A manual of syphilis and the venereal diseases

Front matter

Class.

Book

COPYRIGHT DEPOSIT

Preface

This Manual has been prepared with the intent of meeting the special needs of the student and of the practitioner rather than of the expert. The aim has been to supply in a compendious form, and with detail, all practical facts connected with the study and the treatment of syphilis and the venereal diseases. Care has been taken to avoid all points in controversy and to exclude the data which are to be sought for in the more voluminous treatises on these subjects.

The authors are glad to express their special obligations to the classical works of Fournier, Jullien, and Mauriac ; to Keyes' exceedingly practical treatise on Genito-iirinary Diseases, including Syphilis ; to Morrow's valuable System of Genito-urinary Diseases, Syphilology, and Dermatology, in three volumes, and in especial to the carefully written chapters of that work on stricture of the urethra and syphilis of the eye and ear. The treatise of Bumstead and Taylor, which has so long and so well represented the advance of knowledge in venereal diseases, has frequently been consulted, as has also the standard monograph by Finger on Blennorrhoe , and the excellent handbook of Messrs. Culver and Hayden.

4 PREFACE.

The authors of this manual are also gratified in acknowledging in this public manner their appreciation of the courtesy of Messrs. William Wood & Co. of New York, who kindly gave permission to reproduce the plates originally contributed by Dr. Hyde to their Reference Handbook of the Medical Sciences ; to Dr. Petrini of Galatz, for permission to reproduce his fine plate showing the micro-organism of Ducrey; to Dr. John A. Fordyce of New York, for his kindness in supplying the micro-photograph of gonococci which has been employed as one of the illustrations ; and to Messrs. Lea Bros. & Co. of Philadelphia, for permission to make use of one of their original cuts.

The authors are also glad to express their acknowledgments to Dr. W. F. Robinson for his efficient aid while these pages were passing through the press.

Contents

PAGE

Introduction 17

Syphilitic Affections of the Hair 133

Introduction

The venereal diseases are for the most part transmitted from one individual to another in the contacts incident to the relations between the sexes. The day is long past, however, when a moral stigma could be affixed to the victim of such a malady by reason of the fact of infection. In the populous and crowded centres of modern civilization the innocent subjects of these disorders are numbered by hundreds and even thousands. They are in a special sense entitled to the encouraging assistance and the sympathetic service of the trained physician.

The great majority of the other victims are patients infected at a time of life when passion is most imperious, self-restraint less strenuously imposed, and the discipline which unfolds the deeper meanings of life is less understood and appreciated. The result is twofold : on the one hand are patients for the most part, fortunately, of an age and possessed of a vigor best capable of enduring without serious shock the perils of an intoxication 2 ir of the system, and in a social state least likely to burden others, such as a wife or a child, with the consequences of disease ; on the other hand are the subjects of these infections, who, without fixed habits, are obliged to conform to the rules of best living when actually suffering from their ailments, and who learn lessons which at their time of life are often indelible. The most radical of moral reforms with the best of ultimate results is constantly wrought by the several accidents described in the following pages.

In the early part of this century the prejudices of the people of most English-speaking countries and the odium connected with the acquisition and inheritance of venereal disease extended even to the professional men interested in their treatment. As a consequence, this department of medicine was largely relegated to the charlatan, who, under the control of ignorance and avarice, contributed to the exaggeration and confusion which still cloud the minds of many when they consider the subject.

To-day the change in these particulars is noteworthy. Science has solved some of the profoundest problems and achieved some of its most brilliant bacteriological and pathological victories in the territory once abandoned as a plague-spot. Some of the most cultivated, learned, and distinguished of the physicians of the last quarter of the nineteenth century have been content to labor and to glean in the field that was thus once neglected and abhorred.

