Double Chancre A 
Distance. 
- BY - 
A. H. OHMANN-DUMESNIL, 
ST. LOUIS, MO. 
Reprint from 
St. Louis Medical and Sukgical 
Journal, 
July, 1892. Double Chancre a Distance. An Inquiry into Syphilitic 
Auto-Inoculation. By A. H. Ohmann-Dumesnil, Profes- 
sor of Dermatology and Syphilology in the St. Louis Col- 
lege of Physicians and Surgeons. 
The question of auto-inoculation in syphilis was, at one 
time, a fruitful theme for discussion and led the way to 
numerous experiments of the greatest importance, when 
viewed in the light of the results that were achieved. After 
a lull of several years the question has been revived in latter 
years, but in a different form. It is one of the highest im- 
portance from the fact that, should it be established that auto- 
inoculation is possible, during a certain limited period, it 
would conclusively prove that the disease was still localized, 
and the very fact that this localization existed would render 
reasonable attempts to jugulate syphilis by means of early ex- 
cision of the chancre and of the indurated ganglia anatomically 
connected with it. The following cases are interesting as 
bearing in some respects upon the question of auto-inocula- 
tion, and as affording example of a clinical variety not fre- 
quently met with. 
Case I-Mr. B., about twenty-two years of age, contracted 
a chancre and presented himself to Dr. A. C. Bernays for 
treatment. I saw the patient at this time. He could not fix 
the probable time of infection. Upon examination he pre- 
sented a well marked chancre of the prepuce on the right side. 
The induration was well defined and the inguinal ganglia of 
the corresponding side were also indurated. In the centre of 
the lower lip he presented a sore having the size of a silver 
half-dime, well defined, of roundish shape and implicating a 
portion of the mucous membrane and vermillion border. On 
both sides of the inferior maxillary the lymphatic glands were 
enlarged and indurated. More especially was the condition 
marked upon the left side. The induration of the labial sore 
was very distinct. Patient was subject to fissures of the lower 
lip. He was not aware of handling his preputial sore and 
transmitting the virus to his lip. In fact, he rather thought 
he did not. In about two months after a marked secondary 
eruption appeared and his hair fell out. Both chancres healed 
spontaneously and simultaneously, the induration disappear- 
ing in the sores and lymphatic glands at the same time. 4 
Case II.-Mr. C., presented himself to me for treatment, 
December 22, 1886. He presented two chancres. One was 
situated upon the mucous surface of the left side of the pre- 
puce and extended to the border. It was somewhat larger 
than a silver dime, the induration being plainly apparent to 
the feel. The lymphatic glands were enlarged and indurated. 
The other chancre was situated in the centre of the upper lip 
and was a little smaller than a silver dime. The induration 
wras very marked, so much so, that it partially everted the 
lip. The lymphatic ganglia beneath the inferior maxilla were 
indurated, not so markedly so upon the left as upon the right. 
Those on the right, however, were plainly enlarged. Upon 
inquiry the fact developed that the upper lip was almost al- 
ways fissured, at its central portion, in winter and had been 
in that condition, for some time before the appearance of the 
sore. On February 22, 1887, two months after the patient 
first presented himself, a fine papular eruption made its ap- 
pearance. Upon the face, back and legs pustules were scattered 
here and there. Mercurial treatment caused these to disappear 
in a couple of weeks, but it was not until March 12, that the 
induration of the glands and the chancres disappeared com- 
pletely. This restitutio ad integrum was simultaneous in both 
localities. Inquiry elicited the probabilities of the simul- 
taneous appearance of both sores. At least as far as the patient 
knew, they came on at the same time, but he was naturally 
more solicitous concerning the sore upon his prepuce regard- 
ing the other as merely an ordinary sore due to irritation of 
the fissure. 
Multiple chancres are not rare by any means. They are 
quite frequently seen, if we are to believe the statistics of 
those who see many cases of syphilis. Of course, the relative 
precentage is not great in comparison with the grand total but 
an observer who has not seen this condition has not had many 
cases under his care. The same may be said of extra-genital 
chancres and more especially of chancre of the lip. The con- 
dition, however, which I have detailed does not seem to be 
one that is frequent; in fact, it is a more unusual one, viz : to 
have a chancre of the prepuce and of the lip occur simultan- 
eously. While genital and buccal mucous patches often occur 
synchronously, the primary lesion of syphilis does not seem 
to affect parts so distant from each other, nor those particular 5 
portions which I have mentioned. On this very point F. N. 
Otis,1 speaking of extra genital primary lesions, says, " Usu- 
ually they (chancres) are rare in proportion to their distance 
from the genitalia." How much rarer must this condition be 
when the case is one of multiple chancres, at such a distance 
from each other. 
