Front matter
Shelf . J, 4-5.
UMTED STATES OF AMERICA.
Y"
Preface
This volume is designed by the publishers to be one of a series addressed to the general medical practitioner. My aim has, therefore, been to present the various venereal diseases as clearly as possible, avoiding such unnecessary refinement upon theoretical and mooted points as would be apt to lead to confusion or to error.
Practical utility, as well as what I believe to be sound doctrine, has been kept constantly in view, and no effort has been made to display a long list of remedies. Such means as I have foimd most valuable are recorded, together with suggestions from well-recognized authorities. A physician cannot afford to have many remedies for a given disease if he expects to use any of them well.
My views on many of the subjects included in this volume are already before the public, scattered through various books and essays. In the main these views are unchanged. Such alterations as time and a larger experience have effected are recorded herein. My ideas on the treatment of syphilis are only modified in that the tonic dose of the specific is made rather smaller, and the course rather longer than formerly.
I have opposed the views of those gentlemen who are throwing confusion in the way of the general practitioner by trying to break down the distinctions between the initial lesion of true syphilis, and chancroid; and who teach that chancroid may be derived from the products of the syphilitic early or late lesions. I have also taken issue with the experimenters who claim to prevent syphilis by excising the initial lesion, on the ground that something more than induration in a sore is necessary in order to prove it to be a syphilitic chancre. Without a reliable history showing previous freedom from syphilis in such patients, added to confrontation, the records of excised chancres fail to be convincing, and the moderate percentage of claimed success is, thus far, not proven. It is to be hoped that some good will eventually come of these experiments, but more accuracy of observation must be brought to the investigation than has been yet employed.
Finally, I have raised my voice, for what it may be worth, in protest
VI PEEFACE.
against the views of the new school in urethral pathology, which seems to claim that every natural undulation in the tissues of the pendulous urethra is a stricture fit for cutting, and that all the ills of the genitourinary passages may be accounted for by the existence of these undulations, and, usually, made to disappear when the latter are cut.
To the honest labor and mechanical genius of the leader of this school I tender my respect. The profession is indebted to him for some capital instruments and for a broader understanding of the tolerance and of the possible capacity of the urethra than it has yet pos-
The profession as a whole doubtless still underrates the normal capacity of the male urethra, and after the present rage for cutting has passed and the reaction has come, a calm equilibrium will finally establish itself, which, on the whole, will be to the advantage of those patients who in time to come may suffer with urethral difficulties.
The theories of the new school are as ingeniously perfect as the instruments which carry them out ; but, unfortunately, its claims seem to leave out of view that the disease for which the patient seeks relief is only a symptom, and that such symptom may be due to a variety of causes. "What will cure the symptom in one case will not necesarily do so in another. And a serious criticism upon the methods of the new school is that it does not generally, in its lists of published cases, give any prominence to those cases which have been cut without relief of the symptoms complained of.
In short, the pathology and the treatment of the new school are narrow, and tend to encourage routine practice in the young, to the detriment of a careful study of each case.
Thanks are due to Dr. Gr. H. Fox, of New York, for the admirable photographs from nature after which many of the woodcuts illustrating venereal lesions have been made. Syphilitic lesions cannot be perfectly represented without the use of color, but I think that the exhibition of the topography of the different eruptions is in itself enough to justify the use of woodcuts.
E. L. KEYES.
New York, Jan. 1, 1880.
No. 1 Park Avenue, Corner of Thirty-fourth Street East.
Chapter I. Chancroid.— The Non-syphilitic Venereal Ulcer
PAGE
Chancroid. — Definition. — General Description of Typical Clinical Chancroid. — The Nature of the Chancroidal Poison. — Answers to the Objections made to the Existence of any Special Chancroidal Virus, and Discussion of the Alleged Cases of Chancroid purporting to have been produced by the Inoculation of Pus not derived from a Chancroid. — Is the Poison of Chancroid a Modified Syphilitic Virus ?— Unity and Duality in Syphilis. — Twelve Propositions setting forth Facts relative to the Question of Duality, and believed to be sustained by Facts, Experimental and Clinical, now before the Profession. 1
Chapter II
CHANCROID. —DESCRIPTION OF ITS SPECIAL FEATURES AND OF THE VARI- ATIONS TO WHICH THEY AKE LIABLE.
