Practical clinical lessons on syphilis and the genito-urinary diseases

Front matter

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PRACTICAL CLINICAL LESSONS ox

Preface

For a number of years it has been my custom, to distribute, from time to time, to the students of the College of Physicians and Surgeons, short papers, of a few pages each, which were entitled " Class-room Lessons" In these I endeavored to embody important principles, in the study of syphilis and the genito-urinary diseases. The lessons were intended to prevent errors, arising from inattention, or from misunderstanding of the statements made during the lectures in the college, and at Charity Hospital. This was rendered especially necessary, from the fact that my own views, on certain important points, differed, essentially, from those embodied in the text-books in general use. In the first place, on the subject of syphilis : I had been unable to accept the statements of all authorities, that it was a mysterious, instantaneous, poisoning of the organism, in defiance of all known physiological and pathological laws. A careful study of the matter, in connection with modern discoveries in physiology and pathology, had convinced me, that an explanation of all the lesions and manifestations of syphilis was possible, through known physiological and pathological processes, and that, the then universally accepted view of the supernatural advent and behavior of syphilis, was incorrect. This position was taken, in my lectures in the college, in 1868. In 1870, it was presented to the medical profession, in a paper before the Medical Society of the county of New York, and was followed by another paper, on the same subject, in 1871. Up to that time, no systematic effort had been made to explain the various manifestations of syphilis, on a scientific basis. In 1866, Beale had claimed, from his investigations of variola and the cattle disease, the

6 PREFACE.

presence of a germinal cell, as a cause of syphilis. Beisiadecki, of Krakow, had published, in 1867, the results of his microscopical examination of infecting- chancre, in which he showed a localized proliferation of cell elements in the lymphatic vessels, as a starting-point in syphilis, and claimed that this might afford an explanation, through which the general infection might be explained. I took up the matter at this point, and through the results of pathological and histological researches of accepted authorities in pathology and histology, in other fields, succeeded, as I believed, in explaining the various syphilitic phenomena throughout the entire course of the disease. A review of my papers, in the London Lancet of Nov. 9th, 1872, concluded with the statement that " these new views on the physiology of syphilitic infection are not based upon the results of any experiments or new facts, or on the unravelling of observations. They consist mainly of deductions drawn from a close and elaborate reasoning on the acknowledged features of syphilis in connection with the latest doctrines and hypotheses of certain pathological teachers." Starting with the disease-germ, derived from the degraded human germinal cell of Beale, supported by the microscopic examinations of Beisiadecki and Verson, as to the proliferation of new cell material at the site of syphilitic inoculation, and extending only in the line lymph channels ; supported still farther by the clinical facts, in regard to gradual implication of lymph vessels and glands, by the known physiological processes in health, and under the influence of syphilitic infection, and also through the concurring testimony of such histological and pathological authorities as Chaveau, Beale, Schweiggerseidel, Strieker, Kolliker, Teichman, Kohn, Conhiem, Beisiadecki, and others, I was enabled to present a reasonable explanation of the course of syphilis, from its inception to its termination. It was scarcely to be expected, that such a radical departure from the views of the text-books, would be received without discussion ; but the position taken was so amply supported by all known pysiological and pathological facts, that no opposing arguments were offered.

PREFACE. 7

The first authoritative publication in America which followed, practically adopted and supported the new views thus: (Bumstead and Taylor, N. Y., 1869, 4th ed. page 443) " The secretions of syphilitic lesions are found to consist of a serous fluid containing numerous granules or molecules, which are masses of protoplasm or germinal matter holding the contagious properties of syphilis. These microscopic bodies are probably taken into the circulation by the lymphatics, and conveyed over the body. . . In the secondary period of syphilis these cells are very numerous, and the body may be covered with papules and tubercles composed of them. . . As the disease wanes . . the cells no longer have a tendency to reproduction which characterizes them in the early stages, but rather degenerate. Hence we consider the blood and the secretions in tertiary syphilis innocuous." *