It has been well for the race that these men could thus with untiring industry and interest investigate the diseases commonly described as *' loathsome." But many of them have paid a price for their courage. It is

IN TR on UCTION. 1 9

impossible to give accurate statistics of the number of physicians innocently infected with the venereal diseases, and particularly with syphilis, when engaged in the practice of their profession as accoucheurs, surgeons, gynecologists, and those giving special attention to the affections of the genito-urinary organs of both sexes. Hundreds of them have been under our observation and care ; thousands have thus suffered in every country. Only with the incessant precautions suggested by the later knowledge on the subject of the pathogenic micro-organisms can a physician hope to be successful in the management of these disorders and himself escape their defilement. Nor in his attempts to compass this end can he with safety rely only upon the products of pharmacy and the skill of the chemist. He must be, in his person, his instruments, and his entourage, an embodiment of scrupulous cleanliness.

The disorders usually classed under the general title of " venereal " are syphilis, the several forms of infectious urethritis, and the soft (" simple " or " non-syphilitic ") chancre. In a stricter sense of the term, and in the light of modern investigation, there are other disorders described in these pages capable of transmission in the sexual act. The more important, however, of the group are without question those here named. It is probable, though exact statistics are wanting, that infectious urethritis is the most frequent, soft chancre (certainly in particular classes of society) next, and syphilis, in all classes, last. Further comparison teaches that while gonorrhoea is most often a strictly venereal disorder, syphilis is with greater frequency an affection of the innocent ; while, as respects a fatal issue, gonorrhoea, in its ultimate results upon the deep urethra, the bladder, and the kidneys, probably destroys more lives annually than does syphilis. Gonorrhoea more often than syphilis spares the subjects of tender age, and is further capable of indefinite recurrence in one subject ; while for the immense majority of cases syphilis is a disease making but a single attack in the lifetime of the individual. The proposition once held cannot longer be sustained, that gonorrhoea and soft chancre are purely local diseases as contrasted with syphilis, which is admitted to have systemic effects. The generalized results of gonorrhoea are in many instances too striking to admit even of question ; and in special cases the perpetuation of the soft chancre for years, with the damage resulting to rectum, vulva, abdominal wall, and thigh, with the production of marked cachexia, often renders that affection one even of greater severity than the milder cases of syphilis.

The questions relating to the history and antiquity of the venereal diseases have created a voluminous literature, with results not wholly satisfactory. The sacred literature of the Hebrews seems to bear record to the fact that blennorrhagic affections existed among the people of a remote antiquity, and that the gonorrhceal discharge was with them confounded with a seminal flow. Among the writings of Greek, Roman, African, and Spanish authors, both medical and literary, evidences are not wanting as to the existence of such a disease and its occasional confusion with other disorders of a venereal origin. Even as early as the beginning of the present century, English physicians confounded gonorrhoea, syphilis, and non-syphilitic chancre, and it was reserved for a comparatively recent date to distinguish definitely and finally between them.

INTR on UCTION. 2 1

For the remote antiquity of syphilis there are not wanting authors who find in the sacred writings of the Hebrews, in the sarcastic, poetical, and historical literatures of Greece and Rome, in the ancient documents of Egypt, China, and Africa, and in the volumes written during the Middle Ages, records among the people of those periods of the existence of chancres and of the systemic results of certain genital lesions. The evidence of bones exhumed and supposed to belong to a prehistoric era is also adduced in support of the assumed antiquity of syphilis. On the other hand, there are many who believe that syphilis existed among the American aborigines before the advent in 1492 of Columbus and his companions to the American coast, and that the Spaniards, becoming infected by contact with the natives, brought the disease to Europe, where it appeared for the first time after their return. In the subsequent campaign of Charles VIII. of France against the kingdom of Naples the disease appeared and spread among the nations of Europe to an extent and with a severity before then unknown.

In reviewing the entire subject many of the arguments in favor of the historical antiquity of these diseases are, it must be admitted, weakened by the indefiniteness of the descriptions given. The bones alleged to be both prehistoric and syphilitic are either lacking in the display of unmistakable lesions of that disease or cannot conclusively be demonstrated to be both of prehistoric sepulture and since then wholly undisturbed by the hand of man. The arguments in favor of a prehistoric syphilis in America and of its subsequent deportation to Europe are weighty, but not without flaw.