Pathological Histology of Chancroid ; Comparative Histology of Syphilitic Chancre and of Chancroid. — Transmission of Chancroid to Animals. — Transmission of True Syphilis to Animals. — The Relative Frequency of Chancroid. — The Methods of Chancroidal Contagion, Direct and Mediate. — The Inoculation of Chancroid. — Auto-inoculation and Hetero-inoculation. — Case illustrating the Diagnostic Value of Auto-inoculation. — Inoculation in Generations. — How to Practise Experimental Inoculation. — The Incubation of Chancroid; Variation in Incubation. — Course of Chancroid; Period of Increase; Stationary Period; Period of Repair; Variations in Course. — Situation of Chancroid; Variation in Situation. — Number of Chancroids. — Form of Chancroid; Variations in Form. — Follicular Chancroid.— Subjective Symptoms of Chancroid. — Condition of the Base. — Duration of Chancroid; Variations in Duration.— Cicatrix of Chancroid 15
Chapter III. Chancroid.— Diagnosis, Prognosis, And Treatment
Diagnosis. — Diagnostic Table of Chancre, Chancroid, and Herpes. — Ulcerated Non-virulent Abrasions. — Different Varieties of Pseudo-chancre and their Treatment. — Six Propositions of Importance bearing upon the Question of Auto-
Till CONTENTS.
PAGB
inoculation for Purposes of Diagnosis. — The Prognosis of Chancroid. — The Treatment of Chancroid. — Prophylactic Treatment. — Radical Treatment. — The Reason why Cauterization will not always arrest a Chancroid. — How to cauterize a Chancroid. — Palliative Treatment of Chancroid. — Iodoform and its Use, and other Topical Applications. — Anal and Rectal Chancroids. — Urethral Chancroids. — Sub-preputial Chancroids. — Chancroid at the Margin of the Prepuce. — Chancroid of the Vulva and Vagina. — Chancroid of the Fingers 24
Chapter IV. Chancroid. — The Complications Of Chancroid, And Their Treatment
Chancroid complicated by Inflammation. —Inflammatory Phymosis and Paraphymosis, with their Treatment. — Phagedena, Sloughing and Serpiginous, and its Treatment. — Chancroid complicated by Syphilis. — The Lymphangitis of Chancroid, Inflammatory and Virulent, and its Treatment. — The Bubo of Chancroid, Simple, Indolent, Spontaneous (Bubon d'Emblee). — Treatment of Simple Bubo. — Treatment of Indolent Bubo. — Virulent Bubo, or Subcutaneous Chancroid. — Treatment of Virulent Bubo 37
Part II Chapter I. Syphilis
General Considerations upon Syphilis. — Definition of Syphilis. — Effects of Climate upon the Disease. — Present Mildness as compared with former Virulence. — Outline of the Course of Syphilis. — General Pathology of Syphilis. — General Description of the Pathology of the various Lesions due to Syphilis, and the Lack of any Specific Quality in the Elements constituting these various Lesions 53
CHAPTER II.
SYPHILIS.
The Poison of Syphilis : is it a Vegetable Fungus ?— The Production of Syphilis in Different Animals. — The Alleged Antagonism between Syphilis and Cancer. —Secretions which contain the Poison of Syphilis. — Peculiar Virulence of the Secretion of Mucous Patches.— Vaccinal Syphilis. —Pathological Secretions. — Physiological Secretions. — Infection by Milk ; by Semen. — Transmission of Syphilis by Inheritance through the Mother alone ; through the Father alone. — Date at which a Healthy Pregnant Woman must get Syphilis in order to Poison her Child. — Choc en-retour. — Transmission by Inheritance to the Third Generation. 61
CHAPTER III.
SYPHILIS.
