October, 1930 GIROLAMO FRACASTORO-STRATMAN-THOMAS 739 functionless right ureter. Ureterogram demonstrated I am not convinced that mild inflammatory proc- a normal ureteral outline, the upper end, however, esses, without distension, can be depended upon as was blunted and showed no pelvis. The left kidney a cause of this ureteral pain. I think that the dilata- and ureter were normal. On March 11, 1925, a right tion of the ureter for the purpose of studying its ureterectomy was done. The ureter appeared soft and effect upon the pain should be a helpful guide, before normal throughout and no change in the wall could extirpation of the ureter is considered. be demonstrated macroscopically. Microscopically the ureter showed very little except edema and polymor- phonuclear infiltration of the wall with some loss of WILLIAM E. STEVENS, M. D. (608 Flood Building, San mucosa. Culture and microscopic examination of Francisco).-Doctor Michelson's interesting paper smears were negative for bacteria. The patient has calls attention to an unusual condition, ureteral pain had no pain in the right side since, although she has after nephrectomy in the absence of demonstrable had symptoms referable to a ureteral stricture on the pathology of the ureter or other urinary organs. left side. I have never seen a similar case. The disappearance COM MENT of the pain following ureterectomy seems to indicate The reason that more cases of this kind are the presence of some pathologic condition of the ureter, the diagnosis of which was impossible with not operated upon, is due, I believe, to the gen- the methods of examination available at this time. eral conception that pain in the reno-uteral tract A case I saw in consultation a short time ago is is from back pressure due to obstruction. The interesting in this connection. The patient was a kidney being removed and urine no longer se- young girl who entered the hospital complaining of creted, there is no back pressure and pain in the right lumbar region and the upper and the cause lower right abdominal quadrants. The family his- of pain must be looked upon as extra-ureteral. tory was negative. She had been treated fourteen Therefore, according to this way of thinking, months before for pain in the right lumbar region removal of the ureter would give no relief. accompanied by pus in the urine. Her temperature, pulse, urine and blood count were normal. Tender- Nevertheless, it is not improbable that the in- ness was somewhat greater on deep palpation at Mc- flammatory reaction is due to infection, carried Burney's point. Pyelography revealed an enlarged by the lymphatics around the ureter. One must right kidney pelvis. Indigo carmine injected intra- venously appeared at the left ureteral orifice in five also bear in mind the sensitiveness of the parietal minutes, but none could be detected on the right side peritoneum, to which the ureter is attached, and in one-half hour. Further examination was refused. not overlook the fact that any inflammatory con- Following a provisional diagnosis of appendicitis dition of the ureter may react on this membrane. her doctor removed an appendix not definitely patho- logical. Notwithstanding the abnormal condition of In both the cases to which I have alluded, the the upper urinary tract the lumbar and abdominal pain was the deciding symptom. And the fact pain disappeared following the appendectomy. In that pain was present when there was no back view of the findings treatment directed toward the urinary tract would have been justifiable but probably pressure, and disappeared upon resection of the no ureter, shows definitely that pain in like cases, improvement would have resulted. even where the kidney is still present, is not due exclusively to back pressure. THE LURE OF MEDICAL HISTORY CON CLUSION In cases where, after nephrectomy, pain is pres- GIROLAMO FRACASTORO (1478-1553) ent, apparently along the line of the ureter, and this pain is severe and persistent-after elimina- AND SYPHILIS* tion of other possible causes, removal of the By W,. K. STRATMAN-THOMAS, Ph. D., M. D., ureter should be seriously considered. D. T. M. AND H. 490 Post Street. New York City DISCUSSION OUR hundred years ago (in August ANDERS PETERSON, M. D. (1136 West Sixth Street, 1530), Los Angeles).-It has not occurred within my experi- Girolamo Fracastoro, the genial Veronese phy- ence that the ureter free from pathology has caused sician, astronomer and poet, published that most any disturbances following nephrectomy. On the con- interesting medical poem Syphilis sive Morbus trary, many pathological ureters are permitted to Gallicus. Dedicated to his remain at the time of nephrectomy, and only a few friend, the Cinquecento of these cause any disturbance. This, I think, is par- pagan, Cardinal Pietro Bembo, the poem surveys, ticularly true in cases of tuberculosis, where the ureter in the flowery pseudoclassical style of the period, is almost always involved in the tuberculous process. opinions on the origin, symptoms, and treatment In neither one of the two cases reported by Doctor of the disease now known by the name Fracastoro Michelson did the pathologist demonstrate any patho- gave to one of his poetical