REPORT ON DERMATOLOGY Syphilis and Other Exanthemata. By LUNSFORD P. Jr., M. D., Professor of Therapeutics and Clinical Medicine, University of Louisville. REPRINTED FROM THE TRANSACTIONS OF THE KENTUCKY STATE MEDICAL SOCIETY, 1877 LOUISVILLE, KY.: PRINTED BY JOHN P. MORTON AND COMPANY 1877 Medical History of Kentucky I propose to publish, by subscription, a Medical History of Kentucky, from its settlement down to 1876. The work will embrace— hirst. A notice of every thing which has been written on medicine by Kentucky physicians. Second.- Biographical sketches of deceased physicians of note. Third. Histories of the medical institutions of the State. * ’ and of the more remarkable epidemics by which it has been visited. TO WHICH WILL BE APPENDED A Review of American Medical Literature From 1677 to 1876. All will be comprised in an octavo volume of about six hundred pages, and delivered, neatly bound in cloth, to sub- scribers at five dollars. Address LUNSFORD P. YANDELL, LOUISVILLE, KENTUCKY. REPORT ON DERMATOLOGY. Syphilis, Scarlatina, Measles, Variola, and Varicella. In the brief report on dermatology which I had the honor to make to the Society, at its last session, my remarks were confined to the skin diseases proper, meaning by this term those non-specific affec- tions whose major symptoms are observed on the skin, and whose dem- onstrable existence indeed consists in most instances solely in the eruption. This division of the subject is of course purely arbitrary, and is merely adopted for convenience. The correctness of the views expressed in my previous report as to the etiology and therapeusis of the maladies of the skin, has been con- firmed by twelve months’ observation in hospital, dispensary, and pri- vate practice; and I now reiterate the assertion then made, that “the most abundant source of acute skin disease is that mysterious some- thing which we call malaria; the diathetic poison known as struma is the chief source of the chronic skin diseases; and to these two materies morbi we may tracet the greatest number of diseases of the other tis- sues.” Be it understood I am not now including the specific exan- thems; and I do not claim that malaria and struma are the sole causes of the true skin diseases. On the present occasion it is my purpose to consider, as briefly as \ possible, the specific exanthems: scarlatina, measles, variola, varicella, and syphilis. Scarlet fever (scarlatina) was known to the profession as early as the sixteenth century; but its specific nature was first established by Morton about the middle of the seventeenth century. (Ziemssen.) Up to the present day the profession is not of one mind as to the best treatment for it. Our main reliance is in attention to general condi- 2 Report on Dermatology. tions, not neglecting local symptoms. Quinia, iron, and heart tonics, together with baths and anointings, comprise the most promising remedies. Belladonna, either as a preventive or curative agent, is no longer thought of. As to the name and symptoms of scarlatina there is do dispute, but its contagiousness, though generally conceded, has some firm opponents. Measles, formerly denominated rubeola, and now called morbilli by many writers, is said to have been known during the fourteenth cen- tury, though its specific nature was not established till about the mid- dle of the last century. The term morbilli means literally “little dis- ease,” and was first employed, according to Hebra, to distinguish measles from the greater and graver disease, the plague. Measles is from the German word maser, a spot; and rubeola signifies a reddish color. By this name, in former times, several distinct diseases were called. At the present rubeola is frequently used to describe what is otherwise called rotheln, or German measles. This is an extremely insignificant malady, closely resembling milder cases of measles. Little, if any, treatment is necessary, and the prognosis is favorable. In the management of measles much improvement has been made within the last quarter of a century. Its self-limited nature, its brief duration, and its tendency toward recovery, in the great majority of cases, are now recognized facts; and it is only for the relief of symp- toms of unusual severity, or for some complication, that medical inter- ference is demanded. The patient should be allowed food and drink, hot or cold at will, and good ventilation should be secured. Variola is probably of eastern origin, and is of incalculable an- tiquity. A hundred years ago it was the most dreaded and the most fatal of diseases. At that time it was far more exceptional for persons to escape smallpox than it is now for them to contract it. It was esti- mated that from ten to twelve per cent of all the deaths then occur- ring were due to this scourge. Jenner’s great discovery, vaccination, though still violently opposed by a few medical men, has robbed the disease of much of its terror; and it is believed by some that it not only prevents smallpox, but that its influence on the race in general, by heredity, has been to diminish its virulence. Were vaccination universally performed, it is probable that total eradication of variola would eventually be accomplished. The contagiousness of smallpox, Report on Dermatology. 