Anznals of the Royal College of Surgeons of England (I98I) vol. 63

John Hunter and venereal disease

D J M Wright MD Department of Medical Microbiology, Charing Cross Hospital Medical School, London

Key words: HISTORY OF MEDICINE; HUNTER, JOHN; VENEREAL DISEASES; SYPHILIS; GONORRHOEA Summary both diseases did not affect the same part (4). John Hunter's contribution to the understanding He was therefore persuaded, in the interests of venereal disease is reviewed. Hunter's evidence of economy of diagnosis, that as both syphilis for the unitary nature of these diseases is and gonorrhoea could be transmitted by sexual examined and the advances he made in diagnosis, intercourse and often occurred together they pathology, and management are considered. were but one malady (4). He explained that the different clinical symptoms and appear- Introduction ances of syphilis and gonorrhoea were deter- mined by the part of the body that was affected Nowhere in the I8th century does the con- (6). When the skin was affected ulceration ventional surgeon-anatomist merge more com- resulted, while if mucous membranes such as the pletely into the experimental pathologist than vagina or urethra were involved in the disease with the career of John Hunter. He was the process, then a discharge developed. His post- inspiration for both Dr Jekyll and Mr Hyde (i) mortem dissections of the urethrae of two and according to medical folklore he inoculated corpses, retrieved from the hangman, of men himself with the 'venereal poison', becoming a who had suffered from gonorrhoea revealed 'martyr to science' (2). In the Miner Library signs of purulent inflammation and no ulcers verbatim notes of Hunter's lectures on venereal or 'absorbative reaction' (7) characteristic of disease (3) there is the statement, 'I produced in syphilis (8). myself a chancre', but it is unlikely that this is reliable as it was made at least 7 years after That gonorrhoea and syphilis were one disease Hunter's death by an unknown student and may was also suggested by an experiment undertaken be a transcription error. Whatever its historical in 1767 in which gonococcal matter produced basis, the story illustrates the fact that Hunter's a chancre (9). In this experiment urethral pus scientific beliefs arose after they had been verified was inoculated by lancet on to the surface of by personal observation and experiment. His in- the prepuce and glans. An ulcer, followed by timate experience of the subject is found in his buboes, gradually developed. These mani- observations when working between 1748 and festations were partially resolved by treatment I760 with his brother, William Hunter. These with mercury. In Hunter's detailed description observations were extended while serving as an of this experiment it was found that in 2 days army surgeon on Belle Isle and later in Portugal the patient had a 'teasing irritation' which (I76I-63), and further work was based on developed into a visible red preputial spot by patients at St George's Hospital and in his pri- the 4th day. Seven days after inoculation the vate practice. lesion began to slough and by the I I th day had progressed so far that lunar caustic and nature of and calomel dressings had to be applied. At about Unitary gonorrhoea syphilis this time a spot on the glans was noted. The John Hunter's grounds for believing that gonor- inoculation reaction resolved and at 4 months rhoea and syphilis were only one malady were broke down again and became indolent, taking various. It was his settled opinion that a patient 3 years to heal. presented with only one constitutional disease at a time (4). This was the reason, he suggested, Hunter put forward a further argument in that florid measles suppressed the cell-mediated favour of syphilis and gonorrhoea being the reactions following smallpox inoculation (5). same disease-their epidemiology (io). He He conceded that more than one disease could noted that by the time Captain Cook visited the be found in the patient but asserted that if this island of Tahiti on his last voyage both syphilitic happened the diseases would not be found in the chancre and gonorrhoea were prevalent there. same part of the body. So when smallpox In fact Cook described 'the accursed gonorrhoea occurred in a patient already suffering from lues and the little yellow jaundice (infectious Jolin IIunter and venereal disease 199 hepatitis) which was hard to account for' (iI)*. incubation periods were different and that mer- The natives of the island of Tahiti dated the