Methods of Contagion in Acquired Syphilis, Direct and Mediate. — The Duration of Syphilis and the Question of Marriage.— Cauterisatio Provocatoria.— The
CONTENTS. IX
PAGS
Prognosis of Syphilis, and the Influence of Constitution and of Intercurrent Physiological and Pathological Conditions upon its Course and Duration. — Second Attack of True Syphilis occurring in Individuals who have already once had Syphilis 75
CHAPTER IV.
SYPHILIS.
The Incubation of Syphilis. — Description of Syphilitic Chancre : the Raw Erosion, the Superficial Ulcer, the Herpetiform Chancre, the Mixed Chancre, Chancre of the General Integument, Chancre of the Lip, of the Nipple, of the Urethra. — Syphilis without Chancre. — Typical Course of Chancre. — Specific Induration. — Complications of Chancre by Phagedena. — Treatment of Chancre by Excision and other Means. — The Lymphangitis of Chancre. — The Bubo of Syphilis, and its Treatment 85
Chapter V. Syphilis
A Table giving a Comprehensive View of the Features, Course, Symptoms, etc. , of Chancroid, as compared with Similar Conditions, when met with in connection with Syphilitic Chancre. — The Stages of Syphilis : Primary, Secondary, Tertiary. — Malignant Syphilis. — The Second Incubation. — Syphilitic Fever. — Symptoms attending the Beginning of General Syphilis. . . .97
Chapter VI. The General Treatment Op Syphilis
Syphilis a self limiting Malady. — It gets well under all Treatments sometimes, but yields the best Results to small Doses of Mercury continued for a long Time. — Syphilization and Tartarization. — The Hot Springs of Arkansas. — Preventive Treatment of Syphilis. — Excision of Syphilitic Chancre. — The Hygienic Treatment of Syphilis. — The Hygiene of the Mouth. — Hygiene of the Anus and of the Genitals. — Hygienic Medication. — Kumyss. — Specific Treatment of Syphilis. — General Consideration of the Value of Mercury and the Different Kinds of Mercurial Treatment. — Salivation. — Time at which the General Treatment of Syphilis should be commenced. — Detail of the Tonic Treatment of Syphilis by Mercury. — The Time at which a Tonic Course of the Mercurial Specific may be stopped. 104
Chapter VII. The General Treatment Op Syphilis— Continued
Mercurial Fumigation. — Simple Method of taking a Bath at Home. — The Inunction of Mercury. — Other Methods of giving Mercury. — The Treatment of Salivation. — The Local Treatment of Syphilitic Lesions of the Integument; of Mucous Membranes. — The Iodides and the Preparations of Iodine. — The Evil Effects of the Iodides.— The Dose of the Iodides.— The Mixed Treatment. — When to cease giving the Iodides. — Zittman's Decoction, . . . 122
X CONTENTS.
Chapter VIII. Syphilis Of The Skin
PAGE
Special Characters of the Syphilides : Polymorphism, Color, Form, Absence of Subjective Symptoms. — Characters of Scabs, Ulcers, Cicatrices in Syphilis. — The Syphilides : Erythematous, Papular, Pustular, Ecthymatous, Pigmentary, Vesicular, Squamous (Circinate, Palmar and Plantar), Tubercular (General, in Groups). — Tertiary Syphilides. — Rupia. — Tertiary Pustular Syphilide. — Ecthyma. — Pustular Syphilide in Groups. — Tertiary Syphilitic Ulceration. —Gumma of the Skin 142
Chapter IX. Syphilis Op Mucous Membranes
Erythematous, Ulcerative, Mucous, and Scaly Patches, and Gummatous Ulcers of
the Mucous Membranes of the Mouth, Nose, and Fauces. . . .165
Chapter X
SYPHILIS OP LYMPHATIC GLANDS, — OP HAIRY PARTS, OP THE FINGERS AND TOES, OF MUSCLES, TENDONS, APONEUROSES, BURS^E, JOINTS, BONES, AND CARTILAGE.