The conclusions are simple : the evidence of a remote antiquity for the venereal diseases in general is very strong. In the absence of the definite distinctions between them now established, and of a recognition of the pathological connection between the local manifestations of such diseases and their systemic effects, great confusion has existed in the past. Lastly, the venereal diseases have all, without question, been confused inextricably in the past, not merely with each other, but with a large number of dermatological affections, such as lepra, psoriasis, scabies, eczema, simple and venereal warts, and leucorrhoeal and catarrhal discharges.

In the examination of patients affected with one or several of the disorders here considered, a systematic method is of as much value as in other departments of medicine. Besides ascertaining the name, age, residence, married state, occupation, and previous history of the patient, as well as the habits respecting the use of both alcohol and tobacco, it is desirable to know, for reasons that appear later, in the case of both man and woman, the record as respects living and dead children, miscarriages and abortions on the part of a wife, and the relative order of these, as well as the period in pregnancy when a series of abortions or miscarriages occurred. In securing the history of the family and of any antecedent disease it is necessary to record all facts respecting any prior disease of the skin, persistent headache, especially with nocturnal exacerbation, any attacks supposed to be rheumatic, and any persistent or ulcerative affection of the throat, eyes, scalp, or nails.

In the case of venereal disease it is important to know whether the patient can sleep at night without

INTRODUCTION. 23

rising from the bed to empty the bladder; whether there is pain on micturition, and, in the latter event, whether the pain occurs before, during, or after the passage of the stream.

In the physical examination of patients the several bodily organs should be investigated with care, the surface of the body, when found practicable, being searched for traces of any existing or past exanthem, and particularly for scars, each of which may throw light on the conditions existing. The superficial glands of the body accessible to the fingers should be searched with a view to determining any enlargement or induration. The mouth, nostrils, eyes, and ears require minute observation of lesions present; and even in the absence of the latter the nails may exhibit markings indicative of the character, and at times of even the date, of prior nutritional changes.

In the case of male patients the entire surface of the body may often be exposed for examination, and the genital region then requires detailed inspection. By the fingers and the eye the physician can usually determine the existence of pediculi or nits in the pubic region, an eczema or a psoriasis of the cutaneous surface of the penis or the scrotum, mollusca of the latter region, or the evidence of scabies. By manipulation it will be discovered whether there is an inguinal hernia, a nondescended testis, a left- or more rarely a right-sided varicocele, a gumma of the body of the testicle, or traces of an ancient epididymitis involving the globus minor or major as a sequel of a preceding blennorrhagia. By the fingers alone it will often be practicable to recognize a urethral stricture, a periurethral phlegmon, an enlarged prostate, a syphilitic or a chancroidal bubo, a severe phimosis, a subpreputial sclerosis or other lesion, or a urethral chancre. In point of fact, a urethral sclerosis that cannot be recognized by the digit of the trained physician is among the greatest of rarities. Indeed, one might here enumerate the entire list of diseases of the ano-genital region, evidences of which the examining surgeon should not permit to escape his observant eye and trained touch.

In all classes of women the examination should be made with the special consideration to which the sex is entitled. A follicular or furuncular affection of the labia, a catarrhal discharge from the vulva, a sclerosis of the meatus or of the fourchette, or a stellate chancroid of the anal region, may often be determined by inspection alone. The physician must know to distinguish between a languette accompanying a syphilitic stricture of the rectum and a hemorrhoidal tumor. He must be capable of recognizing the marked differences between a pruritus of the vulva, which is simply tormented by scratching, and an eczema of the same part. By carefully inspecting the dry and " sticky " mouth of a woman it can be determined with reasonable probability, before subjecting the urine to chemical analysis, that an " eczema " of the vulva is due simply to a glycosuria. The fingers should differentiate an inflammation of the vulvo-vaginal gland due to gonorrhoea from a syphiloma of the labium. Scabies of the genital region in a woman will usually be an echo of characteristic burrows about the axillae or the breasts. By the touch one should be able to discover a hydrocele of the canal of Nuck, a varicocele, a carcinoma, an elephantiasis, a contracture of the vagina, a laceration, an atresia of the hymen, or a vaginismus.

