I will make another quotation from P. A. Morrow,10 in which he states that "the non-auto-inoculability of the secretion of the chancre is the rule to which there are few exceptions and these only possible when inoculation is performed at an early period after the appearance of the chancre. The four or five cases reported in which positive results have been obtained from auto-inoculation of the chancre are of doubtful authority; the most invariable result is an abortive pustule. A distinction is always to be recognized between the specific serous secretion of the chancre and the inflammatory products of this same lesion when irritated into copious suppuration."

With this I will close citing authors although a number of others holding similar opinions could be quoted. Admitting the auto-inoculability of the chancre for the sake of argument, the question which presents itself is this: At what time does the susceptibility cease, or, in other words, when is syphilis constitutional? The rapid recital of a few cases may throw some light upon the subject. After this I want to make a critical analysis of a few of the reported successful cases of auto-inoculation.

In the first place I wish to call attention to a very interesting and brief résumé on the subject by Dr. E. L. Keyes." In one case (his own) excision of the chancre was performed before the lesion was twenty-four hours old and before any induration had manifested itself. It proved unavailing so far as preventing the general symptoms from appearing was concerned. In commenting upon this the author says: "This case I consider worthy of record because it fulfills the most exacting conditions for testing the question still under consideration in the profession as to whether syphillis is or is not already a constitutional disease when the chancre appears." In Berkeley Hill's case cited in the same paper, a man tore his frenum during intercourse and in less than twelve hours later had the wound cauterized with fuming nitric acid. A month later a general syphilis manifested itself. Leloir12 relates an analogous case. A medical student had a suspicious intercourse and watched his penis constantly for any sign of the chancre. One night at twelve o'clock nothing was apparently visible. Next morning he noticed a macule. This was

largely excised at two o'clock in the afternoon of the same day, and the uselessness of the measure was shown by the appearance of general syphilitic manifestations later on.

13

Barthélemy reports a case of undoubted indurated chancre accompanied by ganglionic involvements in which the induration of the sore persisted for three months and of the glans for four months. No treatment, whatever was given and eighteen months later no general manifestations had shown themselves. The author asks the question: Had I excised the sore would I not have ascribed the mitigation (?) of the disease to that operation? He might have asked himself: was the case one of syphilis ?

Zeissl1 has observed that the excision of the induration does not prevent the appearance of the secondary symptoms; and Delpech has noted, as well as others, that after excision the induration is reproduced at the site of the operation and secondary symptoms follow.

Spillman protests energetically against the abortive surgical measures employed in reference to syphilis. To emphasize his opinion he reports two cases as follows:

He excised the chancre and glands anatomically connected. with it in a case. No cutaneous lesions appeared, nor any implication of the mucous membranes. Internal treatment was not taken and confirmed tabes dorsalis was established. The second case a young woman was supposably infected by her lover. Suspecting that this might occur he caused her to be very carefully watched for any sign of a chancre. This lesion was excised as soon as it made its appearance; yet, despite the precaution, roseola of the trunk and abdomen appeared as well as buccal and vulvar lesions.

In one case I excised the chancre as soon as it became visible. General symptoms supervened, in a mitigated form it is true.

In some of the cases just given extirpation of the initial sclerosis was practiced as soon as it was possible to do so, and yet the results were negative. We must conclude from a clinical point of view that in those cases the disease was constitutional at the time the chancre was excised. The sores were only suspected as the principal signs of differentiation

13. Annales de Dermatologie et de Syphiligraphie, No. 4, 1885.

14. Ibid.

15. Revue Médicale de l'Est, January 1, 1892.

were absent, and it could be very well argued that, had one been excised and not been followed by the general symptoms, the sore was not an initial sclerosis in spite of confrontation and the probabilities of the case.

We will now take up some of the reported cases of successful auto-inoculation and examine them critically. First, we will take the cases reported by Pontoppidan:

1o. Patient with ulcer in the sulcus coronæ, having slight induration. Inoculated in three places on the abdomen. On the eleventh day slight infiltration of base observed.

2o. Infection dating back three weeks. For past fifteen days excoriation on prepuce and ulcer in sulcus coronæ. Later, sclerosis about urethral orifice. Three inoculations on abdomen appeared as papules on the twenty-second day.

3o. Infection a month old. Sclerosis in sulens coronæ. Inoculation showed papules on the thirteenth day.

4°. Infection four weeks back. Inoculation showed elevated reddened places on the twelfth day. On the tenth papules, and on the twenty-sixth a syphilitic eruption.

5°. Infection dating back twelve days. Inoculation visible on the fourth day, reddened on the eleventh, and papular on the eighteenth.