Epitrochlear and Post-cervical Indolent Glandular Engorgement. — Syphilitic Alopecia. — Syphilitic Onychia and Paronychia. — Dactylitis. — Syphilitic Myostitis, Congestive, Diffuse, Gummatous. — Syphilis of Tendons, Sheaths of Tendons, and Aponeuroses. — Syphilis of the Bursas. — Syphilis of Ligaments and Joints. — Syphilis of Bones. — Osteocopic Pains. — Nodes, Dry Caries, Gummy Tumor of Bone. — Mercury as a Cause of Bone Disease. — Syphilis of Cartilage. . . 171
CHAPTER XL
SYPHILIS OF THE RESPIRATORY SYSTEM. — THE DIGESTrYE TRACT, ABDOMINAL GLANDULAR ORGANS, AND THE VASCULAR SYSTEM.
Syphilis of the Nose.— Syphilis of the Larynx; non -Ulcerative— Ulcerative. — Syphilis of the Trachea, Bronchi, and Lungs. — Syphilis of the Digestive Tract. — Gumma of the Tongue. — Syphilis of the (Esophagus. — Syphilis of the Stomach and Intestines. — Syphilitic Stricture of the Rectum. — Syphilis of the Peritoneum. — Syphilis of the Pancreas. — Syphilis of the Liver. — Diffuse and Circumscribed Hepatitis. — Gumma of the Liver; Amyloid Degeneration. — Syphilis of the Spleen. — Syphilis of the Thymus, of the Supra-renal Capsules, and the Abdominal Glands. — Syphilis of the Heart. — Syphilis of the Arteries, Veins, and Capillaries 190
Chapter XII. Syphilis Of The Neryous System
General Pathology of Nervous Syphilis. — Syphilis of the Brain, Pachymeningitis, Gummata of the Meninges, Encephalitis, White Softening, Gummata of the Brain. — Syphilis of the Cerebral Arteries. — General Symptoms of Brain Syphilis, Prognosis. Treatment. — The Special Affections produced by Syphilitic Lesions of the Brain. — Syphilitic Hemiplegia, Epilepsy, Generalized Paralysis,
CONTENTS. XI
PAGK
Catalepsy, Chorea, Aphasia, Insanity. — Brain Syphilis simulating Sunstroke often followed by Desire to Sleep. — Syphilis of the Cord. — Syphilitic Paraplegia. — Syphilitic Locomotor Ataxia. — Syphilis of Special Nerves, of Nerves of Special Sense, and Nerves of Motion. — Syphilis of the Sympathetic. . . 205
Chapter XIII. Syphilis Op The Genito- Urinary System In Both Sexes
Syphilis of the Kidney. — Syphilitic Albuminuria. — Syphilis of the Penis. — Syphilis of the Testicle ; Epididymitis, Orchitis (Diffuse, Gummatous). — Diagnostic Table of Syphilitic, Tubercular, Cancerous, and Sarcomatous Enlargement of the Testicle. — Treatment of Syphilis of the Testicle. — Impotence due to Syphilis. — Syphilis of the Genital System in the Female. — Functional Derangements of Menstruation due to Syphilis. — The Effect of Syphilis upon Pregnancy. — Cause of Abortion in Syphilis. — Syphilis of the Mammary Gland, Diffuse, Parenchymatous, Gummatous 219
Chapter XIV. 8yphili8 Of The Eye And Ear
Syphilis of the Eyelids and Conjunctiva. — Syphilis of the Cornea, the Iris (Plastic and Gummatous Iritis i. — Syphilis of the Vitreous, of the Ciliary Body, of the Choroid, of the Retina (Atrophy of the Retina, Retinitis Pigmentosa). — Syphilitic Optic Neuritis. — Syphilis of the Ear. — Syphilis of the Outer Ear and Auditory Canal. — Plastic Myringitis. — Syphilis of the Auditory Nerve. — Syphilis of the Middle Ear. — Ear Affections found in Inherited Syphilis. — Catarrhal Inflammation of the Middle Ear, Deaf-mutism 235
Chapter XV. Inherited 8yphili8
Syphilisdoes not change in Type during Transmission by Inheritance. — The Syphilitic Foetus. — Bone Syphilis in Inherited Disease. — Inherited Syphilis in the Infant. — Date of Appearance of Symptoms in Inherited Disease. — Pemphigus of Inherited Syphilis. — The Syphilitic Countenance. — Syphilitic and Mercurial Teeth.— Interstitial Keratitis. — General Treatment of Inherited Syphilis. 287
Chapter I. Gonorrhoea In The Male
Definition. — True Gonorrhoea is not acquired by Contact of the Urethra with Pus not in itself Gonorrhoeal. — Cases illustrating that Urethral Pus does not always produce Gonorrhoea in the Female, nor Vaginal Pus in the Female always Gonorrhoea in the Male. — The Causes of Urethral Inflammation. — Symptoms of Urethritis in an Unhealthy Urethra not due to the Contact of a
Xll CONTENTS.