INTR OD UCTION. 2 5

Nor should it be concluded in either sex that a determination of the virgin state precludes the possibility of venereal disease. The physician should ever be on the alert to recognize a chancre of the tonsil, an infecting sclerosis of the lip in the child who has kissed a syphilitic nursling, a gonorrhoea affecting the vulva or the eyes of an infant, a paralysis in the middle period of life due rather to a pachymeningitis than to an apoplectic effusion.

Lastly, the physician entrusted with an intimate knowledge of the sources of diseases that are viewed with shame, loathing, and remorse, often imperilling the life of the individual, the safety of the uninfected, and the happiness of a home, has a part to perform which demands a high order of intelligence and sympathy. His it is to protect the innocent, to guard sacredly the secrets confided to his keeping, to conserve the family relation, and at the same time to bring the sufferer to a successful termination of the disease. It is difficult to decide that any one of these functions has a higher importance than another. It is only as the physician discharges his full duty in all points that he ultimately wins that trust and confidence which are the foundation of the largest professional success.

SYPHILIS.

Syphilis is a general infectious disorder transmitted from one individual to another by both contact and inheritance, chronic in course, and displaying in a more or less determinate sequence symptoms involving one or several of the organs of the body. It is classed with the infectious granulomata, and it is due to the toxic effect of the invasion of the bodily tissues by a morbific germ. Though the identity and relations of the latter have not completely been established (as has been done in the case of the bacilli of tuberculosis and lepra), no doubt can be entertained as to its existence and potency.

ACQUIRED SYPHILIS.

Syphilis is said to be acquired when transmitted in another way than by inheritance. The term " contactsyphilis " has also been employed to distinguish the former from the latter.

Btiology. — The micro-organisms which are effective in the production of this disease have not yet been incontestably demonstrated. Donne, Hallier, Lostorfer, Klebs, Doutrelepont, Lustgarten, Fordyce, and many others have repeatedly, by difficult and delicate methods of staining, recognized bacilli in syphilitic tissue. The failure to distinguish the exact micro-organism whose toxine may be efficient as a cause of the disease is due partly to the fewness of the bacilli present in any one section, to the circumstance that the bacilli found in the smegma praeputii are either identical with or very similar to the supposed syphilitic germ, and to a fact pointed out by Fordyce, that the general absence of giant-cells in syphilitic tissue forbids their use as a guide to the location of the bacilli.

But if the germ of the disorder has not yet been distinguished satisfactorily, no doubt exists as to the fact that a germ-carrying secretion or virus, which may be collected on the point of a lancet, is capable of transmitting the disease. This virus must be furnished by a person infected with syphilis.

The purveyors of this virus are usually in an early or active stage of the disease. They may furnish a pathological secretion, such as that supplied by a mucous patch, a chancre, a syphilitic pustule, or an ulcer. Such a secretion may be commingled with a physiological fluid (tears, saliva, milk), and be thus effective, however innocent to the view, though the physiological secretions of a syphilitic subject not thus mingled with a virus are rarely, if ever, noxious. The blood of such subjects is, however, capable of transmitting the disease. Pathological secretions of other character (gonorrhoeal, leucorrhceal, vaccinal) may readily be commingled with the virus of syphilis, and thus be effective in its transmission.

The evidence as to the date when the syphilitic subject can no longer furnish an infectious virus is confusing. Up to a recent time it was believed that the late lesions of syphilis (so-called *' tertiary ") were incapable of furnishing such a virus. Instances are, however, on record disproving this ; and, though the power to furnish a virus is gradually lost in every surviving subject of syphilis, it is safest to hold that any awakening of the morbid process at a late date may, however rarely, render such persons dangerous to the uninfected.

The modes of infection are both immediate and mediate. The direct contacts of the sexual act (including the perverted and unnatural imitations of the latter) and the opportunities of transmission afforded in kissing, biting, sucking, etc. are often the beginnings of syphilis. In the same category may be named all the accidental contacts which occur in the service of the physician, the nurse, and the midwife, and those where prisoners are manacled together.

