LUES VENEREA. By Henry Alfred Robbins, M. D., OF WASHINGTON, D. C. Read before the Medical Society of the District of Columbia, on November 14th, 1894. REPRINTED FROM THE VIRGINIA MEDICAL MONTHLY, JANUARY, 1895. LUES VENEREA. Mr. President and Members,-A few days ago, I had the honor of receiving a formal invitation from my friend, Dr. Thomas C. Smith, the Chairman of your Committee on Es- says, to address the Society at some time in the near future, on the subject of Syphilis. At first, this request would seem easy enough to comply with, as it is a subject that every drug-clerk and medical student think they fully under- stand. Dr. Smith, in his letter of invitation, states: "The several questions relating to syphilis are generally regarded as fully answered and settled; and yet put a well qualified practi- tioner on the stand, and it is lamentable to witness his dis- play of ignorance on the subject." The cause of this lack of knowledge may be readily un- derstood when you call memory to your aid and look back on your own student days. The subject has been and is still ignored by nearly every medical school. Dr. Charles W. Allen, of New York city, states: " The amount of time and attention given this all-important sub- ject in all the medical schools of this country is farcical. Men are sent out into the world, and are expected to diagnos- ticate syphilis, when the training the college authorities have vouchsafed them in this branch is entirely out of proportion to its importance. I am continually seeing victims of this disease who are no less the victims of this lack of proper clinical instruction and requirements on the part of the medical schools. I say it in a spirit of shame, rather than one of captiousness, that practitioners, from a lack of knowledge, permit patients to marry, and to cohabit, while still sources of danger, and to go about freely with contagious lesions in the mouth or throat, without giving them warning of the facility with which they can transmit the disease to others." In an article published in the Virginia Medical Monthly, 3 October, 1894, on non-venereal, or unmerited syphilis, I gave illustrations how innocent people acquire this disease, and in its most malignant form. Dr. L. Duncan Bulkley states, " Non-venereal chancres have been mistaken for epitheliomata, and operations for their removal have been even performed." I have known one case of tubercular syphiloderm of the upper lip, to be diagnosed to be lupus by one surgeon, and epithelioma by another. Gummy tumors have been diagnosed to be sarcoma, and the ever ready knife of the surgeon ordered into use, but where the happy administration of the proper treatment has caused them to melt away like snow under the mid-day sun. Syphilitic testicles have been pronounced to be cancer, and surgeons have castrated the victims, causing bloody mutilations. A correct diagnosis and knowledge as to the treatment would have rendered castration unnecessary. John Hunter said that the two great obstacles to the study of venereal diseases were ignorance and falsehood. Igno- rance on the part of the surgeon, and falsehood on the part of the patient. The ruling of those men, who have control of the clinical training of our medical students, is that assistants to a sur- geon are good enough to prescribe for the victims of syphi- lis, and the charity patients suffering from diseases of the skin. I have prepared and read fifteen articles on the subject under consideration, and I feel as if I had barely touched, or rather skimmed over, the horrors and ramifications caused by this hydra-headed monster. Hercules, of fabulous his- tory, destroyed his by cutting off its heads and applying fire-brands. The arrows he dipped into its poisonous blood were fatal to those he wounded. Thus with the monster Syphilis, the poisonous virus is in the blood of its victims, and proves too often worse than death. We may cut out the wounds, but the virus remains there still. 4 This evening I can only call your attention to a few im- portant, and I trust interesting facts, which I have arranged under the title of Lues Venerea. According to Grecian lore, syphilis is derived from the words together, to love. The synonym of this is lues venerea. Thus the most sacred words that exist are made use of to express the vilest disease, which most frequently is the fruit of lust and debauchery. It is the most far reaching and diabolical scourge that afflicts man- kind. All that is false, in any way relating to the United States of America, is most willingly believed in the lands to the north of us and across the Atlantic, but not in those coun- tries where the language is foreign to our own. Volumes have been written to prove that AuesFenerm was of American origin, and was brought to Europe by the crews of Christopher Columbus, and that this fair land was the cradle of the disease. Our Aborigines were