An interesting question which is now suggested is this : In 
the cases reported above, were the chancres of the same age 
and due to the same inoculation in point of time ? or, was 
there auto-inoculation ? A consideration of this would lead to 
a critical examination of the question of auto-inoculation, and 
the success which has attended attemps to establish the truth 
of its probability. I do not intend to discuss these questions 
exhaustively, but merely analyze a few points, and indicate 
some possible sources of error. In my opinion, in the two 
cases which I have briefly outlined the chancres of the lip and 
of the prepuce, in each case, were of the same age and inocu- 
lated simultaneously. My reasons for this are founded upon 
the fact that the induration of the sores and of the ganglia oc- 
curred at about the same time so far as this was observed. In 
the next place, the induration disappeared exactly at the same 
time, both in the lymphatic glands and in the chancres. In 
other words, while the appearance of the induration could not 
be exactly determined, the synchronous disappearance was 
observed ; and this in two cases. Had either of the chancres 
been due to an inoculation from the other, we would expect 
its induration to appear and disappear as much later than 
that of the primary infecting focus as the period intervening 
between the appearance of the one and that of the other. 
Now let us examine the evidence adduced to support the 
possibility of auto-inoculation and then we will consider the 
probabilities. 
P, A. Morrow says,2 "The initial lesion is unique ; mul- 
tiple chancres are, however, by no means rare ; they may be 
grouped in the same region, or be disseminated over different 
portions of the body. 
11 Multiple chancres are almost always due to the simul- 
taneous inoculation of a number of rents or abrasions; they 
are not produced by successive inoculation, as in the case of 
chancroid. 
1. Practical Clinical Lessons on Syphilis and the Genito-Urinary Diseases. 
1886. 
2. Venereal Memorand i. 1885. 6 
" The non-auto-inoculability of the chancre is a rule to which 
there are few exceptions, and these only possible when inoc- 
ulation is performed at an early period after the appearance 
of the chancre ; the result is usually an abortive pustule." 
E. L. Keyes3 has about the same opinion in this matter. 
He states that " when the chancre is quite young, and the 
organism presumably not saturated with syphilis, some of the 
poison taken from the patient's own chancre may be success- 
fully auto-inoculated, producing a second characteristic chan- 
cre upon him (Puche, Wallace, Sperino, Bidenkap, Lee and 
others.)" 
In Bumstead and Taylor4 the main issue is avoided to 
some extent, as witness the following: " If multiple at all, 
it is almost always true that they (chancres) are so as the im- 
mediate effect of contagion, and because several rents or abra- 
sions were inoculated together in the sexual act. If solitary 
at first, they continue to be so ; since successive chancres 
rarely spring up in the neighborhood, as in the case of chan- 
croid, owing to the fact that the virus ceases to act upon the 
system, as soon as it is once infected." 
Of course, the question is, when does the system become 
infected ; or, in other words, what is the limit to the period 
when auto-inoculation is possible or is it possible at all ? 
The possibility of auto-inoculation from the primary scler- 
osis is doubted by a number of good observers. Fournier in 
giving the differential diagnosis of simple and syphilitic chan- 
cre, states that in the latter the pus is not auto-inoculable. 
H. Leloir5 says that " the infecting chancre is not inocula- 
ble on the carrier of it, and this last proposition may be laid 
down as an invariable rule (une regie absolue) this character- 
istic of the non-inoculability of the infecting chancre is of the 
highest importance and may be considered as pathognomonic." 
He adds a note in which he states that, in some exceptional 
cases, auto-inoculation seems to have succeeded. 
H. G. Piffard6 says that the " Chancre is not, as a rule, in- 
oculable on a person bearing it, or upon another who is al- 
ready syphilitic." 
3. The Venereal Diseases including Stricture of the Male Urethra. 1880. 
4. The Pathology and Treatment of Venereal Diseases. 1883. 
5. Lecons sur la Syphilis, 1886. 
6. Materia Medica and Therapeutics of the Skin. 1881. 7 
Berkeley Hill7 in speaking of the primary sclerosis of 
syphilis says that " the papule is habitually solitary. When 
there are more than one, the papules are all of the one age," 
implying that all were inoculated at the same time. 
Alfred Cooper8 in considering the same questions states 
that "if several hard chancres are found upon the same per- 
son, the probability is that they have become simultaneously 
developed; for a sore of this character is not inoculable, as 
such, upon the subject of it." 
Jonathan Hutchinson9 does not seem to be very favorably 
impressed by the doctrine of auto-inoculation. In referring 
to multiple chancres he says that " the number of these in- 
durated spots, or chancres, will depend upon the number of 
different places which were inoculated at the same time, just 
as is the case with vaccination vesicles. It is not very often 
that more than one is seen, and if there be two, three, or more, 
they are always at the same stage of progress at the same time. 
