Syphilis is a CONSTITUTIONAL DISEASE; FROM ITSUNCEPTION, A. H. OiiMANisr-DuMESisriL, A. M. M. D., Professor of Dermatology and Sypliilology in the St. Louis College of Physicians and Surgeons, St. Louis, Mo. Reprinted from the St. Louis Medical and Surgical Journal, January, 1886- ST. LOUIS: MEDICAL JOURNAL PUBLISHING COMPANY. •2622 Washington Avenue. 1886. Syphilis is a Constitutional Disease from its Inception.* By A. H. Ohmann-Dumesnil, A. M., M. D., Professor of Dermatology and of Syphilology in the St. Louis College of Physicians and Surgeons. That syphilis is at one time purely a local manifestation and that it beeomes generalized or systemic we have no reason to doubt. But the important question arises, at what time does it become systemic and what is a clinical guide upon which we may rely for the determination of this point? The bacillar theory of syphilis has been quite a favorite because it seemed to offer such a ready solution to the question. For, if we admit that the bacilli form a nidus at the point of entrance of the syphilitic virus, there attain their maturity and are thence trans- ferred, by means of the lymphatics further on until the whole economj7 is infected, we have clearly a local condition becoming generalyzed only after the lapse of a greater or less period of time, an interval which careful observation might determine with a certain degree of accuracy. Microbian pathology, be- sides, is very seductive in its aspects and appears so reasonable and so demonstrable that we are led away from a just skepti- cism by the charms it presents. It was on this account that, when Lustgarten announced the discovery of the bacillus of syphilis and the methods of differential staining applicable to it, the medical world rejoiced and the press was not slow to dis- seminate the glad tidings. But other workers in the field, nota- bly Alvarez and Tavel,1 in trying to obtain new data, complete- ly overthrew these great results and claimed to have demonstrated 1. Bulletin de l’Acad6mie de Medicine, Aug. 4th, 1885. * Read before the St. Louis Medical Society, Dec., 26th, 1885. 4 that bacilli are found, in the normal secretions about the anus and genitalia, which are identical with Lustgarten’s bacillus of syphilis. They also resemble the bacillus of tuberculosis being, however a little more slender and granular. But leaving aside the bacillar question it may be argued that syphilis originates as a local lesion purely and that early exci- sion of the local primary lesion ought to procure immunity from any further manifestations. This immediately opens up a number of questions. When is it early enough or rather when is it not too late to perform excision or otherwise destroy the nidus? By what means is the disease disseminated throughout the system? Is the chancre still a local manifestation at the time of induration of its base and of the neighboring lymphatic ganglia ? In answer to the first question I wish to call attention to a very interesting and brief resume on the subject by Dr. Edward L. Keyes.2 In one case (his own) excision was performed be- fore the lesion was twenty-four hours old and before any indu- ration had taken place, the result being negative. The author in commenting upon it 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 syphilis is or is not already a constitutional disease when the chancre appears.” Berkeley Hill’s case, where a man tore his frenum during intercourse and less than twelve hours later had it thoroughly cauterized with fuming nitric acid and followed a month later b}7 a general syphilis, is also quite con- vincing, Leloir3 mentions a case where a medical student had •constantly watched his penis for a sign of a chancre. One night -at twelve o’clock nothing was visible. The next morning, how- ever, an erosion or rather macule was observed, largely excised at two o’clock in the afternoon, but without effect as general syphilitic manifestations followed. From these few cases, which might be almost indefinitely multiplied, it is evident that early and thorough excision of the chancre is fruitless and that, if per- formed as early as the period antedating induration or before sclerosis has been declared so as to be recognizable, the result is 2. “ Cases bearing on Certain Mooted Points in Syphilology,” N. Y. Med. Jour., April 25th, 1885. 3. Le Progrls Medical, August 15th, 1885. 5 the same—unavailing. The question as to how early excision should be performed appears to be one incapable of a definite solution in a clinical point of view. For, evidently, if the local theory is correct, excision was too late in all of these cases; and, if a few hours after the appearance of the initial lesion, is too late practically we can scarcely hope to find relief in an operation of this kind, especially as we have no method of find- ing whether a patient has contracted syphilis before the ap- pearance of the chancre or not, unless it be by confrontation. Barthelemy4 says that he saw what he thought was an un- doubted indurated chancre. The patient was subjected to no treatment and eighteen months later no constitutional symptoms had appeared. He very pertinently remarks that had excision been resorted to the case would undoubtedly have been regard- ed as one of syphilis cured by excision, and as proving the local nature of the disease. As Zeissl5 has well observed the exci- sion of the induration does not prevent the appearance of sec- ondary symptoms ; as Delpeeli has noted, it frequently happens that the induration is reproduced at the site of the operation. But, even knowing positively that the patient has contracted the disease, how are we to determine the point of entrance of the virus ? A single, a number, or no abrasion may exist imme- diately after intercourse and syphilis may or may not be subse- quently developed. In the case of a single abrasion it may be that some other solution of continuity, invisible to the naked eye, is the point of entrance. In regard to another question, as to the channel by which the virus is disseminated; it is equally difficult to determine it. Of course, there is no doubt whatever that the lymphatic system is implicated, but is it alone concerned ? The virus produces tis- sue changes in the walls of the bloodvessels and ceils in the im- mediate vicinity whilst the lymphatics retard its onward pas- sage. It has not been proven, by any means, that the virus is isolated in the lymphatics before being generally distributed. Were this the case the method projxjsed by Dr. A. H. P. Leuf 6 . 