The students' manual of venereal diseases

Front matter

Chap Copyright No.

UNITED STATES OF AMERICA.

STURGIS

Preface To The Seventh Edition

It had been a question in the mind of the author whether it was worth while to reprint a seventh edition of this little book, inasmuch as it had practically fulfilled its function, which was to teach the students of the medical department of the University of the City of New York to whom he was lecturing at the time the manual was published, but Dr. Cabot expressed his belief that if the book were rewritten and brought up to date it would again find favor among the coming generation of medical students and a renewed sale.

So far as the author individually was concerned, he felt much indisposed to give time to the revision of the book, but upon Dr. Cabot's agreement that he would do part of the work Dr. Sturgis consented to take charge of the chapters on Chancroid and Syphilis ; Dr. Cabot to revise those on Gonorrhea.

We trust that the book in its revised and improved shape will find acceptance by the medical students of the United States, to whom this book is "dedicated, and we venture to ask for this new and revised edition some portion of the kindly reception and favor which has been accorded to its predecessors.

New York City. December, igoo.

F. R. Sturgis.

Follex Cabot, Jr.

vn

Preface To The First Edition

It has been said, with much truth, that books are read in inverse proportion to their length, and in preparing this manual I have steadily kept the question of length in view.

Written for students of medicine, it has been my aim to make the book concise, and at the same time practical. I have, therefore, as far as possible, eschewed all mooted points in venereal medicine, and confine myself to giving a careful, and at the same time condensed, description of the commoner forms of venereal diseases which will fall to the lot of the average young practitioner to treat, together with the most appropriate remedies.

How well I have accomplished my task remains for others than myself to say. I trust, however, that it will satisfy a want which, from my experience as a lecturer in this branch, I know exists, and with this hope I send the little manual into the world to take its chances.

1 6, West Thirty-second Street, New York City. 1880.

ix

Chapter I. Simple Venereal Ulcer And Its Com- Plications.— The Chancroid

Before calling your special attention to the cases which I have brought from the wards for the purposes of illustration, it may not be inapt to define what is meant by venereal diseases, and to set before you the principal groups into which they are divided.

Speaking broadly, venereal diseases are those due to, and originating in, sexual contact, and although many forms of these diseases are transmitted without any sexual contact, as I shall show you further on, the name may, for convenience sake, stand. They are at present divided into three principal groups or divisions : Gonorrhea, chancroid, and syphilis. Each is distinct and separate one from the other, having nothing in common with each other, although they may all be present in the same person at the same time, and they are possessed of certain characteristics which are more or less peculiar to themselves.

Of these three diseases only the last one, syphilis, is constitutional ; the other two, gonorrhea and chancroid, are local. I say this advisedly, notwithstanding the fact that within recent years cases have been reported in which systemic 2 17 infection appears to have been induced by, or to occur after, an attack of gonorrhea, owing to the absorption or transportation of the bacterium peculiar to gonorrhea, the diplococcus of Xeisser. For the present, however, you may assume it as true that gonorrhea and chancroid are local diseases ; syphilis is not : that infects the entire system.

The first case I present for your consideration is one of chancroid in a male subject, whose history, I regret to say, is imperfect, no uncommon occurrence in cases coming into hospitals ; but from what I can glean from him and the record book, his sore, which you see is quite a large one, came on two or three days after coitus, and was at first quite small. Here is a point to which I wish you to attend, one of the most important upon which to base your diagnosis of a chancroid, and equally noteworthy as a differential mark between this lesion and the first manifestation of syphilis — what is commonly known as chancre. The sore came on two or three days after coitus ; in other words, but a short time elapsed between the infecting connection and the resulting ulcer. The effect was almost immediate.

When we come to treat of syphilis, we shall find that this is no longer true ; an appreciable interval elapses between cause and effect : what is technically called the period of incubation.