The same views of syphilitic infection were presented in the second edition of Berkeley Hill's work, by Berkeley Hill and Arthur Cooper, London, 1881 (p. 75), and erroneously attributed to Auspitz of Vienna (although in a foot-note the reader is referred, for further information on the subject, to my work on the Physiological Pathology and Treatment of Syphilis) thus : " The syphilitic virus enters the system by the absorbents. It first sets up plastic growth in the walls of the lymphatic vessels at the part where it is implanted. These walls thicken and throw off into their interior, cells which contain the virus; as these cells float along they convey the virus still further inwards. But the infiltration of successive parts of the walls of the lymphatic vessels also conducts the virus inwards. When a lymphatic gland is reached, the same proliferating process ensues in the gland, until the cells are sent off through the effersent ducts to other glands, and so on to the thoracic duct. Thence cells, containing the virus, are poured, direct into the circulation, by the veins, and are thus quickly carried to the several tissues of the body. Then appear the signs of general constitittional infection."

* Italics my own.

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Again, in the work of M. Cornil on syphilis (Paris, 1878), translated and edited by Profs. Simes and White, of the University of Pennsylvania, " with the consent and approval of the author," and published in 1882, this same view of the mode of syphilitic infection, is extracted from my book, preceded by a statement (p. 21) of opinion that, " it presents fewer inconsistencies than any of the other theories /" and on page 23, " that it seems impossible, in the light of certain well-known facts, to deny that the syphilitic poison gains access to the general circulation, chiefly, if not entirely, by the lymphatics ;" and again, page 25, " the action of mercury in relieving the early symptoms, also becomes intelligible in the light of this theory, through its influence in hastening destructive metamorphosis and bringing about fatty degeneration ; and its general undoubted tendency to relieve tissues encumbered with superfluous material. Small doses, most naturally, first influence newly-formed immature deposits, such as those due to syphilis, and hence the advantage of the modern treatment, which avoids salivation, due to the toxic action of the drug on the healthy tissues, and depends upon moderate, long-continued doses. The necessity for the use of iodide of potassium, in the later stages, with or without mercury, also becomes apparent, when it is remembered that iodine is the most powerful diffusible stimulant of the function of absorp. tion. with which we are acquainted, and that also, it has a certain established value, in hastening tissue change, especially in unhealthy formations."

In view of the direct, or implied, approval of my position, by these recent eminent authorities in matters involving the nature, behavior, and treatment of syphilis, it has seemed proper that I should make use of every opportunity to advance these views, and to explain, on physiological and histological grounds, the various points in the diagnosis and treatment of cases of spyhilis and its sequelae, herewith presented.

In the second place: Early in my clinical teaching, I had found myself unable to accept the conventional views, held by authorities on many important points in genito-urinary diseases. Especially as to the nature

PREFACE. 9

and treatment of gonorrhoea and urethral stricture and the normal urethral calibre. As to the latter, I could not accept the standard universally taught, but claimed, from actual measurements, an individuality for every urethra, a proportionate relation, between the size of the urethra and the organ in which it is situated, and an average calibre, much greater than previously estimated. I also claimed, contrary to all previous teaching, a radical cure of urethral stricture, through complete division. These views, and others growing out of them, involving important questions in practice, supported by several hundreds of practical examples, defended in written and in oral debate, against eminent authorities in this country and in Europe, made it especially necessary for me to have a medium of communication Avith students, which could not be misinterpreted or misunderstood. With an especial view to this, the second volume of this work was suggested. No attempt has been made to make it a systematic general exposition of genito- urinary diseases. The aim has been, chiefly, to present clinical cases, selected as typical and practical, which have been subjects of observation and study, in my private practice, and in my cliniques, and such additional material illustrative of important practical points, and my own experience in the treatment of such cases, as I could readily command. When some learned and not too busy surgeon, in gathering, from every quarter, the material for a full and systematic treatise on genito-urinary troubles, meets the everyday experiences which have been presented in the foregoing pages, it is my ambition, that some points may be found among them, which will be considered worthy of preservation, in more pretentious form. Meanwhile, I trust that many surgeons may find, in the cases recited, and in the principles and treatment advocated, a key which will help to explain much that has heretofore appeared obscure, and difficult of management.

F. N. Otis.

New York, 108 West 34th Street, April 30, 1883.