Haslund" reports five cases of multiple chancres due to auto-inoculation, a brief notice of which is as follows:

1o. Ulcer of prepuce, near frenum, superficial. Six days later indurated as also inguinal gland. In two days after it was excised. Ten days later, a small ulcerated point, due to the tearing out of a suture, indurated; and, a few days later there was found a small ulceration at the meatus urethræ which became distincly indurated. Four weeks later a macular syphiloderm appeared.

2o. Small excoriation of frenum. No induration. Cauterized with chromic acid and dressed with chloride of lime. Five days later wounds became indurated. In two more days, two superficial erosions, one on internal surface of orifice of prepuce, the other in the sulcus coronæ. In three days one sore indurated and a new ulcer in the middle of the balanopreputial sulcus. Ten days later there were eleven indurated ulcers. About a month later abundant macular syphilide.

16. Annales de Dermatologie et de Syphiligraphie, No. 4, 1885. 17. Annales de Dermatologie et de Syphiligraphie, No. 6, 1887.

A number of the ulcers healed, leaving a well-developed induration.

3o. An indurated ulcer on the left side, in the sulcus coronæ. Left inguinal ganglia indurated. Two days later an indurated ulcer on the inner surface of prepuce. A month later a macular syphilide appeared.

4°. An indurated ulcer in the sulcus coronæ a little to the left of the median line. Three days previous one had appeared on the right side on the preputial portion of the sulcus coronæ. Ganglia indurated on right side. In about forty-two days a papular eruption appeared.

5°. Right labium majus affected with two indurated ulcers; two smaller ones, also indurated at posterior commissure and on perineum to the left of the raphé. Glands in both groins involved very typical on the right side. Five days later an indurated ulcer on internal aspect of left labium minus. Twenty days later a macular syphilide appeared.

A critical examination of these cases would lead us to look upon them as special pleas. Mracek, in reviewing Pontoppidan's cases, states that, as proofs of the auto-inoculability of the chancre, they have but little weight. In Case 1, of Pontoppidan's experiments we have an inoculation made with pus and slight infiltration observed in the inoculations. In Case 2, also purulent inoculation and papules appeared on the thirtyseventh day after appearance of ulcer. In Case 3, we have insufficient data, papules appearing. In Case 4, we have elevated reddened places as the result of inoculation, papules appearing on the nineteenth day, and one week later a syphilitic eruption. In Case 5, the inoculation was visible on the fourth day and papular on the eighteenth. We do not find a description of an initial sclerosis in any of these inoculations and the author simply presumes that because lesions appeared at the site of inoculation that they must be chancres. In Haslund's cases we find that the ganglionic involvement is always on the same side as the original chancre (Cases 1, 2, 4, and 5); and that when the other side is involved general symptoms appear and other portions of the lymphatic system are also involved (Cases 1, 3, 4). In these cases the auto-inoculations are also supposed to be the result of the action of the pus. Taking the tout ensemble, it will occur to any fair-minded 18. Vierteljahresschrift fuer Dermatologie und Syphilis, No. 4, 1885.

person that these examples are not satisfactory, nor are the experiments crucial. In reported successful cases we also note that an infiltrated sore is most generally the result of the inoculation. Even if an apparent induration takes place there is no corresponding induration of the lymphatic ganglia anatomically connected with the artificially produced lesion, unless it be at the time that general involvement of the lymphatic glands takes place.

We must not forget that inoculations, more especially when pus is employed, are irritating and the resulting lesion is what has been denominated the "irritative sclerosis" of syphilis.

Taking all these points into consideration it seems to me that 1°. The probability of auto-inoculation in early syphilis has not been proven. 2°. While there may be strong presumptive evidence in favor of it, it is only at best a possibility. 3°. The most crucial experiments prove that excision of the chancre at the earliest possible moment is futile and falls short of its purpose. 4°. In multiple chancres à distance the lesions are due to the same inoculation, as a rule. 5°. In multiple chancres of different ages it is probable that the younger lesions are merely irritative scleroses. 6°. Experiments so far apparently prove that syphilis is constitutional at the time the initial sclerosis makes its appearance.

TWENTY-FOUR CASES OF TUBERCULAR PHTHISIS TREATED WITH TUBERCULIN-KOCHII. By E. F. BIEWEND, M. D., St. Louis.

[Concluded.]

CASE XII. Male, aged thirty-one years; occupation, locomotive engineer; height, five feet eight inches; weight, 115 pounds; general appearance, slightly stoop-shouldered, thin, florid complexion. The upper lobe of the right lung was affected. His cough was very troublesome, and his expectoration profuse. Occasionally there were night sweats. His appetite was fair, and his bowels were regular. The disease was hereditary, his father having died of consumption. The sputum contained bacilli (No. 3 Gaff ky), and the temperature ranged in thirty-six hours from 972° to 100°. The patient had been sick for about two years.

From April 27 to June 30, I injected the patient every third day, beginning with one-tenth of a milligram of the one