John Hunter’s (1728–1793) account of venereal diseases

Introduction

John Hunter was born on 13 February 1728 in Long Calderwood at Lanark in Scotland. He was the younger brother of another successful anatomist, William Hunter (1718–1783). John’s contributions to medicine include the nature of digestion, child development, the role of the lymphatic system and proof that the maternal and foetal blood supplies are separate. In 1748 John moved to London where he became William’s assistant in dissection and was soon running practical classes on his own. ¹ By 1756 he was an Assistant Surgeon at St George’s Hospital after already having studied under William Cheselden (1688–1752) at the Chelsea Hospital and Percival Pott (1714–1788) at St Bartholomew’s Hospital. In 1760 he was commissioned as an army surgeon and was staff surgeon on the expedition to Belle Ile in 1761. In 1762 he served with the British Army in the expedition to Portugal. ² In 1764 he established his own anatomy school in London and started a private surgical practice. Hunter’s surgical skill could be attributed to his sound anatomical background. In 1767 he was elected a Fellow of the Royal Society.

Hunter’s contribution to the understanding of venereal diseases is reviewed and his argument of the unitary nature of syphilis and gonorrhoea is examined, and the progress he made in diagnosis and management is also discussed.

The unitary nature of syphilis and gonorrhoea

The details of John Hunter’s work on venereal diseases were published in a 398-page book titled A Treatise on The Venereal Disease, published in 1786 in London at Leicester-Square. Hunter believed that gonorrhoea and syphilis were one disease and, because of his reputation as an authority on venereal diseases, his theory was not disputed until several years later. There were several reasons for this opinion. It was his view that a patient presented with only one constitutional disease at a time ³ and he suggested this was the reason why florid measles suppressed the cell-mediated reactions following smallpox inoculation. ³ He admitted that more than one disease could afflict a patient but insisted that when this happened the diseases would not be found in the same part of the body. Thus, when smallpox afflicts a patient that is already suffering from lues, both diseases did not affect the same part. ³ In the interests of economy of diagnosis he was therefore convinced that as both syphilis and gonorrhoea could be transmitted through sexual intercourse and often occurred together, they were but one malady. ³ He suggested the different clinical symptoms of appearances of syphilis and gonorrhoea were dependent on the part of the body that was affected. ³ He proposed that ulceration resulted when the skin was affected while a discharge developed when mucous membranes such as the vagina or urethra were involved in the disease process.

Hunter further asserted his argument that syphilis and gonorrhoea were the same disease based on their epidemiology, especially in the islands of the South Seas. ³ He noted that both syphilitic chancre and gonorrhoea were already prevalent in the island of Otaheite (Tahiti) by the time Captain James Cook (1728–1779) visited after earlier visits by the French and another British crew. Hunter asserted that there was no proof to suggest that any other ship could have introduced venereal diseases to the island on Cook’s first voyage in April 1769. ⁴ Hunter disagreed with the belief that chancre must have been first introduced into Otaheite before gonorrhoea. His argument was based on the theory that chancre cannot be carried for long on a voyage without destroying the penis whereas gonorrhoea may continue for a long time. The Otaheiteans had ascribed the introduction of the disease to Frenchman Bougainville and his crew, whose ship called at the island in April 1768, as his ship stopped at several places where his men could have contracted the disease, the last of which was Rio de la Plata. ³ It is believed the disease is unlikely to have been introduced by British men, Captain Samuel Wallis and his crew, who visited the island in July 1767, because the disease was not evident upon Bougainville’s arrival nine months later. This interval provided sufficient time for the inhabitants of the entire island to have been infected if Wallis’ crew had introduced the disease which was present in every form on the island when Cook visited during his last voyage in 1776–1779. Hunter felt the disease must have been propagated from one root, probably gonorrhoea.

Manifestation of symptoms

Hunter stated that in most diseases there is a certain time between the application of the cause and the appearance of the effect. ³ He suggested this time varies significantly in venereal disease, probably due to the ‘state of the constitution when the infection was received’. ³ He claims that the gonorrhoea and chancre appear earlier after contamination than the lues venerea and that, of gonorrhoea and chancre, gonorrhoea appears sooner. Hunter was of the opinion that the onset of symptoms in gonorrhoea varies greatly from a few hours to six weeks. He suggested that six, eight, ten or twelve days appeared to be the commonest period though it is capable of affecting some people much sooner and others much later. ³

Simple and virulent gonorrhoea

Hunter was of the opinion that gonorrhoea could be either simple or virulent. He claimed that the surface of the urethra is subject to inflammation and suppuration from many other sources aside the venereal poison and that sometimes discharges happen spontaneously when an immediate cause cannot be identified. ³ He suggested this may be called simple gonorrhoea and is not associated with venereal infection, although those who have been previously exposed to virulent gonorrhoea are more liable to simple gonorrhoea. He proposed that in distinguishing simple from virulent gonorrhoea, the simple gonorrhoea comes on immediately after copulation and is at once virulent whereas the virulent comes on some days after and gradually with symptoms such as rigors, fever and restlessness.

