SYPHILIS OF THE INNOCENT. By Henry Alfred Robbins, M. D., Washington, D. C. CLINICAL LECTURE DELIVERED AT THE SOUTH WASHINGTON (D. C.) FREE DISPENSARY, DECEMBER 3, 1896. Reprinted from the Maryland Medical Journal, January 23, 1S97. Tins little colored girl, aged eleven years, has been referred to us for exami- nation. She complains of sore mouth. On examination you will notice a typical opaline mucous patch, located just under the right bicuspid tooth. Look further and you see another in the right side of the buccal cavity, back by the first molar tooth. You find enlargement and hardness of the post-cervical, sub-maxillary and epi- trochlear glands. Dr. Arwine has placed he child in proper position on the table and you at once will notice a papular in- durated chancre, located on the right labia externa, which is edematous. Oozing from the vagina, there is a most foul dis- charge. On the corresponding side of the chancre, in the inguinal region, you feel a well-marked bubo. There is the macular erythema, the first eruption of syphilis, ex- tending over the chest and abdomen. On November 11 I reported to the Medi- cal Society three cases of what I supposed were syphilis ofnon-venereal origin. They were all colored female children, each nine years old. One had enlarged glands, and the inguinal and epitrochlear were es- pecially well marked. Over the abdomen there was the characteristic macular erup- tion. Seated on the labia inajora there were a number of condylomata and there was a slight oozing of a mucous discharge at the posterior commissure. The labia were very edematous and on account of the tender age of the child we could not make a thorough examination. The mother has brought the child with her to- day. You notice now that the edema has subsided and the soakings of black wash and daily dusting of calomel have caused the condylomata to disappear, also the cauliflower-like excrescences that extended to and around the sphincter ani. Upon separating the labia you see located just within the labia externa, a little to the left of the fourchette, a papular chancre, about the size of a pea, with its ring-like indura- tion. The water-closet has been accused of being the place where venereal diseases are acquired. There are only two ways in which the disease can be acquired and that is by direct or indirect contact with something that contains the virus of syph- ilis. These cases may have been acquired 2 by contact with the parts described, of a not properly cleansed clot, which has been used during the menstrual period of a syphilitic woman, or they may have been produced by design, as it is a well-estab- lished fact that certain of the degraded and vicious classes think that if they acquire syphilis they can rid themselves of it by giving it to a child. Several years ago my friend Dr. Cuth- bert sent for me in consultation to see a little colored boy aged five years. We found a characteristic chancre on his pre- puce, enlargement of the lymphatic glands, and he was covered with a macular ery- thema. The child confessed to us that his grown-up nurse had taken liberties with his person. Only a few days ago, we had in our service a little colored boy seven years old with an acute attack of gonorrhea, the gonococci of Neisser being found in large numbers in the smear of gonorrheal pus on the slide. This shows the great importance of hav- ing a hospital for treatment of venereal dis- eases. where suspected servants can be sent for examination and treatment. The world at large begins to recognize the contagiousness of pulmonary tubercu- losis. Syphilis is just as contagious -I mean acquired in an innocent way. It is not a pleasant topic, neither is smallpox ; but the big pox is far more dreadful, for it is not recognized and many of its symptoms are attributed to other diseases, examples of which I gave in a paper called " Syph- ilis of the Vital Organs." It is fashionable just now to establish sectarian hospitals for the treatment of the eye, ear and throat. Take away syphilis and there would be no necessity for such hospitals, as it is the chief cause of the eye, ear and throat cases of those who seek aid at the dispensary service. This colored boy is seventeen years old and he says he has a sore on his penis and also a " waxing kernel." Now take a good look at that sore. You will not have to put on your spectacles or make use of a magnifying glass. It is of mature age and can speak for itself. I imagine it saying, '•Gentlemen, I am an ulcerating initial lesion of syphilis, and my brother Bubo the boy calls a ' waxing kernel you may rec- ognize us in various forms, for we have possession and have come to breed." This is called the Hunterian chancre, but Ambrose Pare discovered it one hundred years before John Hunter was born, and was the first to give an accurate descrip- tion of what is now known as the initial lesion of syphilis. You will notice that it is located on the right side of a long prepuce. We have al- ready reported several varieties of chancres, initial lesions. I have always in my mind's eye the four types as described from a clinical point of view by the greatest of all living syphilographers, Alfred Four- nier, viz : First. The erosive desquamative chan- cre. Second. The ex-ulcerative chancre. Third. The ulcerative chancre. Fourth. The papular chancre. The erosive chancre consists simply of an epidermic epithelial desquamation, which merely denudes the derma without excavating it. The ex-ulcerative chancre attacks the derma superficiallv, laying it bare, but not actually excavating. The ulcerative chancre (whose acquaint- ance you have made to-day, is a speaking illustration), on the other hand, is hollow, excavated, jagged ; an ulcer, in fact, but an ulcer at the expense of its own tissue. Finally, the papular or elevated chancre is situated on a sort of raised plateau and forms a disk rising above and sharply de- fined from the surrounding tissues; it sometimes assumes the appearance of the ulcus elevatum described by some authors. Three of the little girls that you have recently seen answer to the description of the fourth type of chancre as described by Fournier. The boy tells us in his own language that he was exposed about three weeks ago and that he does not remember running against a cart-wheel and that he has not been lifting any heavy logs. This is a classical case, for twenty-one days is the average stage of incubation. Accord- ing to Fournier, the first act of the drama of syphilis is contamination. Then appar- ent repose of the organism. Nothing ap- preciable betrays the disease as yet. Second Act.