If appropriate dressings and compression fail in the treatment of these fistula or sinuses, it may be necessary to lay them open with the knife. Sometimes the enlargement of the orifice is sufficient, or it may be necessary to divide them in their whole length; or if the situation of the sinus permit, a counter-opening will generally answer all the purposes of complete incision, a practice attended with much terror and pain to the patient. Counter-openings may be made with the caustic potash; the caustic as well as the opening may contribute to the cure in these cases. The fistula may likewise be cauterised internally by means of solid nitrate of silver, or a small portion of the powdered bichloride of mercury, introduced by means of a grooved director; this practice is painful, but generally suc cessful in its results.

M. Ricord has laid down a positive law, "that a bubo which suppurates specifically-that is to say, which furnishes an inoculable pus-is never followed by secondary symptoms." (28th Letter, p. 287.) Inoculation is not practised to a sufficient extent in this country to enable me to indorse or refute this opinion. All I can say is, that buboes which suppurate freely, and to all appearance specifically, are followed in some cases by secondary symptoms. I mention one or two cases under my

own care.

M. L., never before diseased, contracted a soft chancre, followed by a bubo in each groin, which suppurated. Before they were well, he had ulcers on the tonsils, and a scaly eruption.

M. A., never before diseased, large suppurating bubo in one groin, following a small soft chancre. Six weeks after, he had a copper-coloured mottling all over the body (roseola), ulcers on each tonsil, enlarged sub-occipital glands, and severe pains in the head.

On the other hand, I could detail numbers of cases where buboes which have suppurated specifically, and assumed a most formidable local condition, have not been succeeded by the least constitutional taint. The law appears to be, that the suppurating bubo is not followed by secondary symptoms; but to this law there are occasional exceptions.

The indolent bubo, symptomatic of indurated chancre, of

which I have already spoken, and which consists in a chain of enlarged glands in one or both groins, requires little local treatment. These buboes have generally no tendency to suppurate; they are the first indications of a constitutional taint, and are to be dispersed by constitutional treatment only: the treatment I have mentioned as applicable to indurated chancre is to be adopted here. They generally subside with the induration of the chancre, but this is not always the case. After all taint on the system has apparently been eradicated, and all induration of the chancre has disappeared, one or more glands, although reduced in size, do not diminish to their pristine condition; they remain permanently enlarged, although they may have lost all their specific character. I have seen them remain for years, the patient otherwise in good health. In two or three instances where secondary symptoms have been very rebellious to treatment, I have known these buboes slowly suppurate; and I have also noticed, when this suppuration has taken place, that the constitutional taint, previously difficult to treat, has quickly and permanently disappeared.

PART II.

CONSTITUTIONAL OR SECONDARY SYPHILIS.

CHAPTER XIII.

OF CONSTITUTIONAL OR SECONDARY SYPHILIS.1

CONSTITUTIONAL or secondary syphilis consists of a class of morbid actions, which make their appearance sooner or later after a discharge from the urethra, or after the healing, or during the course of a primary venereal sore on the genitals or elsewhere; or, again, it is due to other causes hereafter to be mentioned. Constitutional syphilis is produced by the absorption of the syphilitic virus and its mixture with the blood; it is a blood disease, a dyscrasia or diathesis, of which the various effects about to be mentioned are the symptoms.

The phases of syphilis have been divided into the primary, the secondary, and the tertiary; or, as Hunter has already laid down, constitutional affections of the first and second order of parts. The primary symptom is due to the direct application of the venereal poison by means of sexual intercourse or inoculation. This is capable of propagation, from one individual to another, by intercourse or inoculation. The primary symptom may be followed by a series of symptoms which are successive or continuous, but not constitutional or secondary; these are new chancres, buboes, or abscesses, &c., of various kinds, these

1 "Syphilis constitutionnelle; accidents secondaires et tertiaires,”– Ricord. "Maladies véneriennes consécutives,"-Desruelles.

being purely local, and not dependent upon an affection of the constitution generally.