No new ones are ever produced subsequent to the full development 
of the first.* 
If, for the sake of experiment, it were attempted by direct 
inoculation to produce others, the attempt would fail; just as 
we should fail to re-vaccinate an infant, on the eighth day, 
from his arm spots." While we see that the possibility of 
auto-inoculation is mentioned, the author makes some pretty 
positive statements to the contrary. 
I will make another quotation from P. A. Morrow,10 in 
which he states that " the non-auto-inoculability of the secre- 
tion of the chancre is the rule to which there are few excep- 
tions 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 
7. Syphilis and Local Contagious Disorders. 1869. 
8. Syphilis and Pseudo-Syphilis. 1884. 
9. Syphilis, 1887. 
*. It is possible that certain rare exceptions to this statement may occur. H. 
10. Atlas of Venereal and Skin Diseases, 1888, 8 
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 interest- 
ing and brief rdsumt on the subject by Dr. E. L. Keyes.11 In 
one case (his own) excision of the chancre was performed be- 
fore 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 con- 
cerned. In commenting upon this the author says : ' ' This case 
I consider worthy of record because it fulfills the most exact- 
ing conditions for testing the question still under consider- 
ation 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 appar- 
ently 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 appear- 
ance of general syphilitic manifestations later on. 
Barthelemy13 reports a case of undoubted indurated chancre 
accompanied by ganglionic involvements in which the indur- 
ation 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 ? 
11. N. Y. Medical Journal, April 25,1885. 
12. Progres Medical, August 15,1885. 
13. Annales de Dermatologie et de Syphlligraphle, No. 4, 1885. 9 
Zeissl14 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. 
Spillman15 protests energetically against the abortive surg- 
ical 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, de- 
spite 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 con- 
stitutional at the time the chancre was excised. The sores 
were only suspected as the principal signs of differentiation 
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 suc- 
cessful auto-inoculation and examine them critically. First, 
we will take the cases reported by Pontoppidan16: 
1°. Patient with ulcer in the sulcus coronse, having slight 
induration. Inoculated in three places on the abdomen. On 
the eleventh day slight infiltration of base observed. 
2°. Infection dating back three weeks. For past fifteen 
days excoriation on prepuce and ulcer in sulcus coronse. Later, 
14. Ibid. 
15. Revue Medicate de 1'Est, January 1,1892. 
16. Annales de Dermatologie et de Syphiligraphie, No. 4,1885. 10 
sclerosis about urethral orifice. Three inoculations on abdo- 
men appeared as papules on the twenty-second day. 
3°. Infection a month old. Sclerosis in sulens coronas. 
Inoculation showed papules on the thirteenth day. 
4°. Infection four weeks back. Inoculation showed ele- 
vated reddened places on the twelfth day. On the tenth 
pa ules, 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. 
Haslund17 reports five cases of multiple chancres due to 
auto-inoculation, a brief notice of which is as follows: 
1°. 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 urethrse 
which became distincly indurated. Four weeks later a macu- 
lar syphiloderm appeared. 
2°. Small excoriation of frenum. No induration. Cauter- 
ized 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 coronse. In three days one 
sore indurated and a new ulcer in the middle of the balano- 
preputial sulcus. Ten days later there were eleven indurated 
ulcers. About a month later abundant macular syphilide. 
A number of the ulcers healed, leaving a well-developed in- 
duration. 
3°. An indurated ulcer on the left side, in the sulcus cor- 
onse. Left inguinal ganglia indurated. Two days later an in- 
durated ulcer on the inner surface of prepuce. A month later 
a macular syphilide appeared. 
4°. An indurated ulcer in the sulcus coronse 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 coronse. 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 
17. Annales de Dermatologie et de Syphiligraphie, No. 6,1887. 11 
on perineum to the left of the raphe. 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 macularsyphilide appeared. 
A critical examination of these cases would lead us to look 
upon them as special pleas. Mracek,18 in reviewing Pontop- 
pidan's cases, states that, as proofs of the auto-inoculability 
of the chancre, they have but little weight. In Case 1, of Pon- 
toppidan'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 thirty- 
seventh day after appearance of ulcer. In Case 3, we have 
insufficient data, papules appearing. In Case 4, we have ele- 
vated reddened places as the result of inoculation, papules ap- 
pearing 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 des- 
cription 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 Has- 
lund'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 
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 ana- 
tomically connected with the artificially produced lesion, un- 
less it be at the time that general involvement of the lympha- 
tic 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 
18. Vierteljahresschrift fuer Dermatologie und Syphilis, No. 4,1885. 12 
that : 1°. The probability of auto-inoculation in early syphilis 
has not been proven. 2°. While there maybe strong presump- 
tive evidence in favor of it, it is only at best a possibility. 3°. 
The most crucial experiments prove that excision of the chan- 
cre at the earliest possible moment is futile and falls short of 
its purpose. 4°. In multiple chancres d 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. 
5 South Broadway.