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ORIGIN AND SPREAD IN EASTERN

ASIA

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ISTORICAL evidence as to the origin and spread of syphilis in China and Japan based on reliable native sources has been wanting until the publication of Prof. K. Dohi's book "Beiträge zur Geschichte der Syphilis inbesondere über ihren Ursprung und ihre Pathologie in Ostasien," 1923, Tokyo. This constitutes a most important contribution to the history of syphilis, rounding out as it does, the world history of the spread of syphilis in the period following 1495. According to Dohi, syphilis, at least in its virulent form, was not known in the Far East until the beginning of the sixteenth century. Tracing the progress, Dohi states that the malignant form of syphilis appeared first in Calicut, in 1498, brought there by the Portuguese explorer, Vasco da Gama, sailing from Lisbon. Thence it spread to Ceylon in 1505, and to Malacca in 1511, whence it soon reached IndoChina, appearing in Canton and other ports of southern China. From Canton it passed on to Japan, appearing in Kyoto and Tokyo in 1512. The whole seaboard of the Yellow Sea was quickly infected, and from the ports the spread to the interior of China soon followed. The disease was known by various names in different places, just as in

Europe. Some of these names indicated a European origin; in India it was first recognized under the name of Phiranga, "the disease of the Franks." This gives added proof to the view that the malignant type of syphilis originated in Europe, and was carried thence to the Orient. Dohi's researches are confined to the spread of the malignant epidemic form of the disease, and, therefore, do not throw any light upon the still more important question of the previous existence in the East of an unrecognized milder form of the disease, such as certainly was present in Europe before the voyage of Columbus and the discovery of America. Further researches along this line into the Japanese and Chinese records of the pre-Columbian centuries for evidence of the presence in the Orient of such a mild form of syphilis would be of great value in settling the much-disputed question of the origin of syphilis, and it is to be hoped that some capable Oriental investigator may be able to accomplish this. Dohi seems to have a very clear case for the European origin of malignant syphilis; he shows that the same clinical forms existed and that similar therapeutic measures were adopted in the East as in Europe. The majority of dermatologists, particularly American ones, still cling to the view that syphilis was of American origin and was taken back to Europe by the sailors of Columbus. For this there is no good historical evidence. There is no undoubted

evidence of the pre-Columbian existence of syphilis in America. No bones have been found in the Americas of certain pre-Columbian origin bearing lesions of unquestionable syphilitic character demonstrated by any trained pathologist. The classic literature of Greek and Rome contains no descriptions of diseased conditions that can definitely be decided upon as syphilitic, or as being definitely associated with a venereal etiology. Some of the Satirical writers certainly hint strongly at the latter, but the medical character is too vaguely put to throw any decisive light upon the pathology. Before the great epidemic of malignant syphilis in 1495 a milder, nonepidemic form of the disease was certainly known in Germany, France and Italy as early as the thirteenth century. It is very probable that much of the leprosy so abundant at that time was in reality syphilis. Even then it was sometimes called the "French disease," and was treated with mercurials. Some of the rules for the regulations of brothels and bathbrothels and bathhouses before 1492 indicate most strongly the existence of a disease apparently identical with syphilis. It is also incredible that the returning sailors of Columbus could start an epidemic so widespread as that of syphilis had become in 1495. That

That

this epidemic had any relation to the legendary siege of Naples has no historical foundation because no such siege ever occurred. A campaign of the French in Northern Italy in 1495 was brought to an end by an epidemic which Singer and other responsible medical historians regard as being most probably paratyphoid. Certainly it did not have the character of syphilis. With all of the historical sources in our hands at present the epidemic of virulent syphilis of 1495 seems to have begun earlier in Germany than it did in Spain or Italy. There is no evidence that it spread first from the latter countries. By 1496 it was all over Europe appearing almost simultaneously in the majority of European countries. After lasting in this form for about a generation the virulent form spread throughout the world, following the great navigators, as Dohi has pointed out in the case of its invasion of the Far East. Our knowledge of the origin of syphilis is, therefore, confined to that of the virulent form. This is certainly of European origin. What we most need to know now from the epidemiological standpoint is the origin and pathology of the milder form that certainly existed in Europe before 1492. Did this form occur before this time also in the Far East?

PHENOLPHTHALEIN ERUPTIONS

The habit of taking proprietary laxatives is widespread, and as the majority of these contain phenolphthalein it is surprising that the number of reported cases of skin eruptions ascribed to this substance is exceedingly small. This apparent great disparity may perhaps be easily explained in that many cases of phenolphthalein dermatitis go unrecognized as such, neither the patient nor the physician, if there be one, attributing any relationship between the use of a laxative and the dermatitis. As a knowledge of such a relationship is spread, it is very probable that the number of cases observed will increase. Apparently the first observation on phenolphthalein dermatitis was made by Abramowitz in 1918. He described five cases of persistent erythema multiforme associated with pigmentation, in one of which he was able to show that phenolphthalein derived from Ex-lax which the patient was using as a laxative was the cause of the cutaneous eruption. Ayers (1921), Wise and Abramowitz (1922), Carson and Sidlick (1922), and Rosenbloom (1922) reported additional cases in which the laxative use of phenolphthalein was shown to be the etiologic factor in cases of erythema, urticaria and herpes. E. W. Netherton (Medical Journal and Record, 1924, CXIX, p. 134) reports an additional case with a review of the literature. As the previous cases had been reported in dermatological journals, Netherton's paper is the first one to call the attention of the general practitioner to this form of skin affection and its cause. As in the case of fur-dermatitis and other forms of dye- and drug-rashes it is to the general practitioner that the great majority of the cases of anomalous erythemas, urticarias and herpes go first. Ignorant of the great variety of possible etiological