4. Sur les Autoinoculations du chancre syphilitique. Annales ■de Dermat. et de Syph. No. 4, 1885. 5. Ibid. 6. On the Eradication of Syphilis during the First Stage by Surgi- cal Means. N. Y. Med. Jour., July 11th-, 1885. 6 would be an excellent one. He thinks that excision of the in- durated ganglia and possibly of the connecting lymphatic vessels would prove effective in eradicating syphilis. Ho practical de- monstration has yet been made in this direction, so it remains a purely hypothetical method. A great objection to the theory of the localization of the syphilitic virus is that cases exist of men affected with a mild “latent” syphilis who infect their wives who, in their turn, never exhibit a chancre but manifest the presence of the disease by such symptoms as falling of the hair, periostitis, exostoses, me- trorrhagia, etc., in whom these all disappear under antisyphili- tic medication. How, is it not reasonable to suppose that the virus will develop and will produce the changes which are ob- served in the general system and find its expression in an explo- sion upon the surface, as it is held chained for a time in a cer- tain circumscribed space only to fulfill the former condition ? The different periods of incubation and their regularity to- gether with the fact that general measures given at certain peri- ods merely retard certain explosive outbreaks would seem to indicate that the infection is general. A thorough consideration of the whole matter will also seem to indicate that the initial sclerosis is but an indication of a systemic infection. The fact that auto inoculation has been successful after the appearance of the induration as detailed by Dr. Pontoppidan7 does not invali- date the position, for it is merely a local sclerosis of the skin. There is induration, but unaccompanied by induration of the lymphatic ganglia anatomically connected with the induced scle- rosis. The experiments are somewhat vitiated also by the fact that pus was used in the inoculations. As is well known, the lower animals are, as a rule, not sus- ceptible to 1 is. On this account, experiments have not been possible. Ho one is willing to submit to inoculations for the sake of a theory, and an experimenter would not consider it justifiable to do so without the consent of the subject. For these reasons, all that has been done has been through clinical obser- vation and anology, each observer endeavoring to make certain facts explain a pet theory. When Bell differentiated gonorrhoea from syphilis, a howl arose from a numerous horde of opponents who detailed num- 7. Annales de Dsrmai. ei de Syphiliog. No. 4, 1885. 7 berless supposed facts to prove that he was wrong. Hunter discovered a positive diagnostic sign of the chancre and still something was wanting. fticord gave us the intra-urethral chancre with which he explained everything. Since that time we have had the “mixed” chancre brought to our notice to ex- plain a number of apparently anomalous cases. But, one fact has towered above all these; one which has remained constant despite the various perturbations of theories and it is that syph- ilis is a constitutional disease. In spite of the numerous mis- takes which have been made and the errors of theories, it re- mains such to this day, so accepted by the vast majority of the profession. Nearly all the observations that have been made point to this one fact—that 83rphilis is constitutional as soon as the chancre has made its appearance. We will not take into account the theories of the unicists, whose death-knell was tolled when Wigglesworth announced the result of his well- known experiments. To arrive at a clearer general understand- ing it will be better, to define some terms. We do not know of the presence of syphilis in an organism until the chancre has made its appearance. But as this sclerosis is the result of a virus, which has had an opportunity of developing during a cer- tain amount of time—the period of incubation—it represents, as it were, what the disease is. To show that the virus has been at work before its appearance, it is only necessary to have in mind the fact that, frequently, during the primary period of in- cubation patients will be affected with cephalalgia, rheumatism, become anaemic, depressed in spirits, melancholic, etc. So that we may regard syphilis as constitutional ab initio, recognizing as the beginning of the trouble that time at which it can be recognized, viz.: upon the appearance of the chancre. This is a theory which will be found to agree more closely with clinical facts, than others, no matter what we may sup- pose the prime cause to be and is itself based upon clinical ob- servation. It will satisfactorily explain many otherwise puzz- ling cases and not only this but it will preserve many a patient from useless mutilation and save many a physician from commit- ting a costly blunder.