not the imparters, but the imparted. Captain Dabry, in an article, entitled " La Medicine Chez les Chinois," published in 1863, quotes from an author named Hoan ty, who lived two thousand six hundred and thirty-seven years before the Christian era. This Chinese author gives an unmistakable account of cases of lues venerea, and his de- scriptions surpass those of many modern writers. In my article, already referred to, I endeavored to prove that the brute creation were entirely exempt from this afflic- tion. Almost every variety of animal has been inoculated with the virus of syphilis, and with negative results. Since writing that article, I find that Klebs states that he has been successful in inoculating monkeys with the virus of lues venerea. This will be re-assuring to the disciples of Dar\Vin,and for their gratification I will state that one poor little ancestor, six weeks after the inoculation, or rather cruel implantation, exhibited general and febrile symptoms, at- tended by a papular eruption on the forehead and face, and five months later, on the necroscopic examination, Klebs found syphilitic lesions in the skull and lungs. 5 The idea of living organisms being the cause of syphilis was expressed in a rude form as early as the seventeenth century. In 1872, Lostorfer created a sensation by announcing the discovery in the blood of syphilitics of microscopic bodies, pathognomonic, as he claimed, of the disease. The r-odies in question, however, were soon found to exist in other dis- eases, and were shown to originate from the white corpuscles. Not long after this, Klebs announced the discovery of micrococci in the initial lesion of syphilis. He did not, however, find them in the secondary lesions. In 1884, Lustgarten, formerly of Vienna, now of New York city, thought that he had discovered the bacillus in a syphilitic gumma. In 1885, he published a paper giving an accurate description of the bacillus, and the results of a more extended investigation of the subject. He had in the meantime examined numerous specimens of syphilitic le- sions, and as he had invariably been able to demonstrate the presence of the bacillus in them, and its absence in two soft chancres, he expressed his firm conviction that the bacillus was the specific cause of the disease. Koch and Weigert confirmed the discovery, and stated that the bacilli in size and shape greatly resembled those of tubercle. Alas, for mankind ! Lustgarten's germ was not the spe- cific cause of syphilis. Tavel announced in the Archive de Physiol, et Path., 1885, " that he had found in the smegma and secretions of the mucous membranes of the external genital organs micro-organisms, which in shape and reac- tion to staining material, proved identical with the bacillus described by Lustgarten. Kassowitz and Hochsinger state that they have discov- ered a special micro-organism, differing from the rods of Lustgarten, in the tissues of children suffering from heredi- tary syphilis. The microbe was found in the liver, pan- creas, and osseous tissues, as well as in the skin (in pemphi- gus). It occurred in the form of streptococci arranged in chains. These were found in masses in the smallest capil- laries, but were never seen in the cells themselves, being 6 arranged around them. They were found chiefly in those parts in which the inflammatory process was most active, and seldom in tissues in which this process had run its course. Auspitz and Unna have further studied the changes in the vessels of the mass of induration, resulting in a diminu- tion of the calibre, or in their complete obliteration, which they compare to those observed by Heubner in the arteries of the brain; and they express the opinion that in future investigations of syphilitic neoplasms the conditions of the vessels is the chief point of study. Senn, in his "Surgical Bacteriology," states, "It is inter- esting and profitable to know what has been done during the last few years in the bacteriological study of syphilitic lesions, although the claims which have been made are in all probability unfounded." The germ of syphilis, sooner or later, will be discovered, and the name of the discoverer will rival that of Koch. Perhaps no word grates on the ear more than that of chancre. It is always associated with the name of the great pathologist, John Hunter, for it is generally believed that he was the first to describe graphically the indurated chancre. Hunter believed in the identity of gonorrhoea and syphilis. He was chief of the identists, and continued to believe in his theory up to the time of his death; and for the following reasons. To prove his theory he experimented on himself. He took pus from the urethra of a supposed case of gonorrhoea and inoculated himself with it. He made two punctures with the lancet-one on the prepuce, the other on the glans. Both inoculations produced, he said, ulcerations having all the