PAGE
Virulent Pus. — Symptoms of Inflammation in a healthy Urethra, due to Contact of Gonorrhoea! Pus or other Irritating Substance, under Circumstances capable of generating Urethritis. — Chordee. — Lymphangitis of the Prepuce. — Spasmodic Stricture. — Breaking the Chordee. — Gleet. .... 249
Chapter II. Treatment Of Urethral Inflammation In The Male
The Relation of the Physician to his Patient during the Treatment of Urethritis. — The Abortive Treatment of Gonorrhoea.— Hygienic Treatment ; Medical Treatment by Alkaline Diuretics, by Sandal-Wood Oil, by Copaiba (Copaibal Erythema), by Cubebs, by Turpentine, by Iron, by Tincture of Cantharides. — The Internal Treatment of Gleet. — The Use of Injections in Urethritis. — How to Inject the Urethra. — Dressings for the Penis during Urethritis. — Treatment of Chordee. — Treatment of Painful Urination. — Treatment of Retention of Urine in Gonorrhoea. — Treatment of Venereal Warts. — Treatment of Inflammatory Phimosis. — Paraphimosis and its Treatment. . . . 258
Chapter III. Complications Of Gonorrhoea In The Male
Inflammation of the Follicles of the Urethra.— Follicular and Peri-Urethral Abscesses.— Cowperitis. — Inflammation of the Lacuna Magna. — Death due to Gonorrhoea. — Gonorrhceal Cystitis. — Gonorrhoeal Epididymitis. — Sterility following Gonorrhceal Epididymitis. — Treatment of Gonorrhoeal Epididymitis, Prophylactic and Curative.— The Tobacco Poultice.— Strapping the Testicle. — Chronic Epididymitis 275
Chapter IV. Stricture Of Large Calibre
Stricture of the Male Urethra.— Spasmodic Stricture.— Examples of this Form of Stricture. — Stricture of Large Calibre : Symptoms, Diagnosis, Treatment. — Resiliary Strictures of Large Calibre. — Internal Urethrotomy in the Pendulous Urethra, the Limit of the Cut, the Result, and the After-treatment. . . 290
Chapter V. Stricture Of Small Calibre
Symptoms of Tight Organic Stricture; Diagnosis. — Expedients for Threading fine Strictures.— Treatment of Stricture of Small Calibre.— Continuous Dilatation. — Internal Urethrotomy of the Deep Urethra. — Divulsiou. — Perineal Section; with a Guide; without a Guide.— Urethral Fever and its Treatment. .... 311
CONTENTS. Xlll
Chapter VI. Gonorrhoea In The Female
PAGE
Symptoms, Complications, Treatment — Local Treatment. — How to wash the Vagina. — Medicated Vaginal Injections. — Chronic Urethritis and its Treatment. — Chronic Cervicitis. — Sterility in Women following Gonorrhoea. . . . 328
Chapter VII. Complications Of Gonorrhoea Common To Both 8exe6
Gonorrhoea! Rheumatism. — Time of Occurrence, Cause, Parts most often Involved. — Chronic Hydrarthrosis. — The Poly-articular Form. — Neuralgia. — Bursitis. — Nodes. — Treatment. — Gonorrhoea! Rheumatic Iritis, Conjunctivitis, Aquo- capsulitis. — Contagious Purulent Ophthalmia : its Symptoms, Course, and Treatment 334
Index To Illustrations
PAGE
Figure 1. Tin fumigating table and lamp, 123
2. Papular syphilide in the white, 147
4. Condylomatous venereal vegetations, 150
5. Superficial ecthyma, 152
6. Pigmentary syphilide, 153
7. Squamous " 155
8. Palmar " 150
9. Plantar " 156