The articles which have been mediately effective as virus-carriers are so many and so various as to forbid enumeration. The list includes a great number of household utensils (forks, cups, spoons), articles of domestic use (tooth-brushes, syringes, combs), articles employed in the professions (dentists' forceps, surgical instruments and appliances, razors, vaccinating needles, lancets), and, in brief, almost every substance brought into contact with the human body, from nursing-bottle to water-closet seat, and from the finger moistened in the mouth of the nurse and given to the nursling to the tools of the chiropodist.

Given an infective germ in its vehicle (the virus), furnished by an infected subject of syphilis (in a stage of that disease capable of transmissibility by contact), it remains to inquire whether the person inoculated with such a virus, mediately or immediately conveyed, will suffer from the disease. A categorical answer to this question cannot be given. There is reason to believe that all individuals are not equally susceptible to the action of the virus. These reasons are based on the accepted fact of repeated exposures of certain persons without evident results ; of repeated exposures with results that are slight, or, if threatening at first, abortive as to any ultimate consequences ; and of well-known analogies existing between this disease and others in which the proofs of susceptibility and non-susceptibility of individuals are irrefragable.

All such instances are, however, exceptions to a rule that is enforced by constant experience. The husband recently infected as a result of infidelity to his wife communicates his disease to the latter with almost unfailing regularity; the lover with a mucous patch upon his lip gives his disorder with an appalling certainty to the woman whom he kisses upon the mouth. For practical purposes it is best to assume that all men, women, and children are susceptible who have not been protected either by a previous attack of the disease or (a point to which attention is called later) by the experience of the mother who brings into the world a syphilitic child diseased by inheritance from the father, while she seems to escape.

Chancre.

Synonyms. — Syphilitic chancre ; Initial lesion or sclerosis of syphilis ; Hard chancre ; Infecting chancre ; Ger. Hartes Geschwiar ; Schanker; Fr. Chancre syphilitique.

The first evidence of a successful transmission of syphilis from an infected to a sound person is termed a '* chancre," or, as this last term has often been erroneously applied to non-syphilitic local venereal disorders, better the " initial lesion of syphilis,"

The First Incubation. — After the successful introduction of the syphilitic virus into a sound body an interval occurs before the evolution of the initial lesion is appreciable to the eye. This interval is called the " period of the first incubation," a phrase suggestive of the ignorance of the earliest observers. It is almost certain that from the instant of a successful inoculation the subject is, however imperceptibly to human tests, syphilitic, and that there is, without pause or arrest, a multiplication of the effective germs of the disease to the point where the lesions produced by these germs become apparent to coarse methods of observation. This interval is by different observers made to extend over a period of time with singularly varying limits. The average is between twenty-one and twenty-six days, but the period has been claimed to be as brief as from one to two days and as extended as three months. The numerous chances of error in all these estimates need not be pointed out. Between ten and thirty days after infection the vast majority of all infecting chancres appear. The reverse is also true : on the first appearance of a chancre it may safely be estimated that mfection occurred previously between ten and thirty days.

The chancre or syphilitic initial lesion appears at the site of inoculation. Its recognition, when first exhibited as the earliest indication of a serious disease, is a matter of the profoundest importance, seeing that the welfare of the individual, and often of others with whom he sustains intimate relations, may be conditioned upon its correct diagnosis.

The chief error committed by the practitioner and student anxious to master this problem lies in an effort to identify some particular chancre as a type of all others, and to base a diagnosis upon a comparison of others with this as a type. This is the familiar process by which men recognize in nature a flower or a bird, and in medicine a disease of so fixed a type as a corn or a carbuncle.

The sole constant characteristics of every chancre are — {a) an incubative period preceding its appearance ; (b) a sclerosis, induration, or dense thickening of the base of the lesion, widely varying in grade and duration with different chancres ; {c) a simultaneous enlargement and induration of the gland or glands in nearest anatomical relation with the chancre, constituting the " syphilitic bubo," or primary adenopathy. The first of these constant characteristics is an historical symptom, a knowledge of which may be withheld from the practitioner at the date of his examination. The last, though wellnigh constant of occurrence, may not have been declared fully at the date of the examination, or the glandular enlargement may be so slight or so deeply situated as to escape detection. It follows that in some cases it is possible that at a given moment the sclerosis may be the sole chancre-symptom present whereby the nature of the disorder may be declared. Yet there are several nonconstant symptoms which can usually be recognized without difficulty, and which leave the observer in little doubt as to the diagnosis. These symptoms are for the most part explained later.