Cure for gonorrhoea

Hunter was of the opinion that gonorrhoea could be a self-limiting disease. He claimed that most cases of gonorrhoea are cured without mercury or other medical assistance. However, he believed this was not the case with chancre. He stated that gonorrhoea could be cured by the most ignorant but in chancre or lues venerea more skill is needed, the reason being that gonorrhoea cures itself while the other forms of the disease require the assistance of art.

Chancre

Hunter proposed that there are three ways by which chancres are produced – by the introduction of the poison into the wound, by being applied to a non-secreting surface and by being applied to a common sore. ³ He claimed that, irrespective of to which of these three surfaces it is applied, the pus produces its specific inflammation and ulceration and that the matter produced as a result of the different modes of application is of the same nature with the matter applied because the irritations are the same in both. Hunter stated that the poison much more readily contaminates when it is applied to a fresh wound than to an ulcer, likening it to the inoculation of the smallpox. ³ This form of disease, like gonorrhoea, is generally caught as a result of connection between the sexes but any part of the body may be affected by the application of venereal matter, especially when the cuticle is thin.

Hunter claimed that chancre was not as frequent an effect of the poison as gonorrhoea. He argued that the reason for this was because the cuticle cannot be affected by this poison, hence this covering acts as a guard to the cutis and prevents the venereal matter from coming into contact with it. Consequently, only parts of the body such as the glans, the inside of the prepuce or other parts of the body where the covering is thin are usually affected. ³ He asserted that the proportion of cases of gonorrhoea to those of chancre is about four to one.

Manifestation of effects in chancre

Hunter stated that there was uncertainty in the time between the application of the venereal matter and the onset of its effects. He asserted that the time is longer than in gonorrhoea. He was of the view that the manifestation of the symptoms was greatly dependant on the part of the body affected. For example, when the fraenum or the termination of the prepuce into the glans is affected, the disease generally appears earlier than when the glans, the common skin of the penis or the scrotum has been affected. ³ The appearance of chancre after the application of the venereal matter varied widely between twenty-four hours and seven weeks. Hunter noted that syphilis might cause deafness and periostitis but he did not believe that the brain and viscera could be affected.

Chancre in women

While women are also subject to chancre, the complaint is often less complicated than in men. Although when it is lodged in the inside of the skin of the labia and nymphae they are often only affected with gonorrhoea, they are also capable of ulceration. Hunter stated that these ulcerations are generally more numerous in women because the surface upon which they can form is much larger. ³ The ulcers could be found on the edge of the labia, sometimes on the outside and even on the perineum. The ulcers that are formed on the inside of the labia and nymphae would never dry whereas those on the outside of the labia are subject to have the matter dry upon them, which forms a scab, like those on the body of the penis or scrotum.

Treatment of chancre

Chancre can only be cured through medical intervention unlike gonorrhoea which is self-limiting. Hunter proposed this was probably because, as the inflammation in the chancre spreads, it is always attacking new ground, forming a succession of irritations. ³ He claimed that mercury was the cure for chancre but that it commonly took some time before a chancre appears to be affected by the medicine. It takes three, four or more weeks after the administration of mercury before a chancre began to separate its discharge from its surface.

Conclusion

The management of venereal disease was through wild guesswork in the 18th century. However, Hunter discovered that venereal disease was a subject that deserved discussion in the scientific community. For decades, even after his death on 16 October 1793, he was still considered to be the authority on venereal diseases. As a result, his theory about the unitary nature of syphilis and gonorrhoea was not proven wrong until several years after his death. However, his pioneer work, despite some of the inaccuracies, led to further research and consequently better understanding of venereal diseases many years after he died. Hunter himself rightly concluded in his famous book that there are several other unknown diseases resembling the venereal disease he had described and that his work should be considered only as hints for others to conduct further research rather than as a complete account of the subject.