3 although almost universally admitted, has its opponents. In the treat- ment of variola we have no late advances to record. To make the patient as comfortable as possible, to treat symptoms, to assist nature, comprise all that we can safely do. Varicella, or chicken pox, though one of the specific exanthems, is of no importance, and requires, as a rule, no treatment; but in obsti- nate, protracted cases quinia and iron are demanded. I come now to the gravest of the specific exanthems. Though seldom occurring in epidemic form, and less violent than scarlatina and variola, it exists at all seasons and in all countries, and is ever in- creasing. I speak of syphilis. The origin of the word syphilis is an unsettled question, and I ven- ture to offer a theory on the subject which seems to me more probable than any hitherto suggested. “The town disease,” “the town disor- der,” are terms used by the lower classes, and especially among the rustics, to indicate this affection. Syphilis, from our first knowledge of it, has been eminently a city disease. The Latin word civilis signi- fies pertaining to a city or to citizens; and it occurs to me that morbus civilis, i. e. citizens’ disease, or city disease, was probably the first popular name for syphilis. Furthermore, it is perfectly natural, and in accordance with popular custom, that, for the sake of brevity, the word morbus should have been dropped, leaving only civilis. The al- teration in the spelling of the word is not remarkable. Chancre was once spelt shanker, scrofula was spelt scrophula, and often we find even the meanings of words wrenched entirely from their original sig- nification. For instance, gonorrhoea literally means a flux of semen, indolent means painless, and collyrium, which to-day means an eye remedy, once indicated a cylindrical medicine to be introduced into the anus, vagina, or nostril. Any extended history of syphilis in a paper like this would be out of place, and I shall therefore only venture to make a few remarks concerning the origin of the disease. In Lord Bacon’s Natural His-, tory, printed about the year 1660, page 6 (“Experiment solitary, con- cerning the venomous quality of man's flesh,”) he says: “The French (which put off the French disease unto the name of the disease of Na- ples), do report that at the siege of Naples there were certain wicked merchants that barreled up man's flesh (of some that had been lately 4 Report on Dermatology. slain in Barbary) and sold it forTunney;”—[tunnev-fish, I presume— L. P. Y., jr.]—“and that upon that foul and high nourishment was the origin of that disease. Which may well be; for that it is certain that the cannibals in the West Indcs eat man's flesh; and the West Indes were full of the Pock when they were first discovered. And at this day the Mortalest Poysons practised by the West Indians have some mixture of the blood, or fat, or flesh of man. And divers Witches, and Sorceresses, as well amongst the Heathen as amongst the Christians, have fed upon Man's Flesh, to aid (as it seemeth) their imagination with high and foul vapors.” This absurd theory of Lord Bacon’s, it is unnecessary to remark, is not entertained at the present day. Among other conjectures as to the origin of syphilis, sexual inter- course on the part of soldiers with mares affected by farcy has been suggested; also sexual intercourse between the human species and the hog, and sexual commerce between individuals of different races and climates. These doctrines have no followers among modern syphi- lologists. It is an interesting fact that almost every nation has been charged with the paternity of the pocks. It has been called the American dis- ease, the English disease, the French disease, the Italian disease, the Polish disease, the Turkish disease, and so forth to the end of the chapter of peoples. Wars have been, in all likelihood, an important factor in the de- velopment and spread of syphilis, and the armies are most probably the authors of the nicknames just enumerated; for we know that sol- diers are not remarkable for chastity, and are not niggardly in the bestowal of hard names on the enemy. Whatever be the origin of syphilis, and probably we shall never determine the manner of its birth or the country of its nativity, this much we do know, that syphilis is to-day universal in its dissemination, and is steadily increasing in all lands, and that its spread is most marked in countries of the highest civilization. Indeed, it may be said that civilization and syphilis march hand in hand. The prophylaxis of syphilis, this most loathsome of acquirable diseases, is one of the great questions of state medicine of to-day. So far no practicable plan for its arrest has been devised, and I freely Report on Dermatology. 