Lectures on syphilis

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UNITED STATES OF AMERICA.

Preface

These lectures were originally published in The Western Medical Reporter, and they have been collected and republished in their present form, with but little revision. An earnest attempt has been made to present to the student a plain and practical idea of the subject of Syphilis, as taught by our most advanced pathologists and syphilographers, in conjunction with practical points drawn from personal observation in hospital and dispensary practice. The views of Fessenden Otis have been adopted, as the most logical and scientific which have yet been offered, in explanation of the pathological phenomena of the disease. It is hoped that these few lectures may prove more valuable to the student, than some of the larger and more comprehensive treatises.

125 State Street, Oct. 1st, 1885.

Contents

Lecture I. Definition of syphilis. Its contagiousness and wide diffusion. Origin of the disease. Its decreasing malignancy. Duality of syphilis and chancroid. Experiments with animals. Period of incubation. The syphilitic cell. Harmony of the bacillar theory with the physiological pathology of syphilis Pag-e 9.

Lecture II. Initiatory period. Importance of the syphilitio cell. Anatomy and histology of local manifestations of the disease. Adenopathy. Varieties of induration. Necrobiosis. Chancrous secretion. Vaccinal syphilis. Poison bearing secretions of syphilis. Dependence of contagiousness on the syphilitic cell Page 29.

Lecture III. Modes of transmitting syphilis. Absence of primary syphilis in foetal infection. Infection by kissing. Colle's law. Danger of infection by syphilitic child. Illustrations of methods of transmission. Varieties and treatment of chancre. Mixed sores. Syphilitic bubo Page 47.

Appendix

Selected formulae for the treatment of syphilis. . .Page 177.

Lecture I.

Definition of syphilis.— Contagiousness of the disease.— Its wide diffusion.— Origin of syphilis.— Ancient knowledge of the disease.— Its present benignity as contrasted with former malignancy. — Expla-

. nation of the decrease in malignancy by evolutionary laws.— Duality of syphilis and chancroid.— Attempted inoculation of animals with syphilis.— Successful inoculation of the monkey. —Rapidity of absorption of syphilitic poison.— Second attacks of the disease.— Venereal diseases of the lower animals.— Duration of incubation period of syphilis. — Peculiar induration of chancre. — Nature and local results of the syphilitic materies morbi.— Properties of the syphilitic cell.— Its effects and importance during the natural course of syphilis.— Harmony of the bacillar theory with the "physiological pathology" of syphilis.

Gentlemen: — We take up this morning the most important subject which it is my privilege to present to you, and the most interesting of those affections classed as venereal diseases. Syphilis, or as it is sometimes termed "lues", is a dyscrasic or constitutional affection of the type known as "blood diseases," due to the infection of the organism of a human being with a peculiar morbific principle, or virus, or hypothetically, a germinal disease cell, unknown as an entity, but plainly manifest in its pathological results. Its manifestations are, to all intents and purposes, a lesion which is primarily local, but which is followed by a succession of morbid constitutional manifestations appearing at variable intervals, running a somewhat definite course, and being more or less amenable to treatment. The virus of syphilis has not yet been isolated, although we are justified in the hypothesis that it is a degraded cell of microscopic size, and possessed of most potent evil propensities. In many respects syphilis resembles the exanthemata, inasmuch as it is transmissible from the diseased to healthy individuals, has a period of incubation, a stage of eruption, another of decline, and a period of true sequelae. A very minute quantity of the syphilitic virus is sufficient to produce the disease, although it is fortunately only contagious, and not infectious, in the proper sense of the term. The wide diffusion of syphilis through the human family, will not be fully appreciated by you, until you enter private practice, when, especially if your field of labor lies in a large city, you will soon come to believe that no one is above suspicion.

