Secale 85. Sequelae breaking out after the Lapse of years.
Having seen that secondary phenomena generally may set in in four or six weeks, or even at a much earlier period after the breaking out of the first protopathic symptoms, or at any rate, prior in their complete disappearances; the other not less important question now presents itself, how long a period may elapse, after the disappearance of the primary product, before all danger of further developments of the syphilitic disease shall have passed away entirely? If we would believed every thing that writers on syphilis have related on this subject as authentic, it would seem as though this danger continued during the whole lifetime of the patient; so that, if he had been afflicted years ago with a chancre, or even a simple gonorrhoea, and had enjoyed the most perfect health ever since, even for the period of twenty or more years, he may, nevertheless, wake one fine morning with one or the other suspicious looking symptom, or even, according to circumstances, with a whole legion of the most horrid syphilitic products, from the most disgusting cutaneous ulcerations to the most destructive chancres in the throat, and the most painful affections of the bones! Fortunately, inspite of what some authors may write, things are not quite so terribly bad. It is indeed true, that if secondary syphilis has once set in, and is not treated with proper specific means, the disease may break out again, every now and then, in five, seven, ten or even fifteen and twenty years; but experience her like wise shown that, where traces of a prior infection still continue to show themselves after the lapse of so many years, a careful examination of the case leads to the conviction, that a continual series of syphilitic phenomena had existed from the first out- break of the disease, to the very day when the patient afterward presented himself for treatment. We admit that the phenomena of such a series must have been inconsiderable; out they certainly existed, and must have been overlooked by the patient, or not properly recognized by the physician, and treated for something else. If patients tell us that five, ten, or fifteen years after a period of perfect health, they were all at once attacked with symptoms of a previous gonorrhoea or chancre, we feel satisfied that the original disease must have either been badly managed, or that the patient is trying to deceive. What physician does not know that men, who feel interested in concealing former transgressions, are disposed stoutly to deny the suspicious character of existing discharges or ulcerations, even when of recent origin, and undertake to impose upon the physician by the bold assertion, that these symptoms are nothing else than the reappearance of a former infection contracted years ago! Secondary affections, if neglected, may indeed continue for years; but a careful inquiry will show that their first appearance can be traced to a primary infection that had occurred six months, or, at the latest, one or two years previous to that time.
III. VARIETIES AND CLASSIFICATION OF THE SECONDARY FORMS
Secale 86. Essential Differences of these Forms.
Our previous statement, that secondary forms are incapable of transmitting the disease by infection, must not be understood to imply that this transmission cannot take place by the act of coition. On the contrary, it is a well-known fact, that secondary syphilis can be inherited by children. In my own practice, I have met with more than one case, where the father, who in consequence of a suppressed chancre, had become afflicted with masked constitutional syphilis, transmitted unmistakable signs of the secondary disease, not only to his offspring, but likewise to the mother, even after they had cohabited together as man and wife for several years previous to the birth of the infant, during which period no sign of secondary syphilis had been perceived. We shall revert to this case, which we mention in this place simply for the purpose of adverting to the fact, that secondary syphilis may be transmitted from parent to the offspring, although never by direct infection. By the side of such secondary forms as can be inherited (more specially the syphilidae) there exist other forms, such as syphilitic affections of the bones, that seem to be exempt from the liability to hereditary transmission; on which account writers on syphilis have adopted two distinct varieties of secondary syphilis: (a) a variety where the infectious virus, although latent, can still be transmitted to the offspring: and (b) another variety, where this is no longer possible. It has been supposed, moreover, that the symptoms of the last-named variety manifest themselves at a later-period than those of the former. Hence, a third period has been constructed with the phenomena of the second variety, under the denomination of tertiary symptoms. This classification, to which some writers have even added a fourth or quaternary period, has been taught for a long time in our therapeutic manuals with the most rigorous scholastic dogmatism, without our authors having, perhaps examined the matter for themselves, or having even had an opportunity of learning any thing about the subject except from books. In this manner, this purely theoretical classification has been successively adopted by one author after the other, without any of them troubling himself in the least whether it is founded upon actual fact. So far from observing a definite order of succession, secondary phenomena sometimes appear mixed up with tertiary, and even subsequently to the latter. I have treated a woman in whom, after the suppression of chancre by an allopathic physician, an affection of the tibia first broke out, together with cutaneous pustules, after which the throat became affected. Regarding the non-hereditary character of tertiary phenomena, I have treated a child born of very poor parents, that was not only covered with syphilitic, cutaneous, but likewise with exostoses of the skull. Not long before, the mother of the child had likewise been affected with similar ulcerations, the characteristic spots of which were still visible. Exostoses on her tibia were likewise still visible.
Secale 87. Classification of the Secondary Phenomena.
However tenaciously we may still adhere to the old-fashioned and customary division of constitutional syphilis in secondary and tertiary phenomena, we cannot, for the reasons already stated, and for other reasons that will be explained in subsequent paragraphs, accept this arrangement, but prefer following the arrangement which has been adopted by modern writers on syphilis as the most convenient, since it ignores all unprofitable discussions concerning the pathogenetic differences between these phenomena, and otherwise facilitates their diagnosis to a great extent. Modern writers arrange the secondary phenomena in accordance with the tissues where they are located, and where we have the epidermis, the mucous membranes, the bones, muscles, and still other anatomical systems. Considering the degree of predilection which the syphilitic virus seems to manifest for each of these different systems, we shall find that the skin is most frequently affected by the poison, as if, pressed onward from the centre to periphery, it sought to obtain an outlet from the organism. Once located upon the skin, the syphilitic disease assumes the most varied forms, from the simplest maculae to the most hideous ulcerations. Inasmuch as syphilis at its first appearance was, properly speaking, nothing else than an exanthematic disease; the phenomena by which the disease manifest its endeavour to approximate again to its original form, are necessarily the most important, constituting one whole side of secondary syphilis; whereas all the other phenomena occurring in the mucous membranes, bones and other tissues, together constitute the other side of this disease as so many manifestations of an excretory process through the skin, that is either not yet completed or had been interrupted in its course; so that all the secondary syphilitic phenomena together may be ranged in two great, pathologically essentially distinct categories: (A) those where the excretory process has been completed (cutaneous diseases); and (B) those where this process has not yet been terminated (secondary syphilis of other tissues). In No. 124, 125 we shall see what these two categories have in common in pathological respects, and how evidently it follows from a relative contrast of their respective phenomena that there is only a secondary, but that there cannot be a tertiary syphilis; for the present we will simply state that, in accordance with these views, we shall first consider, (1) the cutaneous eruptions, being of most frequent occurrence and deserving our first attention; and (2) under the general denomination of secondary intermediate forms, the secondary ulcers, affections of the mucous membranes, bones, and other phenomena; premising, however, in the first place some general remarks on the diagnosis, prognosis, and treatment of secondary syphilitic diseases.