characteristics of chancre, and were followed by syphi- litic eruptions. This positive result left no doubt in the mind of Hunter, and from that time he was convinced of the essential identity of the virus of gonorrhoea and chancre. The experiment of trying to inoculate syphilis with gon- orrhoeal pus has since been tried in vain. There is not the shadow of a doubt but that the great anatomist had the 7 misfortune of finding a patient who had an urethral chancre, and the pus from that infecting source was com- mingled with the gonorrhoeal discharge. Or, the patient was suffering from constitutional syphilis at the time he had gonorrhoea. John Hunter was born on February 13th, 1728, and died on October 16th, 1792, in the 65th year of his age. As anat- omist, naturalist, physiologist, and surgeon combined, he stands unrivaled in the annals of medicine. Early in 1786, he published his Treatise on the Venereal Disease. Although certain views expressed regarding syphilis have been proved to be erroneous, the work is a valuable compendium of ob- servation of cases. I believe that I am the first to attribute the death of this great man to lues venerea-a disease he inflicted on himself. Unwilling to endanger the life of another, he experimented on himself. His most intimate friend, Edward Jenner- the discoverer of vaccination-diagnosed his friend's dis- ease to be angina pectoris, and so it was; but back of this stood the hydra-headed monster, syphilis. I will describe the tragic death scene, and comment on the post-mortem appearances. While attending a board meeting at St. George's Hospi- tal, Hunter had an acrimonious discussion with a colleague; suddenly he ceased speaking, and hurried into an adjoin- ing room, where he instantly fell lifeless into the arms of Dr. Robertson. His body was examined to ascertain the cause of death. "The carotid arteries and their branches within the skull were thickened and ossified," similar to the changes which have, in later years, been described by Heubner as charac- teristic of syphilis. " The coronary arteries and tricuspid and mitral valves were much ossified. The aortal valves were also thickened and rigid." These arterial changes were, in my opinion, of syphilitic origin. Sir Astley Cooper, the Prince of Surgeons, is more than any one else responsible for the'profound ignorance regard- ing the effects of syphilis existing at the present time. In 8 an article on syphilis of the internal organs called "Organic Syphilis," published in the Virginia Medical Monthly of July, 1893, (not August, 1894), I quoted as follows from the teach- ings of this renowned surgeon : "Sir Astley Cooper, in his lectures on surgery, taught that some parts of the body are incapable of being acted upon by the venereal poison, such as the brain, the heart, and the abdominal viscera." Indeed, he writes: " This poison does not appear to be capable of exercising its de- structive influence on the vital organs, or on those parts most essential to the welfare and continuance of life." Judging from the above, you would think Sir Astley en- joyed abcut the same advantages in studying the effects of syphilis as our present students of medicine have. The late Sir William Gull, who was made baronet for professional services rendered to the Prince of Wales, when all England was praying that the life uf the heir to the throne might be saved, was once called in consultation by Mr. , surgeon. Sir William diagnosed syphilitic lesions of the heart. Mr. , surgeon, attempted to apologize for his ignorance, whereupon the great physician replied, that it was as well that he had not detected it, for then he would have prescribed. The late Dr. Freeman J. Bumstead once told me that the professor of surgery in a leading medical college was teach- ing his students that gonorrhoea was apt to be followed by secondary symptoms, and should be treated with mercury. Do you wonder that the late Dr. Tilbury Fox said and wrote: " Dermatology has been as much retarded by having been viewed too much from the surgical, as it will be advanced, from considering it in the future, from the purely medical point of view, in connection with the recent advances in pathological observation." In marked contrast to the teachings of surgical profes- sors stands Hoan-ty, the Chinaman, who lived more than two centuries and a half before the Christian epoch. Hoan-ty " describes chancres, of which he noticed two kinds, one which suppurates freely, the other emits only a serous mat- 9 ter; he noticed also the accompanying tumors. He would appear to have been very well acquainted with the intra- urethral chancre, which he says is easy to detect by the na- ture of the pus, which it produces, and which is not the same as that of gonorrhoea, and also by the pain felt at a fixed and hard point of the canal."