Perhaps this is an exaggeration, but it is certain that syphilis, like accidents, is liable to occur in the best regulated of families, and often serves to explain otherwise obscure cases of aristocratic aches and invalidism. The origin of syphilis is not definitely known, but it is probably quite an old and respectable disease inasmuch as it is more than likely that some of the forms of leprosy of bible times, were instances of syphilis. Indeed, syphilis and leprosy were confounded only a few centuries ago. Nearly all accounts of syphilis state that the disease appeared in Southern Europe in the latter part of the fifteenth century, the supposition being that it was imported from America by the sailors who accompanied Columbus or Amerigo Vespucci upon their expeditions. The morals of the country at that time being none too rigid, the disease spread rapidly, being later mistaken for leprosy. It has since been recognized in every part of the world, as a distinct disease, and has come to be quite well understood. There is a fact connected with the history of syphilis, which is not generally known, that may be of interest : I am informed upon reliable authority, that the disease was described by the Japanese historians several thousand years ago, and that documents are still in existence, which contain ancient descriptions of the affection, that are exceedingly accurate. This would indicate the Asiatic origin of the disease, it having been brought to America by those nomadic tribes who settled this country some centuries ago, when America and Asia were united by the peninsula now represented by the Aleutian Islands.

As still further evidence of the antiquity of syphilis, may be mentioned the fact that recent translations of ancient Chinese medical writings show that the disease was known in China two thousand years ago. Moses was undoubtedly familiar with the disease, a fact which makes it still more ancient and respectable. During the earlier years of the existence of syphilis in Europe it was so malignant and widely disseminated, as to have been recognized as a form of plague, which created great havoc, and in fact nearly destroyed the various armies of the countries afflicted. The disease has gradually grown milder in type until at the present day the very severe and exceptional cases have come to be classed under the head of i ' malignant. " Now there must be some explanation for this, and I think it would be well to digress slightly, and see if we cannot find logical reasons for the steady diminution in the virulence of syphilis. In the first place it is obvious that improved sanitation, with a steadily increasing knowledge of the pathology, and the consequently more rational measures of treatment of any particular disease, must eventually result in modifying its severity. This has been especially true in the case of syphilis, but I think there is another more powerful influence which is constantly manifesting itself in the case of contagious diseases in general, viz : the fact that disease occurring in individuals of one generation imparts a certain degree of immunity to their descendants.

A very interesting article bearing upon the influence of heredity and natural selection in modifying different contagious diseases, has been recently written by Prof. Lyman of this city, which is so logical in its application to these different affections, that I think we may apply it to syphilis as well. The doctor cites as an illustration of his views, the extraordinary malignancy of measles among the natives of the Sandwich Islands, a few years since. These people were never affected by measles until it was imported by the whites, and consequently had not acquired tolerance of the disease. Although the population of these islands was almost decimated at the time, the disease has steadily decreased in its malignancy ever since. Another illustration cited, is the peculiar malignancy of variola among the negro race. Small-pox was unknown in Africa until imported by Europeans, and after its introduction created fearful havoc among the natives. It has not yet had time probably, to become very markedly modified, but a steady modification is to be expected. When an epidemic attacks a community it attacks those susceptible to the disease, and modifies their organisms in such a way that they become tolerant of future attacks and this tolerance they transmit in a measure to their descendants. A certain number of individuals are insusceptible to the epidemic influence, and consequently escape the disease. This insusceptibility is also transmitted to the next generation. These facts illustrate the influence of heredity. As 1 have stated, a certain number of individuals are primarily insusceptible to the disease and consequently escape it, while those individuals who are susceptible to it, are attacked, with a fatal result in the case of those least able to withstand it. This illustrates the influence of natural selection. Applying this theory to syphilis, we may readily see that the disease has probably destroyed those subjects least able to resist it, and that the immunity from the disease acquired by exposure to its influence in the case of those who survived, and the primary insusceptibility of a certain proportion of individuals have been transmitted to successive generations, until at the present day syphilis is a comparatively mild affection. It is of course admitted that the insusceptibility of one generation, may depend upon the inheritance of unequivocal syphilis from the parent stock, but in certain instances the transmitted impression is very attenuated.

