284 Prof. Monro?Syphilis as seen by a Hospital Physician. SYPHILIS AS SEEN BY A HOSPITAL PHYSICIAN* By T. K. MONRO, M.A., M.D., Professor of Medicine, University of Glasgow. \ " / Mr. President and Gentlemen,?I thank you heartily for the honour you have done me in inviting me to be Honorary President of this Faculty for the session which is now opening. I was duly informed by Dr. Wardlaw that my principal duty as incumbent of this honourable office was to deliver an address to the Faculty, and as his invitation reached me while I was on holiday, with other objects in view, I had time to contemplate the responsibility I had undertaken, and to consider how I was to face it. In getting over the usual initial difficulty as to the choice of a subject, some assistance was afforded me by the President's instruction that the address ought to be one for the general practitioner. Quite a number of subjects would be appropriate from this point of view. I should have been glad to say some- thing on oral sepsis, a condition often spoken of, and no doubt often wrongly blamed, but also apt to be overlooked. Dentists do not always realise how completely one may be misled by the absence of subjective and objective evidence; so that even an experienced man may pass as innocuous a tooth which subse- quent extraction shows to have disease at its root. Medical men sometimes make a mistake in the opposite direction, by insisting, without sufficient justification, on the removal of teeth, e.g., in epileptiform neuralgia. Meantime, it may be said that in all these doubtful cases the sockets ought to be examined by a>rays. In addition to the tooth-sockets, the tonsils and other parts of the digestive tract, including the appendix, may be the seat of chronic disease with general intoxication. An expert examina- tion of the nose and accessory sinuses, carried out simply as a matter of routine in cases presenting no symptoms pointing to * Honorary President's address to the Greenock and District Faculty of Medicine, 11th October, 1921. Prof. Monro?Syphilis as seen by a Hospital Physician. 285 these parts, may reveal the existence of chronic disease; and this in its turn may account for a hitherto unexplained general infection or intoxication, as in rheumatoid arthritis. Lethargic encephalitis also might have been taken as a subject for this address. Many cases of the disease have come under my notice in hospital and in private practice, but it seems to have died out for the present, at least in this district, and the cases which I have seen for the first time in the past few months have been brought under my notice because the patients had not yet recovered from the symptoms which attacked them at a much earlier date. Another possible subject is one that I set aside with some reluctance, viz., endocrinology, or the doctrine of the endocrine or ductless glands, about which much has been written in recent years. In the United States there is an Association for the Study of the Internal Secretions, with its journal, entitled Endocrinology. It is a fascinating subject to consider how the different glands of this group constitute one complicated and yet delicately balanced mechanism ; how the internal secretion of one tends to neutralise that of another; how a gland of this kind, such as the pancreas, may produce both an internal and an external secretion; how glands of this group {e.g., pituitary and adrenals) may be made up of different parts with entirely different functions; and how in practice we meet with cases illustrating excess, defect, or perversion of the functions of these glands. You may have noticed, as I did, that among the results of the War there was a great increase in the frequency of Graves' disease, as happened in Alsace and Lorraine after the Franco-Prussian War of 1870. One of my patients was in London at the time of the air-raids, and apparently acquired the illness as a direct consequence. Fortunately, this outbreak appears to have subsided again. But, attractive though this subject is, I pass from it at the present time, and venture to address you at greater length on a matter which is of perennial interest to us all, for many reasons, viz., that terrible infection syphilis. I know, of course, that many of those who are here to-night see syphilis in its earlier stages?in the primary, and doubtless also in the secondary stage?much more frequently than I do; but, without presuming 286 Prof. Monro?Syphilis as seen by a Hospital Physician. to teach you, I thought it might interest the members of this Faculty if I were to give some account of the guises under which syphilis presents itself to me as a physician in hospital and private practice. I do not forget that some of my audience are also engaged in both kinds of practice, but the seniors will perhaps be willing to compare their experiences with mine, while those who have more recently joined our profession may get an occasional hint that may be helpful. Perhaps it will never be definitely settled whether syphilis existed in Europe before Columbus and his sailors returned in 1493 from their discovery of the New World. The modern name, of course, was introduced by Fracastorius in 1530 in the title of " his poem, Syphilis sive Morbus Gallicus"; but the disease became well known as an epidemic at an earlier period when the French army invaded Italy in 1495; and by the close of the fifteenth century the civilised world was syphilised. That clever rogue, Benvenuto Cellini (1500-1571), refers in different passages of his autobiography to the prevalence in Italy of the "French evil," as it was then called, and tells howT he himself acquired the disease. The suspicion that syphilis is responsible for many internal diseases can be traced back to the eighteenth century, aneurysm being the first important disorder of the kind to be attributed to this cause. According to Garrison, the connection between the two was first suggested by Ambroise Pare (1510-1590) in the sixteenth century. It is only, however, within the past few decades, or it might almost be said within the* past few years, that the ravages of syphilis among the community have come to be recognised in anything like their true proportion, and thus it was that some eight years ago the medical profession, feeling its own helplessness in dealing with such a gigantic problem, made its successful appeal to the State to shoulder the responsibility. The indictment against syphilis was never more ably put than by Sir William Osier in one of those charming and instructive addresses which he gave in the course of the War?a small part of the many and arduous duties he undertook during that period. He reckoned that syphilis is an easy first among the infections as a cause of mortality in temperate climates. But the mortality figures take no account of the Prof. Monro?Syphilis as seen by a Hospital Physician. 287 tremendous amount of physical suffering, or of the unfitness for work, which syphilis brings in its train. And even these three considerations do not complete the indictment. For I am sure you will agree with me, on the basis of your own observations, that, among the intellectual classes at anyrate, there is nothing more capable of giving rise to life-long remorse than an attack of this disease. As Gairdner put it, "Syphilis may be said to spoil a great part of a man's life." How far modern methods of diagnosis and treatment are capable of easing the burden that thus presses on the afflicted individual, and on the community, has still to be determined. A difficulty sometimes met with?more humanitarian and academic than of practical importance?is what to make of cases of undoubted syphilis where the patient denies having run the risk of infection. I am referring to cases in the primary and secondary stages, where the diagnosis is not in doubt, and occurring in intelligent individuals who realise to the full the seriousness of the situation, and in whom there is a genital sore of the usual kind. Of course, it occurs to one that a person who will expose himself to the risk of venereal infection is likely to be capable of telling an untruth, but one feels that this theory is not sufficient for all cases, and the mystery remains. In another difficult group of cases there is not only denial of risk run, but also impossibility of discovering any primary lesion. A hospital nurse consulted me some years ago on account of certain symptoms which included sore throat and a cutaneous eruption. She was seen also by the dermatologist to the insti- tution, and there was no possibility of doubt that she had secondary syphilis. No primary lesion was admitted, and on the advice of the matron she submitted herself to examination under an anaesthetic by the gynaecologist and the dermatologist; but no trace of a genital or other primary sore was found. There was a severe case of syphilis under treatment in the ward where she was on duty, and we felt compelled to assume that the nurse might have acquired the disease innocently from this patient. Among cases of syphilis that I have come across in medical practitioners, either as patients or as professional friends, and setting aside those in which the disease was acquired through 288 Prof.