cury treatment discriminated between the two onset of these diseases to the visit of Bougain- diseases, gonorrhoea being resistant and syphilis ville, whose ship had called at the island in susceptible to this treatment. Hunter even 1768, staying for 9 days (io). The crew had argued that the specificity of mercury in the developed gonorrhoea, but not syphilis, 3 weeks treatment of syphilis was evidence for the syph- after leaving the island. After Bougainville left ilitic nature of rheumatism (M8), which may have the island it is recorded that the Tahitians re- been bone gummata or periostitis, as the con- tired to the interior of the island where gonor- dition was subdued by treatment with mercury. rhoea, unlike the 'pox', could be cured (io). An Hunter recognised that immunity to reinocula- earlier explorer, Wallis, who discovered the tion was a feature of syphilis (1g), while re- island in I767, made no mention of gonorrhoea, peated episodes of gonorrhoea were frequent despite spending 5 months on the island (io). occurrences, implying that immunity to the gono- This lends support to the suggestion that coccal component of the disease did not develop. Bougainville did introduce the disease to the When Hunter's inoculation experiment men- island. It was also known that Wallis was con- tioned above was considered it was suggested cerned about the health of his sailors and had by d'Arcy Power (2) that, as the lesion follow- his crew inspected by the ship's surgeon before ing inoculation of syphilitic material developed going ashore to ensure that they were free from so quickly, the initial lesion might be chancroid. the disease (12). Hunter deduced that Wallis, It is possible that the infection might have who had been at sea for i i months before resulted from lack of aseptic precautions and the arriving at Tahiti (io), was unlikely to have disease may have been rendered chronic by the brought gonorrhoea with him as the time spent application of topical medication. Furthermore, at sea was longer than the incubation period there is no evidence that the person inoculated for this disease, whereas Bougainville, who had refrained from sexual intercourse in the 3 years left Rio de la Plata 5 months previously (io), of observation and might well have contracted would have noticed if his sailors had developed syphilis at a later date. It is unlikely that penile chancre en route but might have over- Hunter missed the diagnosis of an intraurethral looked mild gonorrhoea. Hunter was convinced chancre in the patient who was the source of that syphilis must have been transmitted in the gonococcal material for the inoculation experi- form of gonorrhoea and then developed as ment. He advocated the diagnosis of cowperitis syphilis on the island of Tahiti (io). Hunter by the clinical technique of palpation of the base did not know that when Wallis landed on the of the penis (20). If he had followed his own island a Spanish merchant ship landed, un- directions before beginning the experiment he known to Wallis, on the other side of Tahiti would have detected the diagnostic intraurethral (io) and it has been suggested that it was these mass in the donor's urethra (20). Lastly, it sailors who spread gonorrhoea throughout the seems unlikely that Huniter experimented on him- island if the disease was not already present self since if he had inoculated himself with (I4). Gonorrhoea has been endemic there ever syphilis he surely would have treated himself since (I5). with mercurials, which might have caused skin discoloration, and it is difficult to imagine that Inconsistencies in the theory that syphilis even if this treatment was taken in secret it would not have come to light. The postmortem and gonorrhea were a common disease reports on him indicate no pathological changes The separate identities of syphilis and gonorrhoea attributable to syphilis (22). In addition, all his were not settled until Ricord's experiments in other inoculation experiments were on patients 1837, when he inoculated 2500 'human volun- on whom he attended (23). He was not, how- teers' with gonorrhoea, none of whom developed ever, averse to self-experimentation and was syphilis (i6). Even today, nearly 200 years later, known to have given himself madder root to Koch's postulates for syphilis and gonorrhoea discover whether his urine changed colour, which have not been fulfilled. Jesse Foot, a contem- it did (24). porary of Hunter's who criticised much of his work, accepted the theory of the single nature of the diseases without question (I7). Apart from Immunological observations the clinical differences between syphilis and Hunter made a number of interesting obser- gonorrhoea, Hunter also chose to ignore that their vations on the immunology of syphilis. He was unable to produce lesions by inoculating the *Gook voyaged to Tahiti to observe the transit of disease in patients with secondary syphilis, but Venus, not the transmission of her diseases. he could do so during the primary stage (ig). 