VIRUS OF VENEREAL SORES, ITS UNITY OK DUALITY. liY FREEMAN J. BUMSTEAD, M.D., LATE PROFESSOR OF VENEREAL DISEASES IN THE COLLEGE OF PHYSICIANS AND SURGEONS, NEW YORK. Extracted from the Transactions of the INTERNATIONAL MEDICAL CONG R ESS, Philadelphia, September, 1876 PHILADELPHIA: 1877. THE VIRUS OF VENEREAL SORES, ITS UNITY OE DUALITY. BY FREEMAN- J. BUMSTEAD, M.D., LATE PROFESSOR OF VENEREAL DISEASES IN THE COLLEGE OF PHYSICIANS AND SURGEONS, NEW YORK. Extracted from the Transactions of the INTERNATIONAL MEDICAL CONGRESS, Philadelphia, September, 1876. PHILADELPHIA: 1877. PHILADELPHIA : collins, Printer, 705 Jayne Street. THE VIRUS OF VENEREAL SORES, ITS UNITY OR DUALITY. The question, the discussion of which I have the honor to open to-day, is expressed in the following terms:—u The Virus of Venereal Sores, its Unity or Duality.” In presenting this question, the first inquiry that suggests itself to one’s mind is whether it is identical with the question of the “Unity or Duality of Syphilis,” that, for the last twenty-four years, has excited so much interest and discussion in the medical world. I reply that it is essentially the same. To ignore this fact, to attempt to assume a new departure, to consign the question of “ unity or duality” to the tombs as having no bearing upon our present vieAvs, would be a fraud upon medi- cal history and a source of confusion to the student; since those who have so earnestly advocated the so-called “ duality of syphilis,” have never for a moment supposed that there existed two kinds of syphilitic virus, but merely that there was more than one poison at work in the etiology of a complex disease known for many years under the name of syphilis; and he who now recognizes a duality of poisons in venereal sores, is a syphilitic “ dualist” in the sense in which that term has been employed. It will be seen, however, that the term “ duality of syphilis” has always been a misnomer, and the form of the question presented to us to-day is most appropriately substituted for it. * I take it for granted that the question proposed to us is intended to include the poison or poisons of every kind productive of venereal ulcers, and that the term virus is to be used in its broadest sense, viz., that of contagious 'principle or poison. When speaking of a special poison sup- posed to be incapable of generation de novo, I shall call it a specific virus. Allow me also to add that I shall use the terms chancre and chancroid in the sense which is commonly received in this country—chancre as in- dicating the initial lesion of syphilis, and chancroid as indicating the “soft chancre” of the French school, and the “chancre” of the German school. Three views as to the origin of venereal sores have been entertained :— (1) All venereal sores are due to a single, specific virus, the virus of syphilis. (2) Some venereal sores are due to the syphilitic virus, and others to a distinct specific virus, known as the chancroidal. (3) Some venereal sores are due to the syphilitic virus, and others to the inoculation of the products of simple inflammation, in which latter case no specific virus exists. The clinical observations and artificial inoculations, which have been brought forward, for and against these several theories, must be familiar 4 BUM STEAD, to those here present, and I shall therefore limit myself to reviewing them and drawing my own inferences from them, as a basis for the dis- cussion which is to follow. Indeed, any other course would be imprac- ticable within the limits of this paper. The view first mentioned, viz., that all venereal sores are due to a single virus, the virus of syphilis, had been the prevailing one for nearly three centuries prior to the year 1852. At the same time, it had not escaped the notice of many observers that the results of contagion were by no means identical; that, in some cases, the persons infected showed no symptoms after the healing of their ulcers, while others developed a train of symptoms, lasting through years, and even transmissible to their children. In the year 1852, Bassereau claimed a distinct cause or origin for each of these two classes of cases. He founded his claim, first, on the his- tory of venereal sores, whereby he endeavored to show that, although contagious ulcers of the genital organs, communicated in sexual inter- course, had been well known to the ancients, yet that the constitutional disease which we call syphilis made its first appearance in Europe in the latter part of the fifteenth century. While believing this argument drawn from history to be a valid one, I would not insist upon it in a discussion like the present, which should be based upon scientific data. I will merely remark that this argument will receive additional support, provided that it can be shown that the chancroid is due to a poison generated by simple inflammation, and hence that it must have existed at all times and among all nations. Bassereau’s second argument was based upon the u confrontation” of persons affected with venereal diseases, and