lesion, induration, infection, lymphatic, initial, simple, chancre, tion and affection

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Regarding mesarteritis syphilitica, the following conclusions are reached: I. In the aorta there may be an inflammatory affection of the tunica media, character ized by a circumscribed small-cell infil tration. This infiltration afterward un dergoes transformation into a kind of connective tissue poor in nuclei. Ac companying the transformation there is always a certain amount of shrinking. Here and there may be found some ne crosis of the media. 2. The tunica in tima may be secondarily involved, and may show thickening or may be af fected through the scar-like contraction going on in parts of the media. 3. The tunica adventitia may show small-celled infiltration, but more often there is a diffuse fibrous increase without tendency to contraction. 4. The affection has only been observed in syphilitic subjects, and is regarded as an hitherto unrecorded re sult of syphilis. 5. The affection is very likely the cause of aortic aneurisms in syphilitic subjects. 6. The affection is totally different from chronic endarte ritis, though the two may be associated with each other. F. Backhaus (Befit. zur path. Anat., B. 22, H. 3, '93).

The evolution of the other elements of the local manifestations of i.e., primary lymphoplasia and adenop athy—is practically a duplication of the changes occurring in the initial lesion. 'Within a few days after the latter ap pears the lymphatic vessels leading from the infected surface enlarge and harden, often resembling pieces of pencil or wire beneath the skin or mucous membrane.

The degree to which inflammation enters into the process depends upon the amount of irritation of the primary le sion and the presence or absence of mixed infection. Typically, the lym phatic lesion is an hyperplasia rather than a lymphitis. It would appear that the local influence of the infection travels with slowness and deliberation. After a time the lymphatic glands into which the lymph-current from the infected area flows react to the infection and primary adenopathy occurs. No general involve ment of the lymphatic glands occurs for some weeks, apparently not until the in fection has had time to reach the gen eral lymphatic system via the tissue lymphatics, the central lymphatic cir culation, and the general blood-circula tion. If the infection is not local in its influence primarily, this is a singular phenomenon, for there is no reason why there should not be almost simultaneous involvement of all the lymphatics of the body, granting that the infection is gen eral from the start. Each involved gland would appear to be a depot for the stor ing up, production, and finally the dis tribution of the infection. Each lym phatic gland is affected by a tissue-hyper plasia precisely similar to that existing in the initial lesion. It becomes hard and woody to the touch, its circumscrip tion and induration being explicable upon the same ground as the same qual ities of the initial lesion.

The changes at the site of infection and in the lymphatic glands and vessels first involved have been most appropri ately termed the initiatory period of syphilis.

The Initial Lesion, or Chancre.—The typical initial lesion is an induration pure and simple. The facilities for mixed in fection and for irritation of the lesion are so many and various, however, that a simple induration without solution of continuity of skin or mucous membrane is exceptional. Chancre, as the initial lesion is most frequently termed, presents itself in the following forms: 1. A superficial loss of epithelium forming a non-suppurating open lesion. This is termed simple erosion. 2. A greater or less area of ulceration, saucer-shaped, due to irritation and syphilitic pus-infec tion. 3. A deep ulcerative excavation with sloping edges. 4. Herpetiform and crustaceous chancre. 5. Diphtheroid or so-called diphtheritic chancre. G. An indurated, non-secreting plaque, papule, or tubercle. It will be understood that the open varieties of chancre present in typical instances an underlying more or less characteristic induration. (See col ored plate.) Erosion may be said to include about two-thifcls of chancres, and is usually situated upon the mucous membrane, very often inside the prepuce in the male. In shape it is oval, or perhaps a trifle irregular, with a raw, polished surface of a wine-red color and sometimes a pultaceous base, but usually secreting a simple thin, sanious fluid, devoid of pus, or at least containing a very small amount of pus-corpuscles. These erosions are flat, and may surmount a thin parchment induration, or may cap a hard tubercle as large as a marble. Superficial ulcera tion with sloping edges—the ulcer pre senting a saucer-shape—is found with the parchment, but most often with the split-pea, induration. When this ulcera tion caps a large mass of induration, it is likely to be quite deep and funnel shaped from extensive necrobiosis, con stituting the so-called "Hunterian chan cre." The secretion from a chancrous ulceration is quite likely to be of a sero purulent character. Herpetiform and crustaceous chancres may occur in any situation. The simple indurated papule or tubercle is usually found upon the skin, the integument of the penis, or even upon the prepuce itself when it is short and dry. T:lceration of this form of induration might occur if it were kept moist, the conditions of warmth, moist ure, and irritation combined being espe cially favorable to the production of ulceration. The parts upon which it de velops are perhaps not so rich in lym phatic spaces as those in which a chancre is more likely to ulcerate, the collection of cells being consequently smaller and the tendency to necrobiosis less marked.

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