One of the most important results of modern scientific medical research, has been the establishment of the duality of the poisons of syphilis and chancroid. The experiments proving this have been numerous and conclusive, yet, strange as it may seem, there are those who continue to believe in their unity* This difference in opinion has resulted in a division of authorities into a unicists" and u dualists". The obscurity which formerly clouded the minds of surgical authorities, regarding the venereal diseases, seems very remarkable to us, who have taken advantage of their errors. John Hunter, the greatest surgical philosopher of the eighteenth century, believed that there was but one venereal disease, and that a constitutional affection. He believed this, because he had produced constitutional syphilis in himself by inoculating his arm with gonorrhoea], virus. He labored under this delusion until the day of his death. Fully half a century later, Ricord demonstrated the error of the great master, but he himself did not recognize the difference between syphilis and chancroid. Fifty years later, their duality was shown by Bassereau, one of his own pupils. I will not enter into a lengthy discussion of the different authorities and methods of research proving the duality of the two poisons, for the fact is generally accepted ; but I will mention a few facts bearing upon it. We can all fully appreciate one of the most powerful arguments of tho unicists, viz: u That general symptoms frequently follow

* Among those who adhere to the old theory, may be mentioned Kaposi. Many prominent English surgeons are also unicists, hence the confusion of terms existing in most English works upon syphilis. With them, chancroid is also and erroneously termed, '"'local syphilis."

an apparently non-indurated, simple sore, but these cases are simply exceptions to a well established rule. I have seen, it must be confessed, very innocent looking sores followed by secondary syphilis, but quite rarely; sufficiently often perhaps, to render me cautious in the matter of prognosis in every sore, however innocent looking; but not often enough to shake my own convictions as to the duality of syphilis and chancroid. When chancroidal poison is deposited upon a raw surface and said surface is cauterized soon afterwards no chancroid results. If, however, the syphilitic virus as contained in the secretion of a chancre or syphilitic ulcer, be thus inoculated and cauterized, syphilis will result, as a rule. Hill cauterized a ruptured freenum twelve hours after intercourse, but syphilis developed as if nothing had been done. Fournier cauterized a chancre six hours after its appearance, but syphilis followed. Excision of the primary sore has been practiced, and has recently been revived, but has not as yet been proven to prevent the development of syphilis. It has seemed to modify it in certain instances, and in two personal cases, the subsequent secondary manifestations were very mild. This proves nothing however. The facts that I have given you are sufficient in themselves to prove the non-identity of syphilis and chancroid. Syphilis is essentially constitutional, (even if primarily local) while chancroid under all circumstance is a purely local affection.

Attempts at the inoculation of animals, with sj-philis and chancroid have shown a marked difference between the two diseases. Syphilis is not transmissible to the lower animals while chancroid is, although with a certain amount of difficulty. Depaul, however, speaks of a syphilitic monkey, and Martineau has recently claimed to have produced a hard chancre upon the penis of a monkey. This animal was afterwards exhibited to the French academy, with unequivocal secondary lesions, thus proving the communicability of syphilis to the monkey. Neumann, however, in some recent experiments upon monkeys, cats, dogs, rabbits, and horses has failed to produce syphilis. If the statement that syphilis is transmissible to the monkey alone, of all other animals be true, it would seem to be a powerful support to the Darwinian theory. The course of syphilis and chancroid is sufficiently distinctive in typical cases. In conclusion, we might ask the unicists why, if the poisons of syphilis and chancroid are identical, all venereal sores are not followed by constitutional symptoms, when allowed to run their natural course without interference, and why also, all sores are not auto-inoculable ?

Syphilis may be either hereditary or acquired, and is essentially the same in its manifestations in either instance, save that, as we shall see later on, hereditary syphilis has no primary stage. Acquired syphilis is in every instance due to confrontation and inoculation with a peculiar poison or virus derived originally from some individual suffering from the disease, and which virus is contained in either the secretion of a syphilitic lesion, or blood from a syphilitic subject.

The length of time necessary for the absorption of the syphilitic virus after the inoculation of a healthy tissue, is unknown, but it is unquestionably very short, although no direct experiments have been made. Abrasions have been cauterized within six hours after suspicious intercourse, and yet syphilis has developed. Hill, as before stated, relates a case in which he cauterized a ruptured fraenum within twelve hours after exposure, and in which syphilis followed. Numerous experiments have been made upon poisons bearing an analogy to the syphilitic virus, which are very instructive and allow us to draw some conclusions with reference to syphilis. The experiments with the virus of vaccinia have been especially interesting. Seven children were vaccinated by Martin and the site of the operation destroyed by Vienna paste at periods varying from one to twenty-four hours thereafter. None of the children had vaccinia; but all but one were protected from variola as was proven by the failure to inoculate them by a second vaccination. Clerc vaccinated a number of children, destroying the spot with nitrate of silver one hour afterwards, but vaccinia was not prevented. These experiments suggest that possibly vaccinia consists of two essential elements; a local and a constitutional, which permits the destruction of the morbid impression causing the local process without any modification of the constitutional manifestations of the virus. Whether the same view may be taken of syphilis, remains to be seen.