he and others were able to prove, in several hundred cases, that when the disease was local in the giver it was also local in the recipient, and that when it was constitu- tional in the giver it was always constitutional in the recipient; in other words, that tbe broad line of distinction separating a local disease on the one hand from a constitutional disease on the other, was constant in successive generations without limit. It will be observed' that this proof does not involve any differences real or supposed in venereal ulcers themselves; it may be said to rise above such consideration in that it ascends to the source and origin ; and I do not hesitate to say that much of the confusion and contradiction of opinion upon this subject has been due to the fact that observers have confined themselves to investigating symptoms, which, though generally constant, may yet be poorly marked or even wanting, and which often require practised eyes and fingers for their recognition. Now I maintain that this clinical proof adduced by Bassereau has never been shaken, for, although local ulcers have been produced by the inoculation of matter from syphilitic sores, yet this is susceptible of, and indeed requires, as we shall see hereafter, another explanation than an identity of poisons, and, on the other hand, there has never been a. single authentic case in which syphilis has been produced by the inoculation of chan- croidal matter from a person who has had only a chancroid and not syphilis. Bassereau does not appear to have speculated on the cause of the dif- ference in venereal ulcers. I do not find .in his work the words “ Unity or Duality of Syphilis,” nor any expression of opinion as to the existence of a specific virus for the local sore. He simply says that he is obliged to recognize a different cause (une cause d.ifferente) for the local and con- stitutional diseases. UNITY OR DUALITY OF VENEREAL SORES. 5 A school of dualists, however, soon sprang up, who departed from the simple faith of their founder in attaching undue importance to the characteristics of the sores themselves, and who claimed for the local sore a distinct, special virus of its own. One of the tenets of this school was that the secretion of syphilitic lesions could not he inoculated with success either upon the person hearing them or upon any other person affected with syphilis, and this tenet, in the theory of dualism, was looked upon as vital. It was not long, however, before it was successfully attacked and overthrown. Clerc, of Paris, Melchior Robert, of Marseilles, and others, succeeded in inoculating the secretion of syphilitic sores upon the bearers, with the result of producing ulcers, without incubation, bearing all the characteristics of the chancroid, and inoculable in successive generations. Mr. Henry Lee, of London, and Kobner and Pick, in Germany, also found that a true chancre would become auto-inoculable, if it was irritated by the application to its surface of powdered savine, or by having a seton passed through its base, so as to render its secretion decidedly purulent. Again, Boeck and Bidenkap, in Christiania, in their later attempts at syphilization, took matter exclusively from true chancres, and obtained the same result as when they had inoculated chancroidal pus. In five cases reported by Bidenkap and Gjor, of Christiania, matter was taken from ulcers obtained in the above manner, and inoculated by patients free from syphilis upon themselves, and in only one instance did any general symptoms ascribable to syphilis follow, and these were of a doubtful character. Gentlemen, the import of these successful auto-inoculations of syphi- litic lesions as regards the question before us, deserves our serious consi- deration. Let us inquire what they apparently proved, and what they actually did prove. They apparently proved the identity of the syphi- litic poison with that of the local sore. By their means, it was supposed that the doctrine of duality was demolished, and the advocates of unity were triumphant. Whether this conclusion was not too hasty, we shall presently take occasion to inquire. But these experiments actually did prove the absence of any distinct specific virus in the chancroid, incapable of generation de novo; for here were chancroids artificially produced in- dependently of any descent from chancroids. You are well aware of the defence adopted by the dualistic school— the mixed chancre, a sore combining both the syphilitic and chancroidal specific poisons—which, it was asserted, would satisfactorily explain all these cases and still leave the tenets of dualism, as at that time under- stood, intact. This explanation was for a while regarded as satisfactory, but it could no longer be upheld when such experiments had been multiplied indefinitely ; when their number was so great that the chances of the commingling of two kinds of specific virus and their simultaneous inoculation was reduced to a homoeopathic absurdity; when an indu- rated syphilitic primary lesion could be taken at random, and, after