characters. logical entity. However, it is of interest that in Case 2 temporary relief was experienced by the patient Where Fracastoro got the word syphilis is not following dilatation of the ureter. This, to my mind, known. But that this name of the fictitious shep- did indicate that even though the kidney was removed herd, who Fracastoro says first contracted the ill- some distension of the ureter might well have been ness by defying the sun god, has become the responsible for the pain. common designation of the disease was not mere I have recently had such an experience with a man chance. The jolly Fracastoro deliberately gave upon whom a nephrectomy for stone had been done and some years previouslv who complained of pain * Edited for publication by Dr. S. V. Larkey and in the nephrectomized side. The urological examina- Professor C. D. Leake from notes and material prepared tion revealed several small calculi, lying in the lower by Dr. Stratman-Thomas while in London and Africa as end of the ureter, and this man actually experienced a Guggenheim Traveling Fellow, 1928-1930. * Itead before the California Medical History Seminar, a pain similar to renal colic, extending well up into at a luncheon in honor ofN Dr. and Mrs. Charles Singer of the kidney space. London, on August 19, 1930. 140 CALIFORNIA AND WESTERN MEDICINE Vol. XXXIII, No. 4 countrymen. He died in 1553 from apoplexy, and was buried in his beloved Verona. In 1555 the Senate of Verona commissioned Danese Cataneo to carve a lifesize statue of Fracastoro,2 which now adorns a narrow street arch near the Piazza dei Signori. Klebs has enter- tainingly described 2 another bust, presumably of Fracastoro, by this same Cataneo. Most of the representations of Fracastoro seem to have been taken from the woodcut portrait in his De Homo- I contricis (Verona, 1538), which is supposed to be the only authentic likeness made during Fracas- toro's life. There is, however, a portrait (No. 3949) in the National Gallery, London, which is supposed to be that of Fracastoro, and which is attributed to Francesco Torbido (1486-1545). While it portrays a slightly younger man than the woodcut, there is considerable similarity. The mole near the nose on the right side of the face, wvhich shows on the woodcut, is lacking in the painting. But in the Pitti Gallery (Florence) portrait,3 this mole appears on the left side of the face. Since the National Gallery portrait has not hitherto been published, enough interest attaches to it to reprocluce it here, with the woodcut, for comparison. THE POEM HIER ON Y MI ER AC After the usual flowery introduction, Fracas- Fig. 1-Wood-cut portrait of Fra.castoro in hiis Hoviocen- toro alludes to the belief that syphilis was brought trica, Venice, 1538. Supposed to be the only g-enuine likeness made during his life (1478-1553). to Europe from the New World. He says, as translated by Tate (1686): the cue in the poem itself. As translated in 1686 "Say, Goddess, to what Cause we shall at last by "England's worst poet laureate," Nahum Tate, Assign this Plague, unknown to Ages Past; the passage reads: If from the Western Climes 'twas wafted o'er, WVhen daring Spaniards left their native shore; A Shepherd once (distrust not ancient Fame) Resolv'd beyond th' Atlantick to descry, Possest these Downs, and Syphilus his Name. Conjectur'd Worlds, or in the search to dye. For Fame Reports this Grief perpetual there, He first wore Buboes dreadfull to the sight, From Skies infected and polluted Air: First felt strange pains and sleepless past the Night; From whence 'tis grown so Epidemical, From him the Malady receiv'd its name, Whole Cities Victims to its Fury fall; The neighboring Shepherds catcht the spreading Few 'scape, for what relief where vital Breath. Flame. The Gate of Life, is made the Road of Death?" Later, in the more critical discussion of the dis- It may be that the "Grief perpetual" referred ease in his pioneer treatise on infections, De con- to in the New World was yaws, difficult to dis- tagionibus et contagiosis miorbis (1546), Fracas- tinguish from syphilis, and endemic in the West toro consistently refers to the condition by the Indies. Columbus' sailors may easily have con- name given to it in his earlier poem, Syphilis. tracted this disease and returned with it to While Fracastoro is generally known because Europe. of his famous poem, his scientific position is as- But Fracastoro with much wisdom does not sured by this treatise on infections. Carefully directly accept the vulgar notion that syphilis was analyzed by the Singers,1 they state "the excel- a newly arrived disease for these cogent reasons: lencies of this work are so numerous as to mark Syphilis appeared in some European countries an epic in the history of medicine." As an as- having no traffic with America; the disease be- tronomer, Fracastoro wrote in opposition to the came epidemic in many distant nations at the same Ptolemaic doctrine of a geocentric universe. In time; syphilis was present first in France, then this he may have been inspired by his medical in Italy before it was known in Spain. There- schoolmate at Padua, the famous Pole, Coper- fore, for the origin of syphilis one must look