-(Captain Dabry-La Med- icine Chez les Chinoisi) It was not until men like Virchow, the greatest patholo- gist of the age, and Ricord, the most renowned syphilo- grapher, and Bassereu, and Clerc, and Alfred Fournier, and in England, Wilkes and Moxon, and Jonathan Hutchinson and Bumstead, of our own country, who has been called the Ricord of America, and other men of now international fame, began ther investigations, and not until then were the great discoveries made. Some time ago a medical friend asked me if I was a be- liever in the unity or the duality of syphilis. I will as briefly as possible present both views, and you can make your own conclusions as to what my answer to that question ought to have been. Professor Ferdinand Von Hebra, who died a few years since, was the most renowned German dermatologist. Prior to him dermatological diseases, and nomenclature, were in a chaotic condition. Karl Von Rokitansky, the great pathol- ogist, whose name is always associated with that of Virchow and John Hunter, lived for forty years, you might say, in the pathological laboratory of the great hospital of Vienna. Hebra followed closely the pathological researches of his colaborer, Rokitansky, and in due time brought out that monument to his fame, more enduring than bronze or stone, his work on Hantkrankheiten, diseases of the skin. The daughter of Von Hebra married Professor Moriz Kaposi, who was born under the name of Kohn, but upon his marriage took the name of his native village. Moriz Kaposi is the chief of those who believe in the theory of the unicists. They believe in the identity of the chancre and the chancroid-the hard and soft' chancre; that is, either may produce a hard, indurated chancre, followed by 10 a bubo, secondary eruption and so forth-in other words, followed by constitutional syphilis. The great majority of syphilographers of the present day are opposed to Kaposi, and his followers, recognizing as they all do his very great ability, and as being worthy of the mantle of his most illustrious father-in-law. Those opposed to the unicists are the dualists, who claim the existence of dual poisons, one affecting the constitution, and the other causing only a local trouble. In other words, an inoculation from a true chancre, initial lesion, will pro- duce a chancre followed by adenitis roseola, and other con- stitutional symptoms of syphilis. To my mind it has proved beyond question of doubt, that the substance taken from a so-called soft chancre-chan- croid-has never been known to have been followed by gen- uine syphilis. I must confess that microscopically, I can find no differ- ence between a chancre and a chancroid. I have with me this evening, slides that I put up in the laboratory v>f Pro- fessor Schenk in Vienna in 1878. They are marked pre- putial chancre, and I suppose they are; but if I were to rub the labels off, I do not think there is a microscopist who would positively say that they are sections of chancres or chancroids. Kaposi says: " It appears to me allowable from a histo- logical standpoint, to regard the hard chancre as different from the soft only in the intensity and suddenness of cell infiltration and cell degeneration, but not in their essence." Fournier gives four types of chancres, from a clinical point of view, which have become classical, and can be found in most modern works relating to syphilis. First. The erosive desquamative chancre. Second. The ex-ulcerative chancre. Third. The ulcerative chancre. Fourth. The papular chancre. The erosive chancre consists simply of an epidermic or epi- thelial desquamation, which merely denudes the derma, without excavating it. 11 The ex-ulcerative chancre attacks the derma superficially, laying it bare, but not actually excavating. The ulcerative chancre, on the other hand, is hollow, exca- vated, jagged-an ulcer in fact, but an ulcer at the expense of its own tissues. Finally, the papular, or elevated chancre, is situated on a sort of raised plateau, and forms a disk rising above, and sharply defined from the surrounding tissues; it sometimes assumes the appearance of the "ulcus elevatum " described by some authors. The most difficult form of chancre to diagnose is what is known as the "multiple herpetiform" chancre. I have known accomplished syphilographers wait until the development of a bubo and erythema, before they would positively state that an attack of herpes preputialis, where several crops of vesicles existed, with what appeared to be somewhat hardened tissues surrounding them, was the initial lesions of syphilis or not. I have furthermore seen them pro- nounced to be chancres, when they were not, and vice versa. Dr. Morrow was the first to describe accurately the " diph- theroid chancre." He states that "it consists of a glistening grayish white coating of a leathern consistence, simulating in all its physical characteristics a diphtheritic exudation." The surface is not eroded, but moist and glistening, with no appreciable