due irritation, its secretion could be successfully inoculated with the effect of producing pustules and ulcers bearing every characteristic of the chancroid ; and when the same result could even be obtained at will by the inoculation of the secretion from a purely secondary lesion, as, for instance, a syphilitic mucous patch! If the chancroid was dependent upon a distinct specific virus, its presence in all these cases was simply impossible, and yet not a single shade of difference could be pointed out between the result produced and that from the most emblematic chan- 6 BUMSTEAD, croid ever met with in practice. Dualism was indeed henceforth demo- lished, if by “ dualism” be meant that each of the two kinds of venereal sore has a distinct, specific virus of its own. In the face of the experi- ments referred to, I cannot believe it possible to defend in future any such doctrine of duality. But the last word had not been spoken in favor of a distinct origin of the chancroid from that of syphilis, nor the last experiment made and recorded which would decide the question before us to-day. Let us ex- amine more carefully those experiments I have just referred to. What was the matter so successfully inoculated? The pure, unmixed virus of syphilis ? By no means. It was a compound product, taken, to he sure, from a syphilitic lesion, but a lesion irritated commonly to suppuration by artificial means ; containing possibly the germ of syphilis, but con- taining also, and in fact chiefly composed of, pus. Which of these two factors was responsible for the effect produced ? The syphilitic virus ? In that case this virus should have preserved its power of infecting the constitution, and matter taken from these ulcers, and inoculated upon healthy individuals, should invariably have produced syphilis, which has been shown not to be true. Moreover, if it could be proved that pus alone, free from all suspicion of syphilitic mixture, was capable of pro- ducing the same result, then pus was the guilty factor, and there was no such transformation as supposed by the unitists. Such proof we now have as will be seen from the following cases:— In 1865, Prof. Pick, at the suggestion of Prof. Zeissl, inoculated sim- ple, non-venereal matter of inflammatory origin upon syphilitic subjects. Taking the secretion from pemphigus, acne, scabies, and lupus, he inocu- lated it upon persons affected with syphilis and produced pustules, not preceded by incubation, and the matter of which was further inoculable through several generations. Counter-inoculations upon the persons free from syphilis who were the bearers of these affections, were without effect. The same result was attained by Kraus and Keder with the pus of scabies, and by Henry Lee with pus from a non-syphilitic child. The late Mr. Morgan, of Dublin, also succeeded in producing pustules and ulcers, identical in appearance with the chancroid and capable of re- inoculation through a number of generations, by inoculating syphilitic women with their vaginal secretions. It would thus appear that the skin of syphilitic individuals possesses a marked vulnerability, a peculiar aptitude to become inflamed when acted upon by irritants; but this is nothing more than is seen in other non-syphilitic subjects, whose vital powers are impaired by any cause whatever. For instance, it is well known that among medical students engaged in the dissecting-room, it is those who are run down by hard study and overwork, who are most likely to become inoculated by fluids from the dead body. Again, the idea which was entertained by some that there must be a syphilitic soil for such inoculations to succeed upon, is disproved by other experiments which I have to relate. The earliest of these experiments, as far as I am aware, have never been published, and were performed in the winter of 1867-8 by Dr. Ed- ward Wigglesworth, Jr., of Boston, upon himself, while pursuing his studies at Vienna. He has kindly furnished me with the following history: After stating the grounds which led him to the conclusion — original, it appears, with himself—that u pus pure and simple might be the cause of the chancroid,” Dr. W. says:— UNITY OR DUALITY OF VENEREAL SORES. 7 “ I would state that I was free from all disease either hereditary or ac- quired ; that I had never had a sore of any kind or any local or constitutional lesion of the skin or mucous membranes, and that I was merely a little run down from overwork in the hospital. I took from an acne pustule upon myself, pus, which I inoculated upon myself in three places on the anterior radial aspect of my left forearm at the junction of the middle and upper thirds, first pricking open the apertures of hair follicles and then rubbing the pus into them. The result in the course of three or four days was three well-marked pustules. From each of these I inoculated one new spot upon the same arm nearer the wrist. The result was three new well-marked pustules. From each of the three of the second series I again inoculated fresh spots still nearer the