Secondary symptoms are those which make their appearance after the economy has become generally tainted by the venereal poison, during which process the matter has undergone modifications which, in some measure, change its character. Secondary syphilitic diseases appear on the skin or mucous membranes, in the eyes or the testicles, in the bones, and in the internal organs. Constitutional syphilis rarely makes its appearance before the second week after primary infection, more commonly later, towards the fourth or fifth weeks, or at periods very much more remote.

1

When syphilis has continued in the economy for an indefinite period of time, the symptoms which are termed secondary disappear, or lose the properties which at first characterised them; whilst others of a different kind succeed, to which has been applied the term of "tertiary."2 The tertiary symptoms appear at an indefinite, and generally very long period, after the primary diseases, and in the greater number of subjects, either after secondary symptoms have disappeared, or whilst these are still manifest in the constitution; thus it is exceedingly common to

1 See Yvaren, Metamorphoses de la Syphilis, &c.,' Paris, 1854; Virchow, Syphilis Constitutionnelle, par Picard,' Paris, 1860. In the latter work, syphilis of the spleen, the liver, the lungs, the brain, the heart, the kidneys, and other internal organs, is methodically described.

2 It is the pathological character of the morbid change which marks the symptom as being a secondary or tertiary one. There are two changes which take place in organs as a consequence of constitutional syphilis : the first resemble inflammatory diseases, the second are due to specific changes; the first are secondary, the second are tertiary. The great variety of diseases of the skin which succeed to syphilis, as scaly, pustular, or papular affections, are inflammatory in their nature, or, as Virchow calls them, hyperplastic. These diseases differ in no way in their pathology from other affections of the skin not due to syphilis; they are inflammations, with effusions of serum, pus, or lymph. We recognise in such forms inflammation and its products only; but in the tertiary symptom there is an actual change of structure, a deposit of a specific kind; this is well observed in one form of syphilitic sarcocele. For a minute description of the changes produced in various organs by syphilis, to which changes the term tertiary has been applied, I must refer the professional reader to Virchow's work already quoted, especially the twelfth chapter.

see scaly or pustular diseases of the skin coexisting with diseases of the bones or testes. The diseases which have been termed tertiary are deep-seated diseases of the skin, as tubercles, and affections of the glands and bones, as periostosis, exostosis, caries, necrosis. To these may be added various internal affections, as yet neither well known nor described. Many of the constitutional forms of disease are capable of propagation by contact or inoculation; and in persons cohabiting as man and wife, a secondary syphilitic symptom existing in one is very commonly produced in the other, in precisely the same form.

It may be naturally inquired here, whether any treatment of the primary disease can certainly prevent the constitutional. The early and complete destruction of the primary disease, by an escharotic that will disorganise the tissues to the depth of the ulcer before absorption has taken place, is the only certain mode of preventing constitutional taint. I have before stated that the nitrate of silver is in most cases not sufficiently destructive for this purpose; and the caustics that will char the tissues to the depth of the ulcer are the potassa fusa, the potassa cum calce, the acid nitrate of mercury, the carbo-sulphuric, or the chloride of zinc pastes. This practice is useless in a chancre already specifically indurated, the induration itself being an indication that the constitution is already affected, and the local disease only to be cured by constitutional remedies.

Unhappily there are numerous reasons why the practice just recommended cannot always be adopted with a prospect of success. In many instances the surgeon is not consulted till many days after the establishment of the disease, when, in all probability, absorption has already taken place. In other instances, the situation and character of the ulcer are such that we are prevented from resorting to the method recommended; though in all instances it should be done, if at all practicable.

All persons are not equally susceptible of a constitutional infection from a primary sore; hence some writers have spoken of the syphilitic temperament, a vague expression, to which no definite meaning can be attached. Those individuals are most

1 It is quite certain that many patients throw off a constitutional taint with comparative facility; but in others it remains for years, or for life, in spite of the most judicious and persevering treatment.