nicus (1473-1543). The first to use the term elsewhere than to America. "pole" with reference to the earth, he was also a Further, in this pioneer but poetical discussion pioneer in the scientific analysis of the refraction of the origin of syphilis, Fracastoro states that of light, and the Singers say he was "probably diseases are of two kinds: certain distempers the first to suggest the combination of lenses as are constantly present (endemic) and conse- an aid to vision." Always busy at intellectual quently are always recognized; others may appear tasks, he shunned the political and religious in- only at long intervals (epidemic)-intervals so trigues of his age, and lived quietly in his country long that not only the clinical description of the villa, beloved by his friends and respected by his disease, but its very name is forgotten. Syphilis October, 1930 GIROLAMO FRACASTORO-STRATMAN-THOMAS 741 is one of the latter group, and the Neapolitan A careful dietary regimen is to be observed, pestilence is not the first epidemic of syphilis that says Fracastoro, and bleeding may be employed has spread over Europe-nor the last! if the patient is robust. After these general in- It is the opinion of Fracastoro that the pol- structions, the real cure is to be secured by the lution of the atmosphere is the cause of syphilis. use of mercury. Fracastoro states that the thera- The virus can enter man easily since the air not peutic action of mercury may be explained in one only enters the body by every pore, but is also of three ways: (1) Mercury may immediately inhaled. The causes of this atmospheric pollution, attack the virus and destroy it;. (2) mercury may he opines, are certain untoward conjunctions of be inert, and incapable of destroying the virus the planets, the common explanation of the time until the metal has been acted upon by the human for all major natural phenomena-and reasonable body; or finally (3) it may act upon the human enough, Fracastoro, suggests, for do not the sea- body itself in such a manner that man's very self sons depend on the position of the sun, and the destroys the virus: tides on that of the moon? "The greater Part, and with success more sure, The aid of Apollo is now invoked in describ- By Mercury perform the happy Cure; ing the symptoms of the disease, so that when it A wondrous virtue in that mineral lies . . . appears again it may be recognized and not con- sidered new. And for a Vehicle use lard of Swine "Yet oft the Moon four monthly rounds shall steer Before convincing Symptoms shall appear; This done, wrapt close and swath'd, repair to Bed, So long the Malady shall lurk within, And there let such thick Cov'rings be o'er-spred And grow confirm'd before the danger's seen; Till streams of Sweat from ev'ry pore you force: Yet with unwonted heaviness is seiz'd, For twice five Days you must repeat this Course; With drooping Spirits, his affairs persues, Severe indeed but you your Fate must bear, And all his Limbs their offices refuse, And signs of coming Health will streight appear. The chearful glories of his Eyes decay, The Mass of Humours now dissolv'd within, And from his Cheeks the Roses fade away, To purge themselves by Spittle will begin, A leaden hue o'er all his Face is spread, Till you with wonder And greater weights depress the drooping Head; at your feet shall see Till by degrees the secret parts shall show, A Tide of Filth, and bless this Remedy." By open proofs the undermining Foe; Before discussing in detail the therapy of Who now his dreadful ensigns shall display, Devour and harass in the sight of day. syphilis with mercury, Fracastoro makes a long poetical digression explaining how the gods re- Dire Ulcers (can the Gods permit them) prey vealed to Ilceus the use of mercury for this con- On his fair Eye-balls, and devour their Day, dition. He also gives in long passages an account Whilst the neat pyramid below, falls mouldring away. of the use of the "sacred wood," guaiac, in treat- Whence to the Bloudless Nerves dire Pains ensue, At once contracted, and expanded too; The thinner Parts will yet not stick so fast, But to the surface of the Skin are cast, Which in foul Botches o'er the Body spread, Profane the Bosome, and deform the Head: Here puscles in the form of Achorns swell'd In form alone, for these with Stench are fill'd, Whose Ripeness is Corruption, that in time, Disdain confinement, and discharge the slime; Yet of the Foe would turn his forces back, The Brawn and inmost Muscles to attack, And Pierce so deep, that the bare Bones have been Betwixt the dreadful fleshy Breaches seen; When on the vocal parts his Rage was spent, Imperfect sounds for tuneful Speech was sent." In advising on the treatment of syphilis Fracas- toro reveals sound clinical judgment. He sug- gests that the physician first of all study the temperament of his patient in order to facilitate confidence and cure. To keep the patient from gloomy introspective thoughts, mild outdoor ex- ercise in a good climate is urged. With clear appreciation of the venereal character of the disease, Fracastoro specifically cautions against spreading it through sexual indulgence: "With lighter Labours of the Muses sport, And seek the Plains where Swains and Nymphs resort. Abstain however from the Act of Love For nothing can so much destructive prove: Bright Venus hates polluted Mysteries, An ev'ry Nymph from foul Embraces flies. Fig. 2.