wrist, and again the result was positive. The second series was hardly as well-marked as the first, and the third series was slightly inferior in vigor to the second ; still all were well marked, the nine sores being at the same time present upon my arm. On removal of the crusts, perceptible ulceration of the skin wras found to exist. Zeissl, with whom I was studying at the time (1867-8), happened to be lecturing upon dualism, and requested me to show my arm to the class to prove the production of ulceration from properly inoculated, simple, healthy pus. There were no buboes in mv case, nor did the ulcerations require other treatment than exclusion from the air by means of a simple dressing, and cleanliness. The scars remain to the present day. I thus convinced myself and others— “I. That the products of inflammatory action, if properly introduced into the human integument, may cause local ulcers, closely resembling chancroids and re-inoculable in generations. “II. That this pus need not come from a syphilitic person or be inoculated upon a syphilitic person. If taken from, or inoculated upon, a person debili- tated by any disease as syphilis, the effect would doubtless be the same though probabty greater in intensity Many years subsequent to these experiments of Dr. Wigglesworth, which ought to have been made public at a much earlier date, Kaposi1 pub- lished the following statement: “My own experiments have taught me that non-specific pus, such as that from acne and scabies-pustules, when inoculated upon the bearers as well as upon other non-syphilitic persons, will produce pustules whose pus proves to be continuously inoculable in generations; that from these pustules losses of substance occur, which heal with the formation of scar-tissue; and that as the number of pus- tules produced increases, the inoculability of the pus derived from them diminishes and finally ceases altogether.” It is not necessary for me to dwell upon the exact correspondence of the result of such inoculations and that obtained by the inoculation of so-called chancroidal matter. The idea that the products of inflammation are the source from which the chancroid springs, and that the simultaneous inoculation of these products and of the germs of syphilis will account for the varying degrees of ulcerative and other phenomena met with in varieties of venereal sores, will strike many of you as novel, and it is easy to foresee the objections which will naturally arise. It will be asked: Can it be possible that the pus from acne, ecthyma, or scabies can give rise to a sore equal in duration and severity to that produced by matter from a typical chancroid? Comparative inoculations upon the same individual with these two agents may even be adduced to show that this is not the case. In replying to such objections, it must be frankly admitted that * Die Syphilis der Haut, etc., p. 47. 8 BUM STEAD, we do not as yet fully understand all the laws governing the inoculation of septic matter. We cannot, for instance, fully explain why one indi- vidual should be more susceptible than another, why different parts of the integument, as that of the chest, the arms and the thighs, should develop ulcers so varying in their destructive tendency as is shown in the practice of sypliilization ; why the secretion from purulent urethritis and purulent conjunctivitis should be interchangeable, and yet have no effect upon the mucous membranes of the mouth, nose, or ear; why a chancroid of the prepuce should inoculate other points of that membrane, and yet commonly spare the glans penis; or why one upon the os uteri should allow the walls of the vagina in contact with it to escape; and so with other instances that might be brought forward. That the effect produced is to a great extent proportionate to the ulcerative action of the source from which the matter is taken, is evi- dent to any one who has performed auto-inoculation from indurated chan- cres. If the chancre consist of a simple erosion with a watery secretion, seated upon an indurated base, the first two or three, or even more, attempts at auto-inoculation will probably fail; but as the surface of the sore becomes irritated to suppuration by repeated pricks of the lancet, these attempts will succeed, first in producing minute pustules and ulcers, but subsequently, as the suppuration increases, others larger and better developed. Taking these facts into consideration, it need not be wondered at if comparative inoculations upon the same individual with matter from a simple skin afiection and from a chancroid of the genitals, should show greater severity in the latter. But without enter- ing further into this subject, I claim it to be sufficient to have shown that the inoculation of the products of inflammation will produce an effect identical in kind, even if not in degree, with that of matter from the most typical chancroid; and this is my reply to the objections I have named. I have now, gentlemen, called your attention to the evidence drawn from artificial inoculation in favor of a duality