Chancroids, then, have at the most a very short period of incubation, sometimes none at all, and this depends much upon the manner in which the poison, or virus, so called, is deposited beneath the mucous membranes. If in coitus the membrane is abraded or torn, the chancroidal action begins at once, while, on the other hand, it is delayed if the discharge is deposited in a fold of mucous membrane or in a follicle ; but even then the delay is usually one of only from thirty -six to forty -eight hours.

VENEREAL ULCER CHANCROID. 1 9

Another circumstance in the case is worthy of remark : the ulcer has increased in size — at first, he says, it was quite small. This denotes, in chancroids, a tendency to spread and become larger instead of smaller, a tendency due to the destructive character of the poison. Let me say here a word or two about this virus, or poison. Until within a comparatively short time it was believed to be an unknown quantity, and, notwithstanding what I am about to tell you now, I am inclined to believe that that definition still holds good. The present is an era in which the cause of nearly every disease is ascribed to some bacterium or bacillus, and venereal diseases have been no exception to this rule. Without going back to earliest times, let it suffice to say that about the year 1889 an Italian of Naples, named Ducrey, discovered what he believed to be the bacillus of the chancroid. This he regarded as the solution of the virus of the chancroid. He, moreover, believed that there was only one form of bubo which accompanied the chancroid, to wit : the simple or inflammatory type, the chancroidal bubo being due, in his opinion, to auto-inoculation of the wound resulting from the opening of the bubo. This piece of information fell upon deaf and inattentive ears.

In the same year that Ducrey published his conclusions Krefting, a Norwegian, published views similar to those of Ducrey, except as to the bubo ; on that point he differed from Ducrey.

One peculiarity about this bacillus was that it was incapable of artificial propagation : it could not be cultivated on any of the media which heretofore have been used for the propagation of any given bacterium on foreign soil. And, more than that, in the pus — for only the pus was taken by these two observers — there was such a variety of bacteria — streptococci, staphylococci, and other saprophites — that it was impossible to determine which given bacterium was the real cause of the trouble, and, inasmuch as it was incapable of artificial cultivation, it seemed to put an' end to the determination of this question.

These two observers, remember, had merely taken the pus ; but in all of the specimens it was noted that there was an extraordinary looking bacillus which was short, with rather bulbous extremities, which was constant in all specimens, and this both Ducrey and Krefting considered as the bacillus of the chancroid, and it was known as the Ducrey - Krefting bacillus.

Later Unna, a German of Hamburg; made sections of chancroidal tissues and therein found a bacillus which, however, differed from the bacillus of Ducrey and Krefting in that it was made up of chains or long rods. This bacillus he considered a strcptobacillus, and he found in this the same inability to adtivatc it upon any of the usual bacteriocultural media. It differs in some respects from the other bacillus, and some bacteriologists consider this of no importance, regarding the two as practically identical, while others decline to adopt this view. The same variety of bacteria was also discovered in these sections, but in lesser degree, and the further from the sin face of the ulcer the sections were made, the fewer became the number of other bacteria and the more constant became this one peculiar strcptobacillus. It was fairly supposed that this bacillus was therefore pathognomonic of the chancroid, and the opinion was still further confirmed by Krefting's experiments, in which, finding that he could not cultivate the bacillus by the usual methods, he used its natural soil — to wit, the human body — as the cidtivating medium, and, by repeated auto-inoculations and examinations of the pus, he was later on able to eliminate from the purulent secretion of these chancroids of inoculation

