there is in every case a local origin, what is the local origin of small-pox, which sometimes kills before a pustule is seen? or of the other diseases of the class which begin with general symptoms, and then at a certain stage show local phenomena in a particular part. Again, in the case of cancer, is there really nothing in all those arguments which only a few years ago were supposed to prove indubitably that every local manifestation in cancer is but the topical sign of a general constitutional state? And are the opinions on phthisis to undergo so radical a change that we are to look upon it entirely as a local disease, until by continued absorption of hurtful substances the blood and other parts are contaminated? Certainly not without grave consideration ought we to abandon views formed after full inquiry and no little careful experience. In medicine, as in all other things, we must give way to facts, but we are not called on at once to admit the truth of opinions which go against our accepted doctrines. Now, Virchow's statements of the local origin of dyscrasia are given so briefly and with so little or no reference to clinical facts, that they can scarcely be looked on as more than hypotheses. That there is truth in the local production and absorption of hurtful substances, from chronic inflammation and from many tumours, we have no doubt. That is a doctrine by no means new, but that it expresses all the phenomena of cancer, for example, is most certainly "not proven." And as in the doctrine of inflammation we seemed to see that with much real truth Virchow has mixed up hypothetical explanation, and to make his view consistent has thrown into the background such important phenomena of inflammation as hyperæmia and nerve-implication, so in his statements on tumour it seems to us that he has been too anxious to break entirely with old doctrines, and to look at everything from the point of view which he has chosen. We have hitherto selected for comments those parts of this book which seem to us most essential and fundamental in the doctrine of the "cellular pathology." But the work is not limited to these subjects-it glances at the whole of pathology, and discusses with great ingenuity almost all morbid processes. We have not seen in any of Virchow's writings so good a description of Embolie, Thrombus, Pyæmia, Melanæmia, Leukæmia, Rickets, Atheroma, &c. So also the histological account of the tissues is 'extremely simple and good. We could have wished to have discussed many of these subjects, but this article is already too long, and we can only hope that our readers will study the work for themselves. We can assure them they will have some real enjoyment, and when they disagree, will disagree with respect and admiration for the author. REVIEW II. 1. Lettsomian Lectures on Syphilis. By VICTOR DE MERIC, Esq., Surgeon to the Royal Free Hospital, and to the German Hospital, Dalston.-1858. pp. 68. 2. Lectures on Chancre. Delivered by M. RICORD, Surgeon to the Hôpital du Midi; published by FOURNIER, with Notes and Cases; and translated from the French by C. F. MAUNDER, Demonstrator of Anatomy at Guy's Hospital.-1859. pp. 244. 3. A Treatise on Syphilis in New-born Children and Infants at the Breast. DIDAY, Surgeon to the Hôpital de l'Antiquaille, Lyons; translated by G. WHITLEY, M.D. (The New Sydenham Society.)-London, 1859. pp. 272. By R. How can we explain the discordance of opinion which exists on the subject of syphilis ! Is the disease as seen in the London hospitals different from that which prevails in France? Do modern syphilographers understand in a peculiar sense the terms hardness and softness? Are constitutional symptoms influenced by national habits or tem perature? We confess to a feeling of surprise at reading controversial works, and listening to dogmata which unite only in one point of view-namely, in putting the whole subject in lights which it never enjoyed before. But from this war of words a theory has sprung which, if true, simplifies-but, if untrue, tends to confuse; and it is to this subject that we shall in the first place chiefly confine our attention: we mean the teachings of that school of which M. Ricord is the founder and head. A word upon the origin of the disease: "It is perfectly certain," says M. de Meric, "that previous to the general spread of the disease in 1493–95, no ancient or medieval writer had given a description of the complaint, as seen and depicted by Joseph Grundbeck, Benedictus, and Leonicenus, who wrote in 149395; these authors being the first who published an account of the malady.” (p. 3.) No one, we add, is likely to witness the malady as Benedict has depicted it. 66 "I knew," wrote this trustworthy and learned man, some honest and religious nuns, confined in the strictest manner, who unfortunately contracted the venereal disease from the peculiar state of the air, together with that of the putrid humours and the weakness of their habits of body." From the profundity of the wisdom of the ancients, it was supposed that infection might be communicated by the use of holy water contaminated by a person suffering from the disease; that a "young lady of the period" might catch the pox by being sprinkled with the "asperges" at the church-door. "But," quietly sneered Fallopius, "the disease must have been contracted per unum asperges' ego scio."