200 D J M Wright He attempted a variety of challenge experiments: Observations on transmission of disease he was unable to produce syphilitic ulcers if Hunter had no doubt that the mode of transmis- material for autoinoculation was derived from sion common to both syphilis and gonorrhoea patients with late secondary lesions but could was venereal. He deduced that gonococcal pus invariably succeed if material from a chancre was was infectious because if the pus was removed by used (ig). This may imply that fewer bacteria washing from the urethra of the patient with were present in the late secondary rashes, but gonorrhoea the sexual contact of that patient Hunter believed that the inability to reinoculate was less likely to acquire the disease (34). It was due to constitutional resistance (1g). In followed that if venereal disease were to be pre- fact his view has been borne out by modern vented it was preferable that onanism rather work which demonstrates that in secondary than natural sexual intercourse should be syphilis there is not only a suppression of cellular practised by infected partners (35). Hunter also immunity in the infectious stage, which makes observed that syringes employed to treat gonor- tuberculin-type (luetin) reactions unlikely to rhea transmitted the disease when used for rectal occur (25), but even if a lesion does occur it washouts, causing gonococcal proctitis in those wouild mimic the minimal lesions of secondary patients (36). After studying syphilis in infants syphilis, the stage of the disease that the patient he thought that the disease could not be trans- has reached. In contrast, during primary syphilis mitted congenitally (37), although he was not the luetin test tends to give a positive reaction unaware of transplacental transmission of disease and inoculation ulcers are produced (25). since he had described a case of congenital small- Following Hunter, from the early igth century pox (38). Hunter was also accused of transmit- until relatively recently, physicians regarded the ting syphilis by tooth transplantation (39). How- lack of multiple autoinoculation lesions in syphilis ever, the reactions which resulted from this pro- as a diagnostic test for syphilis as compared cedure were more likely to have been caused with chancroid (26). Hunter considered that the by the rejection of a small part of the tissue re- agent of syphilis was a morbid toxin which moved with the transplanted tooth, perhaps com- multiplied within the host (27). Jesse Foot plicated by a foreign body reaction, than by drew the analogy between this venereal toxin and syphilis. He was unable to transmit venereal snake -venoms; snake venoms, although harmful diseases to animals, but his experiments were to other species, never harm the snake (28); so limited to asses and dogs (40). once the venereal toxin was present in the patient no further lesions would be produced in the Clinical observations event of a fresh infection. Hunter described the relapsing nature of syphilis, Hunter's concept of the functions of lymphoid loss of hair, and the palmar and plantar syphilides tissue was that lymph nodes might also be a bar- as well as the 'transparent' early (roseolar) skin rier to further infection, especially as he con- rash (4I). He thought the distribution of lesions ceived that skin ulcers resulted from absorption was enhanced in the colder parts of the body of noxious foreign matter (29). Some of the (42); preference for lower temperatures may lymph-node enlargements might also follow a re- partially explain the distribution in man of the action to infection (30). Arguing that the late secondary lesion such as condyloma. The syphilitic virus might pass up the lymphatics to ease with which the spirochaete is cultivated in the lymph node, Hunter applied mercury to the the laboratory by inoculation into the rabbit skin of the thigh adjacent to the enlarged testis may also be related to the testis being syphilitic inguinal lymph node, which then re- slightly cooler than other parts of the rabbit, gressed in