In France, numerous experiments upon animals have been made by different surgeons, with the poison of glanders. The seat of the inoculation has been excised within one minute after the introduction of the virus, yet glanders was not prevented. It is probable that the virus of syphilis is not absorbed as quickly as some other poisons, but reasoning from the experiments cited, the period required must be very short. Unlike chancroid, true syphilis is very rarely contracted twice. Second attacks, however, have been reported. Diday has collected twenty-five such cases, twenty of which were in his own practice. These cases are especially interesting, both from their rarity and the fact that they most conclusively prove the curability of syphilis, for were the disease not curable, a second attack would be impossible. A few of Diday's cases were contracted during the existence of tertiary manifestations of the previous attack, and this too is an important fact as showing that the u tertiary syphilides" are not syphilitic at all, but are simply non-transmissible sequelae. The longer the interval beween the first and second attacks, the more severe the latter is likely to be, but in the majority of cases the second attack consists in the primary symptoms alone without any further manifestations of the disease. This of course, lends color to our doubts as to the accuracy of the diagnosis in different cases. I have seen in my own experience two cases which I believe to have been a second attack of true syphilis, the data of which I am unfortunately unable to present to you. In each case there had been a previous attack of true syphilis which had been diagnosed by two prominent gentlemen, one of whom was no less an authority than the late Dr. Bumstead. There is no doubt in my own mind as to the condition for which I treated these men, and I can hardly question the accuracy of the first diagnosis. There are several sources of fallacy in determining the existence of a second attack of syphilis, which must be remembered. 1st. — In the first place you may have some coincident eruption accompanying chancroid. 2nd. — Ecthyma may be mistaken for true syphilis, and, if following a genuine attack, be cited as a case of second infection, or the first attack may have been ecthyma, and the second true syphilis. 3rd. — A chancroid or mucous patch may become the seat of such marked inflammatory induration that it is mistaken for true chancre. 4th. — A tertiary gummy ulcer may be taken for hard chancre.

I have already mentioned the non-transmissibility of syphilis to the lower animals and cited the exception of the monkey as claimed by Martineau. It is, as we have already seen, a demonstrable fact that syphilis differs markedly from chancroid in this respect. But it is claimed that animals also have venereal disease, or affections contracted only through sexual intercourse. There is an affection somewhat analogous to syphilis which affects horses and asses. This disease, termed the doury, is only transmitted during sexual intercourse. It develops after an incubation of four to six weeks, with the phenomena of fever and cutaneous tumors, and sometimes the mucous mem-

22 Lectukes on Syphilis.

branes, eyes, and bones may undergo pathological changes, atrophy or paralysis sometimes following in extreme cases. The disease lasts from a couple of months to three years, and is not auto-inoculable. A local contagious venereal disease is also seen in these animals according to Lancereaux. Inasmuch as these affections differ from syphilis in a marked degree, and particularly in the matter of inoculability, their analogy to that disease is probably very slight. It would seem that mankind has the sole monopoly of the doubtful luxury of syphilis.

After the poison of syphilis has been absorbed, a certain period elapses before its morbid effects become manifest. This period is known as th^. ; stage of incubation, and lasts upon the average about twenty-one days, but varying considerably from this in different cases. Fournier relates a case in which the period was seventy-five days, Guerin, one of seventy-one days, and I have myself noted one case of seventy days. Instead of being prolonged the period may be shorter than usual, thus Hammond relates one of three days, and the late Dr. Nott, of New York, reported his own case as developing within twenty-four hours after wounding his finger in operating upon a syphilitic subject. Dr. R. W. Taylor, of New York, reports one case in which the initial lesion appeared upon the second day, induration upon the fourth day and general symptoms during the sixth week, and another in which the chancre appeared at the end of the first, and the general symptoms during the fifth week. Practically, gentlemen, we may accept the statement that as a rule, true chancre does not appear before the tenth day. Any sore appearing prior to that time, is probably chancroid, while any appearing later, is quite likely to be true chancre. This is a useful practical rule to remember, although it must be confessed that it is often of little service in diagnosis, inasmuch as the majority of individuals contracting venereal disease are in the habit of promiscuous intercourse, and therefore absolutely unable to determine which of their numerous adventures has been the unlucky one. Whenever the induration of a sore is characteristic, we are of course, in no wise dependent upon the period of incubation for a diagnosis.