10. General tubercular syphilide, 157
13. Deep ecthyma, 161
14. Ulcerative syphilide, 162
15. " 162
16. Cicatrix of " 163
17. Dactylitis (toe), 176
19. " result of, 178
20. Syphilitic bursitis, 181
21. " " 181
22. Syphilitic countenance, 243
23. Syphilitic teeth, 244
24. Mercurial " 245
25. " 245
26. Urethral syringe, 266
27. Cupped sound, 268
29. Penis suspensory, 270
30. Bulbous bougie 299
31. Urethrameter— Otis, 300
32. Conical steel sounds, 302
33. Urethrotome— Otis, 306
34. Urethral tampon — Bates, 309
35. Conical soft bougies, 313
36. Tips of whalebone bougies, 313
37. Urethrotome — Maisonneuve, 316
38. Americanized Thompson's divulsor, 317
39. Olivary conical bougie, . . . • . • • . .318
40. Lithotomy tampon — Guyon, 319
41. Catheter guide— Gouley, 319
Chapter I. Chancroid
THE NON-SYPHILITIC VENEREAL ULCER.
Chancroid.— Definition.— General Description of Typical Clinical Chancroid.— The Nature of the Chancroidal Poison.— Answers to the Objections made to the Existence of any Special Chancroidal Vufcs, aud Discussion of the Alleged Cases of Chancroid purporting to have been produced by the Inoculation of Pus not derived from a Chancroid.— Is the Poison of Chancroid a Modified Syphilitic Virus? — Unity and Duality in Syphilis.— Twelve Propositions setting forth Facts relative to the Question of Duality, and believed to be sustained by Facts, Experimental and Clinical, now before the Profession.
Definition. — Chancroid is a virulent ulcer. It is local and never the starting-point of syphilis. It is always due to contact of the surface involved with pus derived from a similar ulcer, and its own secretions are freely auto-inoculable.
These characters are cardinal and uniform. Clinically, a chancroid does not exist which does not fulfil each of these conditions. A number of objective features, which will be detailed later, stamp chancroid with an especial clinical individuality in typical cases, but each of these latter special features is subject to variation : the incubation ; the softness of the base; the appearance of the edges and of the surface; the quality of the secretion, and the subjective symptoms also, in a given case, all may differ from those found in the typical chancroid, without disconcerting the clinical observer. If, however, a chancroid could be due to anything excepting the inoculation of chancroidal pus — if its own pus could fail to take, when inoculated for the first time, upon the clinical bearer of the sore — if chancroid derived from a chancroid could once be shown to be the starting-point of true syphilis — then the labors of Bassereau, Clerc, Fournier, and a host of others have been in vain, and the profession is plunged again into that obscurity regarding venereal disease which obtained in the days of Hunter, and only yielded in the present century to the campaign inaugurated against it by Ricord.
THE VENEPwEAL DISEASES.
The question of one or two poisons in syphilis will be discussed later. Non-syphilitic chancroid first claims a detailed description.
GENERAL DESCRIPTION OF A TYPICAL CHANCROID AS IT IS CUSTOMARY TO ENCOUNTER IT CLINICALLY.