VENEREAL ULCER CHANCROID. 21

every variety of bacterium except the one bacillus, the diplobacillus of Ducrey and Krefting ; and he also obtained this same bacillus from the pus of a virulent bubo. He believed that the bacilli of Ducrey and Unua arc the same, and that the question of difference in form is accidental and perhaps dependent upon different stages in the growth of the chancroid. That is the position in which the matter stands at present, and I have explained this to you as succinctly as possible, in order to give you all the information with regard to the causation of this variety of disease ; although I am perfectly frank to say that I believe the importance of this discovery is grossly exaggerated. Indeed, I believe the statement which I made in my earlier editions still stands good : that it holds in venereal parlance much the same position that the letters x, y, and z do in algebra ; it is still an unknown quantity, notwithstanding the discovery of the bacilli of Ducrey-Krefting and Unna. As to its practical value, I am equally skeptical. It certainly makes no difference in the treatment whether the bacillus is the cause or merely an accidental accompaniment. The treatment will be the same in cither case ; and its only value will be the negative one as regards diagnosis. If you at the termination of your student's career are expert pathologists and microscopists, — which you are almost certain not to be, — you will find that the number of bacteria and microbes which you scrape off the surface of a chancroid will be so confusing that you probably would not recognize the bacillus of the chancroid were you to meet with it ; indeed, the excitement and interest which attended the subsequent discussions on the bacillus of the chancroid have very much diminished, and I do not think that the average practitioner cares much whether the bacillus is the cause of the chancroid or not. He knows his treatment will be the same in either case.

I shall, therefore, continue the use of the term "virus," as it is one of great convenience and it would be difficult to find a good substitute. I shall certainly not speak of the bacillus as being the cause of the chancroid until it has been more clearly demonstrated that it is the real cause. In this connection let me call your attention briefly to the facts that nonvenereal sores have been capable of auto-inoculation within certain limits, — to wit, those of ecthyma and pustular acne, — and the secretion also of an initial lesion of syphilis, if this latter be irritated, is capable not only of auto-inoculation, but also of inoculation on another person without producing syphilis, albeit, as a rule, the secretions of syphilis are not auto-inocidable.

Now, the bacillus of syphilis is entirely different from the bacillus of the chancroid, and, so far as I am aware, no bacillus has as yet been discovered to account for the presence of an ordinary ecthyma or pustular acne, and if this be correct, it would appear that there are other causes besides the presence of a bacillus to account for the auto-inoculability of chancroidal pus. I shall, therefore, in these chapters retain the word "virus," begging you, meantime, to remember that it means an indefinite something, endowed with properties, which produces certain results ; and that that indefinite something may possibly be due to the existence of a bacillus, but the correctness of which surmise must still be regarded as nonproven.

To return to the chancroid. Two points we have brought out, and mark them well : First, a period of incubation, at the most very short, sometimes absent ; and, second, a tendency to destructive action. Let us now examine the sore and see what else we find. We notice one rather large

VENEREAL ULCER CHANXROID. 23

ulcer, of irregular shape, uneven floor, a moderately copious, purulent secretion (this has been somewhat modified by treatment), and upon putting the ulceration on the stretch we observe that it extends beyond the apparent edges of the sore. I repeat apparent edges, because this peculiarity has a decided bearing upon treatment. Chancroids frequently burrow, going along faster below than they do above, hence the external aspect of the sore is no necessary index of its real area ; the edges of the ulcer are undermined, and if in the treatment you decide to destroy the chancroid by caustics, convey the destructive agent beneath the edges and beyond the apparent limits of the sore, even into sound tissues.

The number and shape of the ulcers are the next points which invite discussion. In this subject there happens to be only one ulcer, but such is not always the case, as witness this second man. Here we find three chancroids of various sizes. This multiplicity may be produced in one of two ways : either as original foci of infection or by inoculation.

Note, therefore, that the chancroid is capable of selfpropagation upon the person having it, and also upon others to whom the poison may be conveyed.

It is eminently contagious and auto-inocidable. I shall call your attention again to this point when I come to speak of the initial lesion of syphilis (chancre). In shape the sore is irregular, owing partly to the seat — on the inner layer of the prepuce and the fossa glandis — and partly to the natural tendency chancroids have of spreading irregularly and sending out shoots, but there is often another reason : several chancroids may be seated close to one another and, by destroying the intervening sound tissue, present to view an ulceration with irregular scalloped edges.