Induration of a peculiar type is the distinguishing feature of a syphilitic chancre and the manner of its formation and its histological characters are consequently a matter of considerable importance. This brings us to the consideration of the pathological changes of syphilis, or as Otis terms it, the "physiological pathology'' of the disease. We ought naturally to begin our study of the subject, with the consideration of the primary or initial lesion, and beginning at the seat of infection we have a number of quite important changes. We have first the absorption of a peculiar morbific principle or "virus," which although unknown as an entity is only too plainly manifest in its pathological effects.* The most probable view of the nature of this virus is, that it consists of a degraded infectious cell of very minute proportions. However lacking we may be in positive knowledge of its nature, we at least have tolerably definite views of the manner of its action. The first effect of the syphilitic virus, is the production of a gradually increasing accumulation of lymph or white blood cells at the site of inoculation, which is brought about by a modification of the normal leucocytes and connective tissue elements, by what we will term the ' 'syphilitic germinal cell." This modification probably begins immediately after the absorption of the poison, but is more or less gradual in manifesting itself, hence we have a certain period elapsing before evidences of its action are exhibited. These accumulated cells, previously normal, contain the "germs" of the syphilitic poison, and their constitution is now

*I regard the bacillus claimed to have been discovered by Lustgarten, as yet to be proven. In any event, its existence does not modify the pathology of the disease, for Lust gar ten claims that it acts by incorporating itself with the white corpuscles.

greatly modified. They have become larger, more granular, and contain numerous nuclei, are infectious, and have their powers of proliferation and amoeboid movement exaggerated. In addition they present a marked tendency to retrograde metamorphosis. When removed from their original situation to the tissues of a healthy individual, these cells, by virtue of their infectiousness, produce changes in the normal leucocytes in their new environment, exciting rapid proliferation in them, as well as undergoing rapid changes themselves. Now, how does the "syphilitic germinal cell" act upon the normal leucocyte? It is claimed that through degradation the syphilitic germinal cell may be but 1-100,000 of an inch in diameter, being perhaps merely one of the nuclei of some infected and degraded leucocyte, but retaining all its morbid powers of proliferation and amoeboid activity, the latter being especially marked. As the white blood cell or normal leucocyte is 1-2,500 of an inch in diameter, it is obvious that by virtue of the peculiar affinity of the syphilitic germinal cell for it, the two may become incorporated, with the result of the modification of the leucocyte which I have described.*

*By supposing an incorporation of the bacillus of Lustgarten, with the leucocyte, instead of the hypothetical cell described, we can at once harmonize the bacillar theory of the origin of syphilis, with its "physiological pathology."

