syphilitic maculae, and that such an event may take place, both when vicarious buboes are present or absent. Inasmuch as buboes, mucous tubercles, and figwarts, although in some rare cases they may occur as protopathic symptoms appertaining to the primary period of syphilis, in most cases do not make their appearance until the second term of the primary chancre, that of fungoid growth, has set in; and inasmuch as truly secondary phenomena may develop themselves during this terms, we cannot wonder if these consecutive products of the primary period, even at the very time when they first break out, superinduce, as immediate consequences, or are even accompanied by secondary cutaneous affections, or even affections of the mucous membranes. Moreover, inasmuch as more particularly mucous tubercles and figwarts, in spite of their inherent capacity to reproduce their like by infection, nevertheless, in consequence of the changes which their reproductive energies had undergone, belong to a stage where the original chancre virus had become pathologically altered, it must be evident that these last- mentioned phenomena, even when they seemingly occur as protopathic products, in many cases are followed by secondary phenomena more rapidly than the chancre itself, and may even be accompanied by them at the outset. The same remarks apply to syphilitic gonorrhoea, whether occasioned by the virus of chancre, tubercles, or figwarts; this kind of gonorrhoea is likewise very frequently and very speedily associated with secondary cutaneous affections, by which it can easily and safely be distinguished from common gonorrhoea, as a disease of much more dangerous consequences.