factors in the production of such cutaneous conditions the general practitioner's treatment of such is usually empirical and unsatisfactory. In the case of phenolphthalein eruptions the etiological relationship has been so recently demonstrated that even a dermatologist may be unaware of it. The cases so far observed have presented a uniform eruption so that it is safe to say the phenolphthalein dermatitis is a distinct picture. The eruption consists of numerous scattered, somewhat grouped, irregular polychromatic macular plaques, varying in size from a pinhead to a coin, or the palm of the hand. The color varies from pink to bright red, dusky violaceous and deep purple. The central portion of the plaque is usually violaceous with change in color towards the periphery where a pink or bright red areola may be present. In exacerbations the plaques may enlarge peripherally and become confluent, or new macules may develop near the periphery or upon unaffected areas. As the attack subsides the affected areas become pigmented and remain so for many weeks. During resolution slight scaling may occur. Vesiculation, erosion and superficial ulceration may occur, especially on the mucous membranes of the mouth and on the skin of the genitals. Subjective symptoms of itching and burning may be moderate or severe, and mild constitutional symptoms may accompany the eruption. Clinically the lesion is a persistent erythema multiforme. Relapses may follow the ingestion of phenolphthalein with reappearance of lesions on the sites of the primary ones or as new lesions elsewhere. Antipyrin may produce a similar eruption, but usually more morbilliform, erythematopapular, scarlatiniform or urticarial in character. The so-called fixed arsphenamine eruptions are usually pink and not polychromatic, and have more sharply defined borders. It is also

possible that some of the eruptions ascribed to arsphenamine are due to phenolphthalein as the patient may be using this as a laxative following arsphenamine without his physician's knowledge. In all cases presenting an eruption consisting of polychromatic macular plaques which terminate in pigmented areas, and with a history of recurrence at these sites, a tentative diagnosis of phenolphthalein

dermatitis should be made, and the possibility that the latter substance is the etiological factor should be excluded before any other diagnosis is made. In cases of chronic urticaria and recurrent herpes phenolphthalein should be considered as a possible etiological factor. Patients susceptible to this substance should be advised against the use of proprietary laxatives.

Sex and Sex Worship (Phallic Worship). A Scientific Treatise on Sex, Its Nature and Function, and Its Influence on Art, Science, Architecture and Religion— with Special Reference to Sex Worship and Symbolism. By O. A. Wall, Ph.G., PH.M. V. Mosby Company, St. Louis, 1922. Pages 608, with 372 illustrations, 25 x 17 cm. Cloth. Price $10.00.

He

This volume consists of a vast amount of collected material, more or less anthropological in character, relating to sex conceptions in folk-lore and religion, and their representations in Art. It is arranged in sections rather than in chapters, and these sections are rather loosely bound together by the development of the argument in a somewhat narrative style. The main object apparently has been to present the facts, as many as the author could collect upon the subject, and the material has been drawn from all possible sources embracing everything from the encyclopedia to the daily papers. Upon the basis of this material the author proceeds with a running commentary of personal opinions and conclusions. His attitude towards the various phases of sexual life and habits is on the whole very sane. believes that the intrinsic abnormal sexperversions of Krafft-Ebing are in reality deliberate vices transmitted to us from Greek and Roman times and not be regarded as insanities. Many physicians will agree with this view. He also looks upon the use of phallic symbols in religion as merely a phase in the evolution of all religions, not an actual worship of the generative organs but a use of the phallus and yoni as symbols for certain religious ideas embodied in nature worship. The collected material is of great value from the anthropological point of view, and a knowledge of such is necessary to the student of human life. The author is less fortunate in the illustrations he has chosen. Not wishing to offend by the reproduction of the crude phallic art of the primitive religions he has drawn the majority of his

illustrations from modern art, and these give to the volume a certain taint of erotica not justified by the text. It would have have been better to have treated the illustrations more scientifically. As the illustrations now stand they represent too much a study of the nude in art. A little more primitive art would have been preferable. The book is well printed.

Outlines of Pathology. By E. T. BELL and Associates in the Department of Pathology, University of Minnesota, University of Minnesota Press, 1924. Pages 586, 12 x 19 cm. Cloth,

This book presents the lectures given in the courses in pathology at the University of Minnesota. They are not intended to take the place of a complete and illustrated textbook, but only to replace the oral lectures in pathology formerly given by this department, in order that the students may have more accurate notes than they could take themselves, and more time for quizzes and demonstrations. The lectures were, therefore, published in book form by the graduate school to replace mimeographed sheets formerly given out to the students. They constitute a very condensed resumé of lectures in general and special pathology, and are necessarily incomplete, not fully up to date, and offer in a dogmatic fashion certain amounts of pathologic knowledge done up in small packages. It is in fact a quiz-compend only, but better than the average run of such. Unless supplemented by much oral instruction the students using such a condensed brand of pathologic milk will be only bottle-fed and will gain but little idea of the broad sweep of the philosophy of pathology which is the foundation of practical medicine. The editors of the volume are undoubtedly fully aware of this defect and suggest that their compilation may be useful in schools where a textbook is in use. The inevitable would happen; in such schools the mediocre and poor students would depend upon the