The secretion, as has been already said, is copious and purulent, caused by the destruction of tissue, for pus, as you know, is dead tissue.

Have we explained all the noteworthy characteristics presented by this chancroid ? By no means, for upon handling it we are struck by the fact that though the ulcer is large and angry looking, the tissues upon which it is seated are perfectly supple and soft. And here let me give you a word of warning as to the use of the word soft, which has proved a fruitful cause of misunderstanding. Better expunge the word from your venereal vocabulary and call the chancroid a simple venereal idcer, as contradistinguished from the initial lesion of syphilis (chancre), which is termed the specific venereal ulcer. In the discussions which in former days have been had upon the nature of these two ulcers it was stated and generally believed that no soft sore — i. e., one which had no induration at the base — was ever followed by syphilitic manifestations. This belief is now proved to be erroneous, and sores devoid of indurated bases have been the precursors of secondary symptoms — in other words, the initial lesion of syphilis may be soft. The importance of this you will see later on. If this be true, the inapplicability of the term to a chancroid is apparent, for a chancroid is never followed by general manifestations ; the initial lesion always is, and of this I shall speak more fully later on. Do not, therefore, call the chancroid the soft venereal ulcer, but simple venereal ulcer, if you do not wish to use the word chancroid.

Now, to go back to the chancroid. We find no induration at the base ; the tissue upon which it is seated is perfectly supple and yields readily to pressure, in a manner entirely different from what it does in this third patient, who is the subject of an initial lesion and beneath whose sore, on palpation, you can discover a gristly hard sub-

VENEREAL ULCER CHANCROID. 2 5

stance, the nature of which you will learn more about by and by. We have, then, discovered another trait of a chancroid, to wit: an absence of indurated base; but remember this loses some of its diagnostic importance, from the fact that the initial lesion (chancre) sometimes presents the same peculiarity.

Before passing to the next point let me sketch the salient features of a chancroid, such as we have discovered upon the cases examined to-day. They are these :

Absence, or at most a very short period of incubation.

Tendency to spread irregularly in size and depth.

Tendency to undermining of the walls of the ulcer.

Copious purulent secretion.

Contagious and auto-inoculable character of the pus, thus producing multiple sores.

Absence of induration of the base of the ulcer.

Thus far we have studied the chancroid in its simplest form. We will now consider the complications most liable to occur with this disease.

The first and the one most intimately associated with the chancroid is the bubo, or swelling of glands, usually those of the groin. This is due to two causes, the first being from sympathy (sympathetic inflammation), the second, and most serious, from absorption of chancroidal matter from the ulcer by the lymphatics. I am myself satisfied that this occurs, notwithstanding the fact that the statement has recently been advanced that the chancroidal bubo becomes so from auto-inoculation after opening the bubo, and not from the absorption of matter from the ulcer.

The two subjects I bring before you illustrate these points beautifully. This first patient has, as you see, a large, indolent, brawny swelling in his right groin, and upon his penis he still bears a chancroid, but in the stage of repair. Number two also has a chancroid, seated close to and invading the frenum, but in his groin we find a different condition of things to what we did in number one. Here w r e find an open ulceration, presenting an uneven, grayish floor, everted and undermined edges, and secreting an abundant amount of pus, recalling to mind the characteristics of the chancroid already presented to you. Indeed, you would be right to call it a chancroid, for such it is : caused by the absorption of the chancroidal matter tlirougli the chain of lymphatics, and deposited in the nearest glands (in this case the inguinal), there to produce a condition of affairs similar to what obtains in the original ulcer. In other words, you have here a typical chancroidal bubo, pure and simple. These two, then, represent the varieties of bubo found with a chancroid ; the first one, a bubo from sympathy, which frequently does not suppurate, and if it does, furnishes laudable, healthy pus ; the second one, the true chaficroidal bubo, due to absorption of matter from the ulcer, which invariably ulcerates and presents subsequently the appearance of a chancroid — indeed, is a chancroid.