in the poison of venereal sores, some of them being derived from the virus of syphilis, while others are due to the products of simple inflammation. This view, which I believe to be most consistent with our present knowledge of pathology, and to be supported both by experience and scientific investigation, has of late years found its advocates among medical men. Thus Baumler, in his recent able work on syphilis, after quoting ex- perimental inoculations like those just given, says :—“ The necessary con- clusion is, that the poison of the soft chancre may, under certain circum- stances, he produced de novo without the intervention of the syphilitic virus, while the syphilitic poison propagates itself only in one continuous series. Hence the chancroidal poison, or whatever in these experiments produced the pustules resembling chancroids, cannot even be compared with the syphilitic poison, to say nothing of regarding them as identi- cal.” In the recent and well-known debate upon syphilis before the Patho- logical Society of London, that accomplished surgeon, Mr. Hutchinson, came within one short step of the truth when he admitted the origin of the local venereal sore to be “ the products of syphilitic inflammation, but not usually containing the germs of syphilis.” If he had omitted the adjective, u syphilitic,” before the word “ inflammation,” his expression UNITY OR DUALITY OF VENEREAL SORES. 9 would have been consistent with the facts at present in our possession, and he would have found it inconsistent with such facts to proclaim dualism as dead, since, as I have already shown, dualism is nothing more than a duality of poisons in the evolution of venereal sores. If the view which I advocate be the correct one, it suggests an inter- esting analogy with the history of our belief as regards the nature of gonorrhoea, an'affection which in the last century was regarded as due to the syphilitic virus. Ricord finally adduced convincing proof that it had nothing to do with syphilis. It was afterwards supposed to depend upon a virus of its own, the gonorrheal virus. We now know that it may be caused by any simple irritant, but more especially by the pus from the urethral and other inflamed mucous membranes, whether originating or not in contagion. Such as the history of gonor- rhoea has been, so, I predict, the history of the chancroid will be. In the preceding remarks, I have only casually alluded to the evidence in favor of a duality of poisons to be found in the symptoms presented by venereal sores themselves, and by the lymphatic ganglia in anatomical relation with them. The value of this evidence must always depend upon the observer’s knowledge, skill, and experience in venereal diseases. How often do we witness the grossest errors in the diagnosis of venereal ulcers made by men who are deservedly eminent in general practice? Moreover, instances not unfrequently occur in which the symptoms are ill-defined, and in which the most experienced will wait for further developments before expressing an opinion. Hence, so long as the symp- toms of the sores themselves were alone considered, the question of unity or duality remained undecided. And yet, to my own mind, the evidence founded on these symptoms is not to be despised, for in the great majority of cases they are sufficient to enable us to distinguish the syphilitic from the local sore, and the obscurity of some cases is readily explicable on the ground of the simultaneous inoculation of the products of inflamma- tion and the germs of syphilis, and the well-known immediate action of the one and the incubation of the other. One word as to the form of the question with which we started out. It may appear to some that as the products of inflammation are various, the question should read thus: “ The virus of venereal sores, its unity or plurality?” But this is a matter of small moment. If any one prefers the latter reading, I have no doubt it will be accepted as an amendment. The actual point at issue is whether the syphilitic virus is, or is not, responsible for all the venereal ulcers met with in practice, and this is sufficiently implied in the question as originally worded. Gentlemen, I will not longer detain you. I must apologize for the incompleteness and brevity of my remarks, necessitated, however, by the short time at our disposal. The conclusion which I have to offer you, is based, as I have endea- vored to show, (1) Upon clinical experience, more especially in the confrontation of persons affected with venereal sores. (2) Upon artificial inoculation. (3) Upon the corroborative evidence presented by the symptoms of the sores themselves. For convenience of discussion I shall divide my conclusion into the following propositions:— 10 BUMSTEAD, UNITY OR DUALITY OF VENEREAL SORES. I. The virus of venereal sores is dual. II. Some venereal sores are due to the inoculation of the syphilitic virus. III. Other venereal sores are due to the inoculation of the products of simple inflammation. IV. These two poisons may be inoculated simultaneously.