-Portrait No. 3949, National Gallery, London, supposed to represent Fracastoro. Attributed to Fran- Dire practice! Poison with Delight to bring, cesco Torbido (1486-1545), his contemporary. Courtesy And with the Lovers Dart, the Serpent's sting." National Gallery. 742 CALIFORNIA AND WESTERN MEDICINE Vol. XXXIII, No.4 I4TERONYMI by Prof. W. C. Wright of Bryn Mawr, makes FRACASTORIT Fracastoro's most important contribution avail- S Y P H I L X S. able to modern readers. This should result in general recognition of Fracastoro's significance SIVE MORBVS GALLICVS in the slow transition from the ancient humoral conception of disease to the present specific no- AD P, BEMBVM. tion of fevers. It is heartening to note an in- creasing interest on the part of modern classical Vi rerum scholars in the scientific aspects of classical and af/us uary, quxfemiv mediaeval writers. Prof. Wright's excellent ef- na morbum fort is, let us hope, only the beginning of many similar studies in medical history. q I nfuettum ,nec longa u1i per few Truly Fracastoro was a great and brilliant cula uifum man: physician, poet, astronomer, physicist, and humanist. In his calm achievements, in spite of A vulerint :noflra qui tempeftao the restlessness of his age, we may, four hundred te per years later in a similar restless age, find much omnem comfort and inspiration. E uropam,partim'q, per irbes International Health Board, Rockefeller Foundation, A/ia,Libyp#,; 61 Broadway. S d'uyt: in Laitim uero per trijfia betl REFERENCES 1. Singer, C., and Singer D. The Scientific Posi- G allorum irrupit: nomen4v a gente recepit. tion of Girolamo Fracastoro. Annals Med. Hist., 1, 1, N ec 1917. non or qua, cura :y opisquid comperit ufur, 2. Klebs, A. C. Iconographic Notes on Girolamo M agna4, in bominum Fracastoro. Johns Hopkins Hosp. Bull., 26, 378, 1915. anguflis follertia rebus: 3. Cumston, C. G. History of Medicine. London I t monfirata Deum auxilia, data and New York, 1927. or twunerocwli, 4. Osler, W. Fracastorius, in "An Alabama Stu- H ine canere , tonge fecretas querere dent and Other Biographical Essays." Oxford, 1908. ay caufas p. 278. A era per liquidum, ey uafli per fvdera olympi 5. Wright, W. C. Hieronymii Fracastorii De Con- tagione, Libri III, Translation and Notes. New York I ncipiam, dulci quando nouitatis amore' and London, 1930. CLINICAL NOTES AND CASE Fig. 3-First page of text from Fracastoro's Syphilis, sive ntorbus Gallicus, First Edition, Verona, 1530. Courtesy Dr. LeRoy Crummer, whose beautiful large margin copy REPORTS contains several pages of manuscript material in a con- temporary hand apparently continuing the poem. THE RADICULAR SYNDROME FOLLOWING ing the disease as followed by the natives of INFECTION WITH TETANUS America, where the wood grows, and as revealed REPORT OF CASE by them to the Europeans. The latter part of the poem is concerned with By MARY LAWSON NEFF, M. D. a lengthy mythical story of the shepherd of King Los Angeles- Alcithous, Syphilis by name, who by defying ACASE of chronic unilateral tetanus, not con- Apollo in a bitter drought was punished by being forming to any textbook description of the the first to contract the disease. disease; presenting many of the symptoms charac- It is easy to see how such an interesting poem, terizing the "radicular syndrome"; continuing for combining practical medical skill with great ar- ninety days with steadily increasing severity; and tistic ingenuity, should become deservedly popu- recovering with dramatic rapidity upon the ad- lar. It went through very many editions, and ministration of tetanus anti-toxinr on the ninety- has been translated into almost every important first day-such a case seems of sufficient interest, European language. Fracastoro's De Contagioni- and importance to be reported as fully as the bus (1546), a really great scientific contribution. records make possible. to medicine, deserves similar recognition, for in As the patient was seen and treated at different it is enunciated clearly the modern doctrine of times by several physicians, and the case presented the specific character of fevers, the differentiation before medical groups -for study, the plan of se- as a clinical entity of typhus fever, and the basis curing all available information and fusing this of modern teaching on infection by the classi- with the writer's own records, has been followed, fication of the modes of infection. In addition and the result edited so as to make a connected to its excellent discussion of syphilis, this treatise account. .No one physician could have supplied also contains a still unappreciated, in spite of all the data embodied in this study. Osler's eulogy,4 account of phthisis. REPORT OF CASE The splendid new and complete English trans- A. L., an intelligent working man, aged forty-one, lation,5 with extensive notes.and bibliographical sought relief for what he stated had been diagnosed and historical comments, of the DYe Contagione as a severe neuritis. His previous history was that