There are two other points to which I wish to call your attention : the diffused brawniness of the surrounding tissues in both cases and the side of the body upon which the buboes are seated.

The glands themselves do not seem to be the only parts affected ; the circumglandidar tissue is involved as well, presenting a thickened, doughy mass in which the glands can be indistinctly felt. Note this well, I pray, for when you come to handle cases of syphilis you will find a very opposite condition of things ; the glands will not be fused together nor with adjacent tissue, but they will be distinct, well marked, and indurated.

VENEREAL ULCER — CHANCROID. 2J

The other point is this : in the second case the bubo is seated upon the groin opposite to the side of the penis upon which the chancroid is ; in number one it is upon the same side. The cause is the position of the ulcer. Deduce then the following rule : Buboes are usually seated upon the same side of the body as the uleer which causes them, except when it (the ulcer) is seated upon the frenum, when they will be frequently found upon the opposite side. The same is true when the chancroid in the female is seated upon the "fourchette" and this is due to the decussation of the lymphatics at these two points.

In all the cases I have shown you the lesion has been seated upon the mucous membrane of the genitals. This is its usual seat, but it may be met with upon the skin of various parts of the body, such as the face, the head, the fingers, and, as I have seen in one case, in the throat. Such places are not common seats of the chancroid, so you may always suspect the nature of a sore when located on the parts I have just mentioned ; it is much more likely to be syphilitic ; at any rate, always bear that point in mind.

The course of a chancroid is always destructive, and if not properly treated, may result in severe disfigurement and loss of tissue.

This is especially the case when the chancroid is seated upon the frenum or in the urethra just within the meatus urinarius. In the former place perforation and destruction of the frenum are to be looked for ; and what will perhaps surprise you, is a greater loss of tissue than you had at first counted upon, for here, particularly, the burrowing tendency of the chancroid is shown, and long before the frenum is ulcerated through the sore has attained large dimensions. In the latter place (the urethra) the sore extends rapidly, is difficult of treatment from its comparative inaccessibility, and upon cicatrization produces partial closure of the meatus, requiring subsequent surgical treatment.

As I have already stated, these ulcers have a tendency to spread, and, from their facility of auto-inoculation, to multiply ; hence the treatment to be effective must be prompt and thorough. Under proper care the copious purulent secretion is diminished, the gray floor disappears, granidalions spring up over the surface of the sore, and the undermined edges fill up level with the walls of the ulcer. But bear this point in mind : a chancroid is dangerous up to the very moment of its complete cicatrization ; no matter how superficial or simple it may look, do not remit the thoroughness of your treatment until cicatrization is complete. I have seen chancroids almost well relapse (without a fresh infection) from just that want of care, the slight remaining discharge being sufficient to reinoculate the almost cicatrized sore.

Pliagedena is another and perhaps the worst accident which can attack a chancroid, and when it becomes serpiginous, — that is, when it extends in one direction while healing in another, — may last for a long time (several years) and seem well-nigh hopeless of cure. It, fortunately, is not common, in this section of the country at least, and occurs in those persons whose health is broken down from alcoholic excesses or constitutional debility, such as scrofula and the like. Remember that it is due to constitutional, not local, causes, and to combat it successfully you must take your measures accordingly. This grave accident attacks not only the chancroid itself, but the chancroidal bubo, lasts for an indefinite time, and will put you to your trumps to cure.

Before passing on to the consideration of treatment there are other complications to which I wish to direct your

VENEREAL ULCER — CHANCROID. 29

attention, to wit : phimosis occurring with chancroid, and chancroids of the amis. You already know that the first of these complications occurs with syphilis and gonorrhea, as well as with chancroids, and it is important for you to be able to tell which one of these diseases lurks behind the constricted foreskin, not only for diagnosis, but for treatment. In cases of gonorrhea and chancroid there is a copious purulent secretion from beneath the prepuce ; but in gonorrhea this matter is not auto-inoculable , while in chancroid it is. With a chancroid the penis is much more painful, edematous, and swollen, and the lymphatics on the dorsum penis are more apt to be inflamed and tender than is the case in gonorrhea ; but the crucial test is auto-inoculation. If the hidden ulcer be an initial lesion, the secretion is very scanty, if indeed there be any ; the prepuce is hard and indurated, instead of being edematous and doughy, and the secretion is not auto-inoadable.