5 confess I have no suggestion to offer. Indeed, until the human race become virtuous, there is, it seems to me, but little hope for a decrease in syphilis. Venereal diseases in the past were regarded as among the opprobia medicorum, and were relegated to the surgeons, who, in times gone by, occupied a position less honorable than that which they have since carved for themselves. To-day these affections are claimed by the dermatologists as properly belonging to their branch of medicine; but here, in Kentucky, where despotic specialism is less arrogant and dominant than in some other quarters, every practitioner is more or less of a syphilologist. Those of you who are familiar with the literature of syphilis, are aware of the wide diversity of belief among the recognized authori- ties; and, since we have no established creed, I feel myself at liberty to offer the following brief statement of some of the more important practical truths of syphilis as they appear to me. These are opinions based on twenty years’ clinical observation and study of the subject. Syphilis is a unity. It is due to but a single poison, and can not be produced by any other. Syphilis never produces any other disease than syphilis. The syphilitic virus is inoculable by means of the blood, milk, saliva, semen, pus, and all the other normal and abnormal secretions of syphilitic subjects. This virus, in order to produce its effects, must go directly into the circulation. Applied to the unbroken skin or mu- cous membrane, it is harmless. Taken into the stomach, it is inert. In these respects its behavior corresponds with the poison of reptiles, insects, rabid animals, and the vaccine virus. Syphilis may be transmitted by either parent to the offspring. A syphilitic father may beget healthy children, and a father once syphilitic, but to all appearances cured, may beget syphilitic children. A sound mother may bear syphilitic children without herself becom- ing contaminated; or she may acquire the disease from the child dur- ing the process of gestation. Syphilis is communicable by contact, and transmissible by inherit- ance in all its stages; least so in the tertiary. The division of syphilis into three stages is purely arbitrary. The same poison exists in each, and may show itself in the offspring in either of the forms called primary, secondary, and tertiary. 6 Report on Dermatology, Acquired syphilis appears in the form of what is known as primary, though this stage may escape the observation of both patient and phy- sician, and the secondary may be the first syphilitic manifestation to arrest attention. Inherited syphilis appears as either secondary or as tertiary. The rule in acquired syphilis is that secondary next follows pri- mary, the tertiary succeeding the secondary; but the tertiary may precede the secondary, and the secondary may never appear at all. Primary syphilis, initial lesion of syphilis infecting chancre, Hun- terian chancre, indurated chancre, hard chancre, true chancre, are synonymous terms. This lesion may occur on any portion of the body, but most frequently it appears on the sexual organs, because of their more frequent exposure to the venereal accident. An unique induration, a peculiar hardness, is an almost invariable feature of the primary lesion. This sore is usually single, painless, non-suppurating. It is discovered within a period varying from eight days to three months after exposure. Bilateral, symmetrical, or, in other words, simultaneous enlargement of the lymphatics of both sides of the body commonly accompanies syphilis. Secondary syphilis shows itself within three weeks to three months after the primary. Tertiary comes on within three to six months after the beginning of the secondary. All the stages, in rare instances, may co-exist, and the primary sore often lingers after the secondary symp- toms are thoroughly established. Suppurating bubo is an exceptional accident in syphilis. It is not a natural feature of the disease. Unless the subject of indurated chan- cre be in depraved health, or the sore be injudiciously treated, glandular suppuration will rarely happen. Phagedaena is likewise an accident in syphilis, and has no natural connection with it. Malaria, alcohol, mal- nutrition, and local constriction are its usual sources. Treatment.—Destructive cauterization and excision should never be resorted to, either in genuine chancre or any Other venereal sore. The so-called soft chancre, chancroid, non-infecting sore, never deserves to be cut out or burned out, because it never contaminates the system. It can no more produce syphilis than can scrofula or cancer. The true chancre should never be cut out or burned out, because the system is already contaminated when it is perceived. Its existence is positive Report on Dermatology. 