† Heretofore we were content with squabbling as to whether the venereal disease first broke out at the siege of Naples, or whether it was imported with other western produce by Christopher Columbus from the New World. The vulgar view of the case, that whenever the laws of nature are offended, as by one female receiving the embraces of a number of men, disease is as sure to ensue as that typhus fever will follow overcrowding, is generally rejected as unscientific; and we plunge accordingly into the obscure legends of the past. But of all stupendous assertions, unsupported by any argument or facts, is one of Van Helmont, revived by M. Ricord, which throws common mediæval myth into the shade —namely, that syphilis is a modification of glanders, transmitted from the horse to man. "Now it was not known," says M. De Meric, "at the period alluded to, that this latter disease was communicable from the horse to man; and it has since been suspected that some of the loose female characters, already labouring under simple ulceration, and hovering round armies, might have been infected by an individual suffering from glanders, or having about him some infectious secretion originating from a diseased horse. A mixture of the poison of glanders with the unhealthy and decomposing secretions of dissolute females, may have given rise to the dreadful malady which has for centuries undermined the health of generation after generation. Proof there is none; but a tolerable share of probability."+ We have thus, by way of simplifying the question of the origin of the disease, a portal opened to the whole range of veterinary surgery, in addition to that of archæological research; and we see no reason why speculation should not likewise be extended to the probable effects of the introduction of canine and bovine maladies into the human race, and thus avail ourselves of additional disquisitions calculated to afford delectation to those curious in startling assertions. But let us pass from this unprofitable subject. Cause and effects obey in the history of disease one fixed and immutable law; and we find that when ancient writers confine themselves to describing facts as they saw them, the phenomena which they record differ in no essential manner from those witnessed under similar circumstances in the present day. *Benedict V.: Tract. de Morbo Gallico, cap. 8. + Ibid. cap. 18. Now we read a great deal about the enormous host before Naples, assembled by Charles VIII., King of France; of the length of the siege; of the many causes of disease generated in the camp. What are the facts? That monarch marched into Italy in the month of August, 1494; he had to make his way through Etruria and the Papal States; and he marched out again in October, 1495, leaving behind the Duke de Montpensier, with six thousand men. Why, the whole campaign lasted but little more than one year! It was carried on in a cultivated country, and during the greater part of the time the troops must have been in movement, and therefore more healthily employed than in lying listlessly before a beleaguered place. How comes it that if the tremendous malady of which Gilinus and Leonicenus and others wrote, sprang from this puddle in a storm," similar results have not been witnessed in the vast assemblages which have characterized the warfare of modern times? 66 Have M. Ricord or M. Victor De Meric ever seen a case of glanders in man? It bears as much resemblance to the venereal disease as it does to the mange in dogs. Let us at once refer the origin of the disease, with Coradinus Gilinus, to the junction of Saturn and Mars, Jan. 16th, 1496; or that of Jupiter and Mars, Nov. 17th, 1494; or revive the theory of the learned Wendelinus Hock de Brackenaw, who refers this calamity to the year of God, 1483, because in the month of October of that era there were four planets in Libra-namely, Jupiter, Mars, the Sun, and Mercury. Such statements are quite as satisfactory, and infinitely more clean, than Van Helmont's vision of intercourse with an infected mare. M. De Meric commences his work with modesty : "I may not," he says, on the present occasion, follow the ravages of the disease through the length and breadth of the world, trace its effects in different climates, describe its decrease and occasional exacerbations; compare it with the sibbens of Scotland, the yaws of the West Indies, and the black disease of Canada; but I shall just stop to inquire what aspect syphilis presents in this country in our own refined state of society." (p. 5.) He then proceeds to speak of the rather large proportion of chancres which become phagedænic; of gangrene of the prepuce and glans; of intractable secondary or tertiary ulcers; of carious skulls, which now, as of yore, lead the sufferer to the grave. He speaks, too, of our fair delinquents, once adorned by freshness and youth, turned into objects of disgust and commiseration." "We all know," he adds, "that a man may have had a chancre and a suppurating bubo, and remain for the rest of his life perfectly free from any taint whatever. Such an individual should