size (si). Hunter argued that this enhancing the survival of Treponema pallidum followed the local absorption of mercury to the at the site (43). Hunter noted that deafness lymph node. He may have been influenced in (44), involvement of the eye (45), and periostitis these experiments by the postmortem findings of (44) might be caused by syphilis. He did not Sheldon, who had delineated the lacteals by in- believe that the viscera and brain were affected jection of mercury (32). Hunter had already (46). demonstrated the lacteals, with his brother Wil- Hunter's postmortem investigations showed liam, by using indigo incorporated into milk that although the terminal inch and a half of which was then fed to animals. These animals, urethra might be free from the disease, lacunae when killed, had blue-stained lacteals, having were full of pus and might give rise to the absorbed the coloured milk (33). The analogy sinuses at these sites (8). He contrasted the lack suggested by these experiments was that in- of infection by gonorrhoea in the ovaries with fectious agents might be removed and sub- the disease in the testes (47) but was acute sequently absorbed in the lymph nodes. enough to note that the testicular disease was an john Hunter and venereal disease 201 epididymitis rather than an orchitis (48); he patient withi buboes was begun, but if the mer- failed to look for evidence of salpingitis. Hunter curial treatment was continued rapid healing re- did not understand hoxv gonorrhoea, which sulted without any constitutional disturlbance started in the urethra, spread to the testes. He (63). proposed that 'sympathetic inflammation' ac- counted for the syndrome (49). It is not sur- Conclusion prising that HLunter recognised that urethritis In the latter part of the i8th century venereal could be associated with arthritis, 'the seat of disease was managed with a mixture of hope, rheumatisrn' (50), as the syndrome was sus- wild guesswork, and traditional ignorance. pected by Hippocrates (5i). He described Hunter, with his passion for observing natural weakness and fainting following urethral instru- phenomena ranging from geology to comparative mentation, wvhich resembles the changes found anatomy, included all disease, and particularly in endotoxic shock (52). He suggested that venereal disease, in this category. Hunter found chordee followed dilatation (thrombosis) of the venereal disease was a subject that merited vessels of the corpora cavernosa penis (53); study, making discussion of such diseases respect- Hunter thought that these changes were ana- able in medical circles. The absorption and logous to those described by Cuvier of dilated digestion of his pioneer research freed the sub- penile vessels of elephants after erection (54). ject from indifferent observation despite the A dried preparation of an elephant's penis ex- efforts of argumentative if not perverse oppo- isted in the original Hunterian Collection at nents. He is remembered for his rational tech- the Royal College of Surgeons of England. nique in investigating venereal disease based on Everard Home, 22 years later, drew the analogy observation and experiment. between these vessels and the dilated vascular network in the spleen (55). Grateful acknowledgements are extended to Miss, E Allen, Curator of the Hunterian Museum, and Pro- fessors H I Winner and A J Harding Rains, both of Guidance for treatment Charing Cross Hospital Medical School, for advice Hunter's attitude towards treatment was very and encouragement. conservative. He observed that gonorrhoea was a self-limiting disease tlhat resolved in I in 5 References cases within 2 weeks and in 4 out of 5 cases i Kobler J. The reluctant surgeon: a biography within 2 months (56). There was therefore no of John Hunter. New York: Doubleday, 1960: need to give any treatment other than support- 229. ive measures in the uncomplicated case. He was 2 Power Sir d'A. Selected writings (I877-I930). thus led to abjure the use of topical applications Oxford: Clarendon Press, 1931: I-I3. such as astringents, turpentine, vitriols, evacu- 3 Weimerskirch PJ, Richter GW. Hunter and venereal disease. Lancet 1979;1 :503-4. ants, and other nostrums such as 'dragon's 4 Hunter J. A treatise on the venereal disease, 3rd blood' (57). He arranged a clinical trial in ed with comments by Everard Home. London, wvhich he showed that only i in Io patients with 18I0:4. (First ed published I786.) gonorrhoea was helped by the treatment then 5 ibid:3 available; his control groLp was given bread pills 6 (a) Parkinson JWK, ed. Hunterian reminiscences, (58). However, he lacked a statistical training being the substance of a course of lectures de- and therefore did not hold with 'multiplying ex- livered by Mr John Hunter in the year I 785, periments to prove an already "obvious" propo- transcribed by Mr James Parkinson. London: sition' Treatment should not be withheld Sherwood, Gilbert, and Piper, I833:8. (59). (b) Hunter J, op. cit. (4): I7. if gonorrhoea was complicated by stricture of the 7 Parkinson JWK, op. cit. (6):io. urethra; dilatation was then recommended (6o). 