Chancroids of the aims are, in the male subject, very rare indeed ; and where you find them, always suspect sodomy, and I believe you will seldom be wrong. The same is still more true as regards the initial lesion of syphilis (chancre) in both sexes. But with women, so far as the chancroid is concerned, it is different. With them anal and rectal chancroids are not rare, and their presence does not imply Ve?tus prcepostera. The secretion from the chancroids of the female genitals naturally flows over the perineum and anus ; very few feminine ani but are abraded ; auto-inoculation occurs, and the thing is done, and a very nasty thing it is too. The ulcer extends in all directions, eats through and neutralizes the action of the sphincter ani, producing incontinence of the bowels ; burrows up into the rectum ; is continually irritated by retained fecal matter ; is extremely difficult to heal, and, when it finally does, nearly always leaves a stricture of the rectum behind it ; and if to that you add phagedena, a not infrequent complication in broken-down harlots, the picture is a pretty dismal one.

Chancroids of the female genitals differ in no essential respect from those of the male in appearance or course. Their usual seat is at the vulva and introitus vagince ; they are next most frequent on the cervix uteri, and are very rarely met with in the vagina between these points.

Buboes in women are not so common as in men, excepting when the chancroid is seated at the " fourchette," when they follow the same course of action as that already detailed in the early part of this chapter.

Chapter II. Treatment Of The Chancroid

In the preceding chapter we went over the description of the chancroid and the complications which are its most frequent concomitants, reserving the question of treatment to a chapter by itself. This, then, will form the subject of this chapter, and at the outset I want to impress upon your minds the two cardinal points of treatment, which are, first, the arrest of the virulent and destructive character of the ideer ; second, cleanliness.

First, then, as to the arrest of the virulent and destructive character of the ulcer. This is done either by the actual cautery or other caustics, in severe cases, and by alterative applications in mild ones. Of the first division of remedies the white iron, or the galvanocautery, takes the front rank as a destructive agent ; next to that comes the strong sulphuric acid; third, chemically pure nitric acid ; fourth, pure carbolic acid ; fifth, chromic acid, and sixth, pyrogallic acid. A neat way of using the sulphuric acid is by the medication known as Ricord's carbosulphuric paste, which is made by taking a small quantity of finely powdered willow charcoal, adding, drop by drop, enough of the acid to make a paste of the consistence of thick cream. This is put on with a porcelain or glass spatula, taking care (remember the undermined edges) to carry the agent into sound tissue both underneath and on the surface of the edges of the chancroid. Nitric or carbolic acid may be used in the same way. The advantage of this method is that, besides destroying the virulent ulcer, it makes a firm dressing by the drying of the charcoal on evaporation of the acid, which, dropping off at the end of several days, reveals the chancroid almost, if not entirely, healed. If you prefer to use the acids in a fluid form, then some subsequent dressing must be used, and of all dressings I infinitely prefer the dry to the wet. One of the best preparations is iodoform finely powdered, either alone or in combination, thus :

U . Pulv. iodoformi, I part

Lycopodii, 2 parts.

M.

Triturate well. Apply locally.

The lycopodium has, probably, only a mechanical action, but it absorbs fluid very readily, while the iodoform acts as a local stimulant and alterative. Another good prescription is :

R . Pulv. iodoformi,

Pulv. ac. tannic, p. se.

M.

Triturate and use locally.

This is more astringent than the other. The following prescription is useful when the ulcer is flabby and indolent :

&. Pulv. iodoformi, 5jj