not be said to have suffered from syphilis; his frame is not infected, he has simply had a venereal ulceration, followed by a glandular complication. The words chancre and syphilis might, then, advantageously be reserved for the more serious complaint; and it would at once be plain that syphilis is to be classed with other blood-diseases, as cancer and scrofula." (p. 6.) We will not here enter into a disquisition upon the meaning of blood-disease; nor stop to inquire how far cancer, or even scrofula, may be the better understood upon such a basis. Who has detected morbid changes in the blood of those suffering from either malady? And wherefore is it that the life-endowed cells, which end in the development of the tissues, may not have more to do with the development of malignant disease, than the composition of the circulating fluid? The cancer or scrofula which comes from our parents cannot be eliminated by bleeding, nor cured by transfusion; nor can the disease be transmitted by inoculation. We will, then, drop the term blooddisease, as in this instance too vague for useful investigation. Mr. De Meric looks down upon some practitioners who believe that "the poison of syphilis may be generated spontaneously; that frequent promiscuous intercourse, coupled with uncleanly habits, may cause the development of syphilitic ulcerations." We will ask the author whether it be not true that the poison of typhus is generated spontaneously in crowded habitations that the poison of typhoid fever comes spontaneously from decomposing fæcal matter? And may not the same be said of every other morbid yet non-tangible influence which acts injuriously on the human frame; we know it not, save by its effects. Just as promiscuous intercourse develops syphilis, so does overcrowding induce typhus, or bad drainage develop typhoid fever; we have no need to descend for explanation to the pathology of quadrupeds. Now, nobody denies that there is a syphilitic poison. MM. Ricord and De Meric may therefore spare both argument and illustration in proof of what is known. But when we proceed to the next step: "Nor does the analogy between syphilis and other contagious diseases stop here, for it is extremely probable that the organism is insusceptible of two syphilitic infections,"* we must request the reader to suspend his belief. And before entering upon the point, we will inquire into the nature of primary syphilitic ulcers. M. Ricord asserts that there are two forms of chancre-one the chancre mou, the simple or non-infecting chancre; the other the indurated or infecting chancre. He proceeds to explain that the excess of relative frequency of the simple chancre may be explained as follows:-1. The simple chancre is the most abundant source of the chancrous virus; it is the form of ulceration which secretes pus endowed to the highest extent with the property of contagion, and which retains for a long period the faculty of inoculation. 2. It creates no immunity against a renewed contagion of chancre of the same kind-that is to say, against its reproduction upon the same individual. The indurated chancre is only produced once upon the same subject. To the natural inquiry, are these statements true as regards English experience, we answer unhesitatingly in the negative; they are contradicted by daily evidence of hospitals wherein syphilitic disease is witnessed on a large scale. In the first place, can chancres be recognised in this primary form as infecting and non-infecting? We entertain very strong doubts whether M. Ricord himself would encounter a heavy responsibility in determining this point. He might succeed at a guess; but he could not lay down clear and unmistakeable rules. What are his own words upon the point? "You will remark, that in those places where the induration is most exuberant, it also persists longer than in any other region. On the other hand (and I hasten to point out this fact to you now, in order that you may see the contrast), there are certain anatomical regions where indurations are ill-defined, in which their presence is with difficulty recognised, and from whence they rapidly disappear."t How convenient! The infecting chancre must have a hardened base. If the hardness cannot be felt by the uninitiated, it is due to inexperience. If it cannot be felt by the experienced, it has disappeared, having been short-lived! If constitutional symptoms appear after a proper interval, the indurated base must have been there; perhaps parchment-like. "Induration," says M. Ricord," so difficult to recognise in deep-seated regions, is but a transitory symptom. When once produced, a few days will suffice to allow it to disappear." We cannot pretend to meet this circular sort of argument, which may be thus expressed :-No variety of sore, except that with the indurated base, will produce secondary or constitutional syphilis. If a patient suffer constitutionally, the primary sore must have been indurated. If the surgeon have no remembrance of "induration," he must have overlooked it. If the sore, to appearance, be soft throughout, there must have been a transitory induration; subsiding in a few hours. We ask what species of argument is this? Is it not akin to the Hunterian