secretion; the base supple, with no trace of in- duration. It is intimately adherent to the tissues beneath, and cannot be detached without leaving a bleeding base." A person who has a true chancre-initial lesion-may deposit the virus on the chancroid of another individual, or the reverse may occur. This lesion is what is known as the " mixed chancre." When syphilis is inoculated with the scab taken from an infant-as was the practice in former years-the vesicle will go through the phases of a vaccine vesicle, and later the secondary symptoms of constitutional affection will appear, the same as those I described in a former article, where syphilitic blood was inoculated, as in the case of Dr. Bargioni, 12 who voluntarily submitted to be experimented upon with the blood of a syphilitic woman. Chancres situated at the meatus urinarius have been re- ported by various authors. Jullien, in a total of 1,773 chancres collected by himself, reports sixty-nine chancres of the meatus, and but seven- teen of the deep urethra. Bu instead and Taylor report one two inches, and one three inches from the urinary orifice. Keyes reports two in one of them. It was located one inch and a quarter from the meatus. Hyde reports two cases. When a chancre located at the meatus is constantly irri- tated by the flow of urine, it frequently presents the irregu- lar shape of a chancroid, and phagadena is apt to attack it. Ricord and Vidal de Cassio have shown that chancres of the urethra by extension to the bladder may terminate fatally. Langston Parker reports several cases of urethral chan- cres where severe mutilations of the genital organs have oc- curred. In one case the urethra was opened on the under surface of the body of the penis for two inches; he stated: " I can conceive of nothing more horrible than mutilation of this character, which, in spite of all our care and atten- tion, will sometimes take place, if the disease assumes a phagadenic form, and spreads by rapid ulceration of sloughing." Ambroise Pare, born in 1509, died in 1590, stated : " If there is an ulcer on the penis,'and the part is hardened, it will be an infallible sign that the patient is affected with constitutional syphilis." What is now known as the Hunterian chancre was de- scribed by Pare more than a century before the birth of Hunter. Induration at the base, and surrounding the sore, is the most characteristic sign of true chancre, but it is not infallible. It may be a subsequent, as well as an early symptom, and it may not be noticeable on the female or- gans of generation. Then, again, cauterizations with lunar 13 caustic, will produce a hardness not distinguishable from induration. Generally, it is noticed at the close of the sec- ond week, but it may appear later. It is slight at first, but when at its height, is well marked, circular, resembling a pea, and it surrounds and extends over the limits of the sore. It seldom leaves a cicatrix. It usually lasts two or three weeks, but may continue for as many months. Un- der treatment, its duration is decidedly shortened. As a rule, a chancre comes solitary and alone, and this is a very important point in diagnosis. Four times out of five a true chancre is single; if multiple, it is so from the first, and comes from simultaneous inoculations at various points. Of 456 chancres observed by Ricord in 1856, 341 were single, and 115 were multiple. (Lecons sur le chancre, 1857.) Clerc found, in 267 men suffering from constitutional syphilis, the chancre single in 324, and multiple in 43, or four-fifths. Fournier gives the following statistics, relating, however, to women only. Of 203 patients observed, 134 had a sin- gle chancre; 52 had 2; 9 had 3; 4 had 4; 5 had 5; and 1 had 6 chancres. He also gives as extraordinary, 1 case where 19, and an- other where 23 chancres occurred simultaneously. Fournier inoculated the discharge of 99 chancres upon the patients themselves, and succeeded in but one instance, in which the experiment was performed within a very short period after infection. Puch£ states, as the result of his experience, that auto- inoculation of the chancre is only successful in 2 per cent, of cases. Poisson obtained like results in 52 cases, and Lavoyenne was unsuccessful in every one of 19. Chancres occur wherever the virus has been deposited on an absorbing surface; 95 per cent, occur on the organs of generation, and on those parts most liable to excoriation, and where the specific virus can find a resting place, as the 14 cervix penis and mucous surface of the prepuce in the male and the labia in the female. Only the lack of time, and the fear of exhausting your patience, deters me from presenting the tables prepared by Basserau, and Clerc, and Fournier, and Jullien, giving the exact location of hundreds of chancres. In my article on non-venereal, or unmerited syphilis, I called attention to a great variety of chancres, which