8 Hunter J, op. cit. (4) :31. If dilatation of the urethra by bougies was in- 9 ibid: 3 I 3, 346. effectual Hunter then advised that the urethra io ibid: 13-I7. be opened above the level of the stricture and a il Beaglehole JC. Life of Captain Cook. London: probe be inserted to dilate the stricture from Black, 1974: 568. above rather than from below (6i). He knew 12 Carrington H, ed. The discovery of Tahiti: a that syphilis could not be cured without mercury, journal of the second voyage of HMS Dolphin, the specific antidote, but warned against toxic written by the Master, George Robertson. London: Hakluyt Society, I948; cited Journals I:556. effects such as soreness of the mouth or dis- 1,3 Beaglehole, JC, op. cit. (iI): i88. coloration of the skin (62). He was aware of 14 Forster JR. Observations made during a voyage the Herxheimer reaction as he described a case round the world, on physical geography, natural with 'great debility, hectic heat and colliquative history and ethinic philosophy. London: G swveats which occturred when treatment of a Robinsoni, 1778:935. 202 D J M Wright

15 Willcox RR. Venereal disease in the South Pacific. 34 Hunter J, cited by Foot J, op. cit. (17):35. Br J Veiner Dis 1980;56:204-9. 35 ibid: 2I5. i6 Ricord P, quoted by Longo LD. Classic pages 36 Hunter J, op. cit. (4):30. in obstetrics and gynaecology. Vorlaufiger 37 ibid:3I2-4. Bericht uber das Vorkommen von Spirochaeten 38 Hunter J. An account of a woman who had in syphilitischen Krankheitsprodukten und bei smallpox during pregnancy and who seemed to Papillomen, von Fritz Richard Schaudinn and have communicated the same disease to the Erich Hoffman (Arbeiten aus dem kaiserlichen foetus. Phil Trans R Soc Lond 1780;70:128-42. Gesundheitsamtes (Berlin) 1905;22:527-34). Am 39 Hunter J, op. cit. (4):422. J Obstet Gynecol I978;132:571-2. 40 ibid: 9, 20. 17 Foot J. Observations upon the new opinions of 41 ibid: 340-2. John Hunter on his latest treatise on the venereal 42 ibid:335. disease. London: T Beckett, 1786: 24. 43 Weber M. Factors influeilcing the in vitro sur- id Hunter J, op. cit. (4): 303. vival of the virulent Nichols strain of Treponema I9 ibid: 312-3. pallidum. Doctoral thesis, Johns Hopkins Uni- 20 ibid:48. versity, 1953:51- 2! Lovemani AB, Morrow RP. The value of dark- 44 Hunter J, op. cit. (4):327. field examination of lymph nodes in the diag- 45 Hunter J. A treatise on the blood, inflammation nosis of early syphilis. American Journal of and gunshot wounds, ed E Home. London: G Syphilis 1944;28: 44f-8. Nicol, I794:362. 46 Hunter J, op. cit. 22 Turk JL and Livesley B, cited by Qvist G. John (4):325. 47 ibid:68. Hunter's alleged syphilis. Ann R Coll Surg Engl 48 ibid:67. 1977;59: 205-9. 49 Parkinson JWK, op. cit. (6): 26. 23 Hunter J, op. cit. (4): 220. 50 Hunter J, op. cit. (4):34. 24 Sheldon J. History of the absorbent system. Lon- 5 I Chadwick J, Mann WN, trans. The medical don: Sheldon, I784:31. works of Hippocrates. Oxford: Blackwell, 1950: 25 Wright DJM, Grimble AGS. Why is the infectious 34-5. stage of syphilis prolonged? Br J Vener Dis I974; 52 Hunter J, op. cit. (4): I46. 50:45-9. 53 ibid: 240. 26 Heyman A, Beeson PB, Sheldon WH. Diagnosis 54 ibid:24 of chancroid, relative efficiency of biopsies, cul- 55 Home E. On the structure and use of the spleeni, tures, smears, auto-inoculations, skin tests. JAMA Phil Trans R Soc Lond I8o8;98:45-54. 1945; I 29:935-8. 56 Hunter J, op. cit. (4):353. 27 Hunter J, op. cit. (4):9. 57 ibid:87 28 Abbe, cited by Foot J, op. cit. (I7):35. 58 ibid: 76. 29 (a) Parkinson JWK, op. cit. (6): IO. 59 ibid:218. (b) Hunter J, op. cit. (4) : 278-9. 6o ibid: II 3-8 30 ibid:278-83. 6i Parkinson JWK, op. cit. (6) : 299. 31 ibid:347. 62 (a) ibid: 67. 32 Sheldon J, op. cit. (24): I29 (b) Home E. A short account of the life of John 33 Hunter W. Medical commentaries, part i. LoIn- Hunter. In: Hunter J, op. cit. (45): 62. don: A Hlamilton for A Miller, 1762-4:42. 63 Parkinson JWK, op. cit. (6):13.