Now gentlemen, I wish to impress upon your minds a thorough understanding of the nature of the modified cell which I have described, for a knowledge of this cell is the key to the study of syphilis. Just as the leucocyte is the primordial cell in the normal physiological processes of growth, so is it the basis of all pathological processes, — and particularly those of syphilis — when it is modfied in the manner peculiar to the particular morbid change in the tissues. Taking as our point of departure, the initial lesion of syphilis, we have a localized proliferation of this very cell, and following it in its course, we have thickening of the lymphatic vessels and enlargement of the lymphatic glands, produced by this same cell accumulation. The cell now travels on, enters the receptaculum chyli, and is finally emptied into the circulation by the thoracic duct, to be then driven to the superfices of the body with the general blood current. In the different tissues we now have various secondary phenomena, and we will briefly consider some of them. General enlargement of the lymphatic glands occurs, as a result of the proliferation of the cells carried to them by the blood, and an accumulation of infected germinal material collected by the absorbents from the superfices. Engorgement of the fauces and pharynx now occurs and is due to a "localized cell accumulation" in the rich network of lymphatics, which as we shall see later on, is a marked feature of the anatomy of the fauces, tonsils and pharynx. Mucous patches are likely to occur, and are simply papules upon moist mucous surfaces, due to a circumscribed collection of the characteristic cells. The same description will apply to the true papule upon the integumentary surfaces. This papule may have an excessive accumulation of cells, and become a tubercle, or, from pressure upon and interference with the nutrition of, the normal tissue elements by the cells, in combination with their own tendency to retrograde metamorphosis, we may have a pustule formed which may break and result in ulceration. Nodes or peculiar periosteal swellings occurring in syphilis, are simply collections of proliferating syphilitic cells. You will notice that I have not mentioned syphilitic roseola, and you perhaps fail to see how we are going to explain it, but by a little roundabout pursuit, I think we can again catch our cell at work, not this time by a localized accumulation, but producing the syphilitic roseola by its effect upon the sympathetic system, which becomes manifest in capillary dilatation and stasis. I think I have shown you the potency of the syphilitic cell in the pathology of syphilis, and I will next endeavor to demonstrate the therapeutic importance of a thorough knowledge of its properties and actions.

Lecture II.

Initiatory period.— Importance of a knowledge of the properties of the syphilitic cell in the therapeusis of the disease. — Anatomy and histology of the chancre and of syphilitic lymphitis and adenitis, so-called. —Condition of glands in general adenopathy.— Definition of the initiatory period.— Varieties of induration of chancre.— Cause of chancrous " ulcers."— Extent of induration. — Duration of i duration.— Character of chancrous secretion.— Cicatrix of chancre.— Chancrous secretion not auto-inoculable.— Course of syphilis in hetero-inoculation. — Vaccinal syphilis.— Multiple chancre. — Poisonbearing secretions of syphilis.— Necessity for the presence of the syphilitic cell in contagious secretions of syphilis.

Gentlemen: — In my last lecture, I endeavored to demonstrate in a general way, the pathological importance of the syphilitic cell, by following it in its tour of mischief, and noting briefly its results. Now, as I have already stated, this cell is not only important as regards the pathology of syphilis, but a knowledge of its properties and actions, is absolutely indispensible to the intelligent application of remedies to the cure of the disease. We will premise that the natural course of the syphilitic cell is to accumulate in, and obstruct, various tissues, thereby forming neoplastic masses very similar in structure to inflammatory neoplasia, and finally to undergo retrograde metamorphosis and elimination, which result eventually in spontaneous cure of the disease.* The danger of permanent injury to the tissues is proportionate

* Vide Otis, "Physiology and Pathology of Syphilis."

30 Lectukes on Syphilis.

to the amount of the accumulated cells, and the length of time they remain in contact with the normal tissues, thereby producing secondary changes in their structure. Understanding these facts, we most naturally seek for remedies, the administration of which tends to remove new formations and cell accumulations, by favoring or directly inducing retrograde metamorphosis in, and elimination of, such morbid material. These remedies will receive attention later on, as I now wish merely to impress you with the importance of an accurate knowledge of the pathology of syphilis in explaining the rationale of their action. You will readily appreciate the fact that a careful study of the characteristic cell which constitutes the basis of all syphilitic processes, will enable you to thoroughly understand the disease in all its manifold forms.

Now let us see how this little cell which I have already described to you, brings about the various changes characteristic of syphilis. As we have seen, the first manifestation of syphilis is a peculiar lesion characterized by induration. This is due to a localized accumulation of cells, which are infiltrated in the meshes of the connective tissue, and the adventitia of the blood vessels, forming a circumscribed mass. The cells vary somewhat in their general characteristics, those in the coats of the vessels being either round, spindle-shaped, or branched, but the bulk of the mass consists of the characteristic round, multinucleated granular cell, which we have already known to be a modified leucocyte. These changes are very similar to those seen in simple dermatitis excepting that there is no serous exudate, the induration being consequently dry and hard. This absence of fluid is due to the thickened walls and contracted lumen of the vessels, which renders it difficult for the serum to exude from them. For the same reason, there is anaemia and innutrition of the neoplasm.*