oc- curred on all parts of the body, from the eyelids to the toes. Extra-genital chancres occur in men in the proportion of 6 per cent, of all kinds. In women, the proportion of extra-genital chancres is much greater, amounting to 15 per cent., an important clinical fact. The usual sight of extra-genital chancres is about the mouth in both sexes, and in women about the anus and on the breasts. Chancres of other extra-genital localities are much less frequent. Dr. Samuel Wilks, pathologist, and physician par excel- lence, my former instructor at Guy's Hospital, expresses, in terse and admirable language, the symptoms and ills which occur after the inoculation, or absorption, of the syphilitic virus, as follows: "From one week to one month, after the local develop- ment of the virus, the glans, which receive directly the lym- phatics of the part primarily affected, become symmetrically enlarged and indurated, as in chancres of the penis, and vulva, the superior chain of inguinal glans. Acute or sup- purative adenitis is not common. The lymphatics may be- come enlarged and tender, but angeioleuctis is rare. When induration of the base of the' true chancre exists, it is by many, and probably rightly, regarded as the first of the constitutional symptoms, ' the prelude of the diathesis and the local re-action of the general poisoning.' " Not unfrequently after the local sore has lasted two or three weeks, rheumatoid pains, headache, weariness, etc.- according to Fournier, the third act of the drama of syphi- lis-are complained of. These are early and sure tokens of systemic infection. They are very commonly followed, in the course of four weeks to two months, by symmetrical 15 exanthenus on the skin, and mucous membranes, and sym- metrical affections of the nails, hair, eyes, and later unsym- metrical ulcerations in the mouth, throat, and skin, tending to spread widely, and deeply, with fibre-plastic exudation of the periosteum, connective tissue, muscles, fascia, nerves, vis- cera, not usually symmetrical, chronic in progress, and at- tended often with ulceration, or even a sloughing disposi- tion, with tendency to relapse; for when the virus has en- tered the system, there is scarcely a tissue that may not be implicated, and that always in a specific and characteristic manner, by the exudation of fibro-albuminoid material, modified to some extent by the organ in which it happens; in the solid organs as circumscribed masses, whilst on free surfaces it is seen on the base and border of ulcerous sores, the same as in the primary local lesion. There is quite often entire freedom from any symptoms, lasting for months and even years, as if the virus had been exterminated, but usually certain reminders, in the form of scattered, scaly patches on the skin, as so-called psoriasis, palmaris-sores on the tongue, lips, etc., appear from time to time. So long as this tendency or state exists, it is evidence of the pres- ence of virus in the system, communicable by direct or in- direct means. Either from the prolonged effects of the spe- cial toxic agent upon the constitution, or from other con- comitant causes, a cachectic condition may come on at a later period, varying from a few months to twenty years, wTith a tendency to fatty degenerations of the various struc- tures of the body, and, perhaps, to those known as waxy or lardaceous. These are the so-called tertiary symptoms, but are more properly the sequelae of syphilis. True chancre gives a relative and not absolute protection against subsequent attacks of the malady. In my article on " Organic Syphilis," already referred to, I gave illustrations of grave mistakes in diagnosis; I closed the subject as follows: " The cases reported above show that organic syphilis is not detected in many cases by the physician, and it will never be known how many have died, or may die, where 16 the cause of death is certified as coming from morbus Brightii, disease of heart, apoplexy, phthisis pulmonalis, marasmus, etc.; but where, in the dim back-ground, stands the grim monster Syphilis." "They also show that where a proper diagnosis is made, what brilliant results follow the proper treatment." The immortal Shakespeare thus describes the effects of Lues Venerea, in his "Timon of Athens," Act IV, Scene III, in an address to Phrynia and Timandra: * * * * Season the slaves For tubs and baths, bring down rose-cheeked youth To the tub fast, and diet. Consumptions sow In hollow bones of man ; strike their sharp shins And mar men's spurring. Crack the lawyer's voice, That he may never more false title plead, Nor sound his quillets shrilly; hoar the flamen That scolds against the quality of flesh And not believes himself; down with the nose, Down with it flat; take the bridge quite away, * * * Make curl'd-pate ruffians bald And let the unscarred braggarts of the war Derive some pain from you. 1750 M Street N. W.