A chancre is a modification of the sound or pathologically altered skin or mucous membrane, occurring after syphilitic infection, and displayed after an incubative period, characterized by a circumscribed sclerosis of tissue, and accompanied by an enlargement and induration of neighboring glands. Every chancre means a syphilis, mild or severe, that will follow. Every case of acquired syphilis points to a precedent chancre, recognized or unrecognized. Every chancre, further, is a symptom not merely of a syphilis that will follow, but of a syphilis actually present. The proof is found in the fact that infection of a sound individual from such a chancre is followed by the development not merely of a new chancre, but also of a new syphilis.

It is important to note at the outset, considering the definition given above, that a chancre may be either an isolated first lesion of syphilis or a mxodification of some symptom of another disease. Briefly, the study of chancres is the study less of lesions than of a series of singular modifications of lesions recognized in many other diseases, which, under the influence of syphilis, take on new aspects and undergo singular metamorphoses. Thus, the chancre may develop upon the sound skin of the arm as a consequence of intentional experimental inoculation, or upon the sound mucous membrane of the vulva as the result of infection in the sexual act. It may also originate as an untoward modification of a "cold sore" (herpes labialis) of the mucous membrane of the lip infected in the act of kissing, or be a significant change in the evolution of a vaccine vesicle, a blister on the finger, or an excoriated nipple.

Chancres may thus be represented at one time or another by every recognized lesion of the cutaneous surface, including the macule, papule, vesicle, pustule, bleb, tubercle, tumor, and ulcer. Only the most common types can here be enumerated conveniently.

Erosion (Superficial erosion). — This is the least conspicuous, the oftenest ignored or misunderstood, and yet the commonest of chancre symptoms. It is recognized as a roundish, oval, or quite irregular macule or spot resting, soon after its evolution, upon a delicate bed of induration, giving to the touch the sensation of a thin sheet of parchment or of mica let into the underlying tissue. It is usually distinctly circumscribed, and exhibits a shallow or scarcely depressed erosion, centrally fixed or involving its entire face. In size it varies from a large pin-head to a bean, and may be many times larger. Its color is dull-reddish, grayish, or even whitish ; it often resembles in hue a section of raw ham. It may be dry and glazed, or slightly moist and secreting a thin serum which glues to its surface any dressings that may have been applied to it. At times it has a grayish-white film over its face, and may even have a diphtheroid aspect. It may be uniformly level with the neighboring skin, or its edges may be raised and its centre slightly depressed. It very rarely suppurates freely or degenerates into a well-marked ulcer. These complications usually result from external irritation (caustics, mixed infection, urine flowing over the site, as in urethral chancre). The accidents of phagedena and sloughing are still rarer. When these chancres survive until general syphilis is declared, they are gradually transformed into symptoms of general syphilis, readily enlarging to elevated, granulating, rarely hemorrhagic masses smeared with a highly contagious puriform mucus and merging thus into the mucous patch and condyloma. These erosions may be lifted away from their original sites by extensive underlying scleroses, and be thus greatly modified in appearance. They are then changed from flat macules to large-nut-sized and even larger sv nil LIS.

Plate 2.

Chancre and papillary growths of the tongue (Hutchinson).

irregularly outlined masses, ridges, and deformations of the lip, the vulva, or the preputial rim — favorite sites for their development. These odd-looking swellings, unlike each other and conspicuous chiefly for their irregular bulging, often as firm as ivory to the touch, are capped at one point or another by the smooth, shallow, dry and glazed or slightly secreting erosion described above. All are essentially giant-papules, undergoing a special evolution because of the pressureand friction-effects of their particular environment.