doctrine, that all syphilitic sores require the use of mercury? If a suspicious-looking sore get well by simple means, it cannot be syphilitic? The experience of London hospitals does not support such assertions; on the contrary, it gives them daily refutation. The character and appearance of the primary sore are chiefly modified, as Mr. Lawrence has for many years pointed out, and as has been shown again in a modern work (Coote on the Treatment of Syphilis '), by the tissue to which the poison is applied. There are distinct and recognisable varieties of sore on the glans penis; the orifice of the prepuce, the integument of the penis; the integument of the body. Induration at * De Meric, p. 7. + Maunder's translation of Ricord's Lectures, p. 62. + Lectures on Syphilis, by V. De Merie, p. 20. the base occurs chiefly at the reflexion of the prepuce on the glans; but may, in rarer instances, be seen in other situations. An indurated chancre is very rare indeed in the female. Sores are sometimes superficial for a few weeks, and then become indurated at the base just as the process of cicatrisation is complete; but the induration is never transitory. Now, M. Ricord, in commenting on the fact that of two primary sores possessing the same faculty of physiological or artificial reproduction, one produced contamination of the organism, the other left the organism unscathed, inferred that the virus was the same, but that some constitutions resisted and others not. But, in 1852, M. Bassereau, one of his pupils, published a work on syphilitic eruptions, wherein he endeavoured to prove that differences as to constitution, mode of life, sex, age, and climate, had nothing to do with the development of constitutional syphilis or its nonappearance. From a large number of cases collected at the Paris Lock Hospital, he took one hundred, who, after chancre, had suffered constitutionally; and an equal number whose chancres were not followed by secondaries, and who had no treatment capable of warding off systemic syphilis, and found in these two series of cases the same proportion of lymphatic temperament, weak frames, bad hygiène. He took into particular account the fact that the same person may, at short intervals, take first a soft, then a hard chancre; and also that patients have been known to present soft chancre successively through a certain number of years, and to contract at last an infecting sore, which contaminated the economy.* Finally, by confronting the person infected with the individual who had been the cause of the contagion, he found that all those patients who presented chancres followed by constitutional symptoms, had taken the disease from persons affected in exactly the same manner. He likewise found that individuals suffering from chancres which had remained local symptoms, and had not affected the economy, had been diseased by persons with whom the chancres had also lert the organism untouched. From these observations M. Bassereau has founded his theory, to which M. Ricord has yielded a willing assent-namely, that the cause of this difference lies in the poison itself. "The chancre which taints the frame appeared only at the epidemic of 1495, and from that period were those fearful constitutional symptoms observed which are rife up to the present moment. The soft chancre, M. Bassereau believes, is as old as the world; the hard, with its dismal train, began its reign, and that in the most ruthless way, towards the close of the fifteenth century."t We admit that temperament exerts a dubious sway over the development of secondary syphilis. But not so sex or climate. Out of 200 males admitted into the venereal wards of St. Bartholomew's Hospital, 92 had constitutional symptoms. Out of 200 females, only 54 were similarly affected. Climate, too, exerts a most marked influence when combined with proper diet and regularity of habits. The convicts at Gibraltar are reported by Mr. Nesbit, one of the Government surgeons, to be rarely sufferers from systemic disease, although most of them have primary syphilis in one form or another at the time of conviction and banishment. But it will be replied, there is no direct evidence that any of these persons were suffering from an indurated chancre, or that exact form of ulcer to which M. Bassereau refers. To this we can make no reply, except that surely among so many who are sufferers, there must have been some the subject of the infecting chancre. But in addition to this, secondary symptoms already existing slowly subside under the influence of proper hygienic rules, and do not recur. We positively deny the statement that the indurated chancre, as understood in England, is the only infecting sore. It is of course difficult to demonstrate the point, because of the shifting nature of the ground taken by those who support the opposite doctrine, and affirm that the induration may be transitory, or insensible, or involved in some complication. The following case is, however, to the point: In 1843 a young lady left an evening party clandestinely in company with a gentleman and never returned to her family. After a few months she was left to her own resources, when * Op. cit. p. 62. + Lectures on Syphilis, by V. De Meric, p. 21. |