A typical chancroid, unirritated and uncomplicated, is a rounded ulcer. In a furrow it is oval, large or small, single or multiple, simple or composed of several ulcers which have run together; its general physical characters are as constant as are those of any classical cutaneous lesion — as constant, for instance, as are the physical characters of vaccinia. A faint pink areola surrounds a chancroid. Its edges are abrupt, sharply cut at right angles to the surface (not sloping away), very often slightly undermined, because the superficial integument resists the advance of the spreading ulcer a little longer than the less dense underlying structures. The bottom of the ulcer is either pallid, with pink granulations, bathed in thick pus, or, more often, pultaceous, yellow, looking like dirty cream; and this surface, composed of sloughy structures, permeated with pus, is adherent, and blood flows on any attempt at its removal. The structures all around and those underlying this ulcer are perfectly normal, soft, and flexible. The base of the ulcer can be easily lifted up from the tissues beneath, and when rolled between the thumb and finger presents no rigidity.
Such an ulcer does not cause pain. Its bearer may be unconscious of its existence, excepting that he sees it. The pus is creamy and freelv secreted from the ulcerated surface, and contains the broken-down detritus of the anatomical elements which have been involved in the progressive march of the destructive ulcer.
Such is the simple clinical chancroid as seen in a typical case. Many complications, however, may attend it and subject its appearance to corresponding variation. The more it differs from the type, the less possible is it for the surgeon to be positive in his diagnosis of its character. Nothing is more capable of correct diagnosis by mere inspection than typical chancroid; complicated chancroid may confound the astuteness of the closest differential diagnostician.
It is therefore of the first importance, in commencing the study of venereal disease, to comprehend what a chancroid is and to what variations it is liable, especially in these modern days when every ulcer produced by inoculation finds some sturdy advocate ready to proclaim it a chancroid.
An attempt to trace the history of chancroid has given occasion for the display of much erudition. No author has been more painstaking in this direction than Bassereau, 1 who brings out evidence from the writings of ancient Greek, Latin and Arabian surgeons, which establishes the presumption that contagious venereal ulcers have existed from all time; and that some at least of these ulcers were chancroidal, it is hardly reasonable to doubt. Such discussions, however, have no place in a text-book dealing only with the practical aspect of the question.
The nature of the poison of chancroid is unknown. Different observers (Donne, Didier, Salisbury) have described varying parasites as
' Traite des affections de la peau symptomatiques de la syphilis. Paris, 1S52. p 217 et seq.
CHANCROID. o
the essential cause of chancroid; but no convincing demonstration has been given to the profession of the truth of any theory, and the world is to-day as ignorant of the nature of the essential poison of chancroid as it is of the nature of the poison of syphilis or of scarlet fever. There is a growing tendency in the profession, particularly noticeable of late years, to disclaim the existence of any poisonous quality in chancroidal pus. Such well-known authors as Hutchinson of London, Baumler of Freiburg, and Bumstead of New York, have held this view. The latter, in a very able article read in Philadelphia, 1876, before the International Medical Congress, claims that the inoculation of the products of simple inflammation may produce a chancroid upon persons who are syphilitic or much debilitated.
But why an ulcer, let it resemble a chancroid perfectly — why such an ulcer produced upon a person in a pyogenic condition by the inoculation of indifferent inflammatory pus, should be called a chancroid, even although the pus be repeatedly auto-inoculable in generations, it is difficult to understand. Surely a pustule of acne is not a chancroid. If it were a chancroid it would spread peripherally and behave like that classic ulcer. The auto-inoculability in generations, of pus derived from a pustule of acne, confirms the well-known conclusions of Von Roosbroeck, that all pus is more or less irritating, more or less contagious. Many individuals in poor health notoriously "fester" when they are scratched, without requiring the inoculation of any substance to produce a suppurating sore. The violence done to the skin shows up the quality of the latter, and it is the pus-forming tendency which develops the ulcer upon a patient whose integument may be subjected to violence of a mechanical or of a chemical sort, and not necessarily any poison introduced from without.
If chancroid could be produced de novo by the inoculation of ordinary pus upon syphilitic and cachectic persons, the number of chancroids clinically observed upon respectable people, syphilitic and cachectic, would be vastly greater than it is. Balanitis (from tight prepuce), suppurating herpes progenitalis, gonorrhoea, and suppurative leucorrhoea in the female, are very common in such patients, but chancroid is exceedingly rare among respectable people, and does not occur (so far as the writer knows) clinically, excepting under circumstances which allow an opportunity for contagion, direct or indirect, with the secretion of a similar ulcer.