7 proof that the system is already poisoned. Excision and cauterization irritate the sores, aggravate the existing inflammation, and thus enhance the chances of suppurating bubo. Venereal sores require exactly the same treatment as other sores, and heal most quickly under the application of anodynes, astringents, and protectives, accompanied by the internal administration of iron and bitter tonics. The occasional application of sulphate of copper often promotes their healing. Soap and water are irritants to syphi- litic sores as they are to all others, and should rarely be used in the management of any of the solutions of continuity. To cleanse the sores oil is the best material. Diet in Syphilis.—The diet should be the best at the patient’s com- mand, and meats and fats should be especially insisted on. Tobacco and alcohol must be imperatively prohibited in all the stages of the disease. They act both as local irritants and constitutional poisons. Secondary and tertiary sores require the same management as the primary lesions in all respects. Far too much attention is usually given to local treatment in syphilis, as in other eruptive diseases. Mercury is the only antidote to constitutional syphilis, and syphilis is always constitutional. For mercury we possess no substitute. Iron and bitter tonics, and all agents which promote nutrition, should be given in connection with the mercury, and large doses of quinia are often demanded; cod-liver oil, syrup, hypophosphites, syrup, ferri iod., and the extract of malt, are valuable remedies in the advanced stages. In the treatment of tertiary syphilis, iodide of potassium possesses great palliative, if not curative influence, and without it it is impossible in many cases to control the more advanced and serious manifestations of the disease. It should be given largely diluted, and from a drachm to one ounce or more in the twenty-four hours is often required. The best form of mercury for internal administration, in my judg- ment, is corrosive sublimate in solution. The best method of admin- istering mercury is the moist mercurial vapor bath. The baths remove the symptoms of the disease with greater certainty, with more rapidity, relapses are less frequent, and the risk of producing the ill effects of mercury under this treatment is nil. Mercurial inunction is the most satisfactory method in infantile syphilis, though the bichloride acts well in these cases. Whatever form of mercury or method of administration 8 Report on Dermatology. be adopted, the treatment should be prolonged uninterruptedly for some weeks or months after all signs of the disease have disappeared; and the mercurial treatment should be followed by a more or less prolonged course of iodide of potassium. Prognosis.—An eminent German syphilologist is said to have de- clared that not only is syphilis never eradicated from the system, but that the ghosts of pock-infected inhabitants of this world will suffer from the dread affection in the land of shadows. And there is a widely prevalent popular belief that syphilis is never entirely cured, and not a few physicians entertain this opinion. My belief is that syphilis is one of the positively curable diseases, and I know of no malady the symptoms of which yield more kindly and certainly to proper treatment. Indeed, I believe that bad treat- ment and exaggeration of statement are largely responsible for the fearful reputation this disease has acquired for violence, malignity, and obstinacy. At the same time I must admit that in extremely rare instances, cases may be encountered which defy all treatment. Prognosis is most favorable in children, and the younger the better are the chances. Next to children women are most satisfactorily treated. Young men stand next in point of curability; the older the patient is the less is the likelihood of permanent cure. How we may know when our patients are cured of syphilis is a ques- tion impossible to be satisfactorily answered in the present state of our knowledge. I consent to patients marrying after twelve months of freedom from syphilitic manifestations, if they have previously under- gone a thorough course of mercury and potash. At the same time I warn them that the only proof of cure is immunity from the symptoms, and that it is possible that, either in himself, his wife, or his offspring syphilis may crop out. But if the disease returns it almost always yields speedily to treatment; and if the wife or child get it they, as a rule, quickly recover. I hope I may not be understood as advising syphilitics to marry. It would be safer and far better for the race if all syphilitics, con- sumptives, rheumatics, epileptics, and all others not indisputably sound, could be prohibited the privilege of procreation. But since such people will marry, we should give them all comfort possible within the bounds of truth.