-Production at the point where the virus has penetrated, and only here, of a lesion called initial, which, for the time, constitutes the only expression of the disease. Third Act.-Explosion of 3 multiple and disseminated lesions beyond and outside of the seat of contamination. 'The average time of incubation varies according to the experience of various authors. Diday found the mean duration fourteen days, and so on up to Du Mauriac, who mentioned forty days. There are ex- ceptions, as Fournier reports a case in which the stage of incubation was seventy days after exposure. Simonet and Le Fort report three cases with a duration or ninety days. The late Dr. F. J. Bumstead told me of a number of cases in which the disease was acquired in Europe and was developed in this country. I met a young man in Paris who acquired the disease in Portland, Maine, and it made its first mani- festations after he had arrived in the capi- tal of France. The next thing to look for after the ap- pearance of the initial lesion is enlargement and hardness of the lymphatic glands near- est to the lesion. This is what is called a bubo, or lymphadenitis. There you see it with its cord-like chain of lymphatic vessels leading up to it. Jonathan Hutchinson says that the immoral glands are located above Poupart's ligament, as this one is. Enlarged glands do not always mean syph- ilis, but I do not remember ever having seen a case of the disease in which there were not enlarged glands, especially of the epitrochlear. You may find enlarged lym- phatic glands, and especially below the ligament of Poupart, caused by over-exer- cise, as excess in dancing, swimming, etc., and also from a sore on the foot or leg, of not a specific nature. We will not take up chancroidal buboes now, only to say that " spyhilis very rarely follows an open bubo." A true syphilitic bubo does not generally go on to suppuration. Now we disrobe the boy and we find a most abundant eruption over the chest and abdomen. This is known as the erythema syphiliticum, or the macular syphiloderm or syphilide. It is very slightly elevated above the surface of the skin. It varies in form and size. They are rounded hyperemic blotches. In the white race, the eruption is generally known as the roseola syphilide. As it does not itch, it sometimes comes and goes without being observed. Frequently you call the patient's attention to it. Now our patient tells us that he suffers from headaches and rheumatism. The explosion has taken place and Fournier's drama of the third act of syphilis has com- menced. In plain words, the history of constitutional syphilis is complete and the disease is ripe for treatment. Every one thinks he knows how to treat syphilis, especially those who fail to recog- nize it when they see it. I regret to state that I have met disciples of yEsculapius who knew just about as much of the dis- ease as Nicodemus did of the new birth. I have hesitated about writing a paper on the treatment of syphilis, because every case lias a history peculiar to itself, and requires a treatment adapted to that par- ticular case. Some have the disease so lightly that I verily believe that they re- cover without any treatment at all. Other cases assume the most malignant type and go on from bad to worse, in spite of the most approved treatment. Dr. A. E. Roussel, in the Medical News, May 20, 1S93, reported a case that was of great interest to me. The patient was a man of exceedingly good record be- fore he acquired the disease. He was forty years of age. Dr. Roussel had charge of the case from the time that the second- ary symptoms first appeared. The patient, in spite of the employment of the very best methods of treatment, developed tertiary symptoms with most agoniz- ing pains over each tibia. He also had necrosis of the hard palate as well as the alveola processes of the superior maxillary bone and of nasal bones. In the eighth month of the disease, he was reduced from a weight of 190 to 140 pounds. He died a little over one year from the beginning of the disease. This is a very uncommon history, I am glad to state, but I remember one some- what similar that occurred here in Wash- ington about twenty-five years ago and which has never been reported. The man was a patient of one of our very best and noted physicians. This man lost his hard palate and it was with the greatest diffi- culty that you could understand his nasal twang. I remember that he had to be fed through a stomach tube. He was a mar- ried man, who paid dearly for only one licentious indulgence. From an exalted position in a Presby- terian Assembly and holding an excellent 4 social position he was reduced to an offen- sive mass of humanity, a most pitiable ob- ject. I remember that his wife forgave him and clung to him until they both dis- appeared from view. I heard that he had returned to his native land on the other side of the Atlantic. Most fortunately, I have had no such cases. I know of no other disease that re- sponds so promptly to the skilful admin- istration of the proper remedies. Often the results of our treatment seem only a little short of the miraculous. We will give this boy one-quarter-of-a- grain closes of the proto iodide of mercury three times a day. You notice that we have ordered an ointment containing calomel gi, unguent, zinci oxid. §i, to be applied to the initial lesion. Long ago we ceased to cauterize the chancre. There is no possible objec- tion to removing some forms with the knife. I would recommend it, but I do not believe that it shortens the disease a day. You might as well cut out a vacci- nation inoculation and expect to abort the secondary fever, pustulation, etc. The virus has already been absorbed and is- there to do its work.