The experiments of Pick, Koebner, Kaposi, Kraus, Reder, Lee, Bidenkap, Morgan, Wigglesworth, Von Roosbroeck and others, demonstrate that all sorts of irritating secretions may produce ulcers and auto-inoculable ulcers; but no one has shown that the minute prick of a pin dipped in such pus will produce an ulcer yielding a chancroidal bubo — the virulent, not the simple suppurating bubo. No one has produced a typical chancroidal ulcer by inoculating from a half-glass of water in which one drop of simple inflammatory pus had been placed — as did Puche with a drop of chancroidal pus. And Boeck, the sturdy advocate of syphilization, would certainly not have gone to the trouble of collecting chancroidal pus in the hospitals of Christiania to send into the surrounding country for the purpose of syphilization, if ordinary pus would have done as well. Boeck himself stated that chancroidal pus would yield positive results to inoculation even when diluted with eleven hundred parts of ordinary pus.
Some 3'ears since, at the Charity Hospital, I endeavored to produce cutaneous ulcers by inoculation of indifferent patients with indifferent pus, but the experiments were not long continued, for, although some pustules were obtained, nothing resembling the rapidly spreading destructive chancroid appeared.
Tarnowsky, an excellent and competent observer, declares ' as deductions from a number of experiments, that the sores produced upon syphilitic persons by Bidenkap, Keder, and Koebner, are distinguishable by their form, course, absence of bubo, and results, from true chancroid, and are only the characteristic effects of the irritation of the skin in syphilitics. He believes that any irritant, if strong enough, will produce like results. He states that inoculation from these sores upon healthy subjects may produce syphilis, but not chancroid.
Zarewicz 3 of Krakau inoculated syphilitic products upon syphilitics. Pus was taken from the lesions so produced (without admixture of blood) and inoculated upon healthy persons, always with negative results, while the same pus yielded positive results when inoculated upon syphilitic persons. This proves that the lesion was not a chancroid and was not syphilis, but simply that irritating pus could be positively inoculated upon syphilitic persons, while the same inoculations were negative upon healthy persons.
On the other hand, a claim has been made by Bidenkap and Gjor (quoted by Bumstead), that five patients, not themselves syphilitic, inoculated themselves from sores produced by inoculation of the products of an irritated syphilitic chancre upon syphilitic patients, and that while the inoculated ulcers took (like chancroids) upon these healthy persons, only one of them became syphilitic, and in that case syphilis was doubtful.
Only one of these cases is important, and that one at first sight seems convincing. It is described bv Bidenkap, and originally appeared in the Wiener Med. Wchnschrft. of 1865 (No. 34).
A young woman, free from syphilis (in the hospital on account of urethral and vaginal suppuration), inoculated herself with a needle through curiosity, from ulcers which Bidenkap had produced upon a syphilic patient by first taking pus from an irritated syphilitic chancre and reinoculating it through many generations. An ulcer lasting two months and producing another by spontaneous inoculation was the result upon the young woman — but no syphilis. Eighteen months later she acquired syphilis in the usual way.
The facts in this case may be explained as follows: whatever syphilitic poison taken from the chancre was inoculated upon the syphilitic patient from whom the young woman got her pus, died out, since syphilitic virus does not propagate itself by auto-inoculation. Acrid pus, auto-inoculable in generations, only was left behind, and this the young woman used, not getting any blood, and therefore avoiding contamination of the pus she used with any of the true poison of syphilis. Had the true poison of syphilis been inoculated she must have had chancre, which she did not have; not having chancre, did she have chancroid? There is nothing in the case to show that the syphilis of the patient furnishing the pus was active at the time the pus was taken bv the young woman, and there is nothing to show that other irritating pus, such as that found in simple ecthyma, or in scabies, might not have also taken upon the young woman, if properly inoculated, and have produced an indolent ulcer, itself auto-
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