Class RC 2-QI Book Ji^i_ Copyright^? COPYRIGHT DEPOSIT. 1 Iti it SYPHILIS IN ITS MEDICAL, MEDICO- LEGAL AND SOCIOLOGICAL ASPECTS SYPHILIS IN ITS MEDICAL, MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS BY RAVOGLI, M.D. Professor of Dermatology and Sy philology in the Medical College of Ohio, Medical Department of Cincinnati University, Dermatologist to City Hospital of Cincinnati ; Member of the Ohio State Board of Medical Registration and Examination THE GRAFTON PUBLISHERS PRESS NEW YORK USflARY of CONCUSS Two Cooles Receiveo SEP 7 *90f Copyncht Entry CLASS>A XXc„ No. COPY B. Copyright, 1907, by THE GRAFTON PRESS To Dubois-Havenith to whom humanity must feel indebted for his courageous and persistent work for the public prophylaxis of syphilis and kindred diseases this Book is humbly dedicated PREFACE Contagious diseases, as a menace to the individual by their method of spreading, and as a menace to the race by their transmitted heredi- tary taint, offer an interesting field of study to the physician. The physician, more than anyone else, must try to prevent their spreading, and must enlighten the people concerning their existence and their consequences, so that the necessary precautions may be taken to protect society. Syphilis, as an infectious and contagious disease, which is communicated to the healthy by inoculation, and is trans- mitted by heredity to the fetus, either kills the fetus in utero, or causes the child to come into the world a tainted creature, demands our atten- tion as a subject for study of deepest interest. The connection between syphilis and social relations is so little understood that the name of the disease alone is sufficient to cast a mark of dishonor on the man who has had the misfortune to be inoculated. The public in general, ignorant of causation, is unable to understand the difference between one innocently infected and one who exposes himself to infection through lack of morality. Indeed, we shall never expect to be understood by superstitious people who, with religious devotion, carry about a potato in their hip pocket, which they believe will absorb all their rheumatic humors, or by those who carry pieces of carbon left by the arc lights for the same superstitious purpose. Neither do we expect to be understood by those who, on account of their belief in occult virtues, wear an iron ring on their little finger, which they claim to be electric and able to cure them of all their rheumatic pains which may be the result of a gouty condition, or perhaps of an old neglected syphilis. Whoever entertains such irrational views and such dispropor- tionate hopes, is superstitious and incapable of realizing that when a man has an eruption on his face, although it may be of a syphilitic nature, the fault of the infection does not necessarily rest on the lack of morality of the person. A great many, ignorant of the manifesta- tions of any disease of the skin, are likely to think any eruption on the face or on the hands the result of syphilis. It is for this reason we have decided to publish a few sociological considerations on this dreadful disease, for the purpose of placing the man who is infected with syphilis in a true social light. In many viii PREFACE cases the fault is with the man infected, who in a moment of forget- fulness, misled by his companions, may have been indiscreet, although his moral character is good and irreproachable. For a young man of this kind, contracting this disease is a lesson in life which will remain vivid in his memory. The fear of the disease and of its con- sequences makes him take care of himself, stop the use of alcoholic beverages, stop smoking; reforming him entirely. We also find a large number of patients who have been acci- dentally infected with syphilis, cases which have been called syphilis insontium, where the disease has been contracted accidentally, or in the discharge of professional duties, as among physicians, dentists and midwives. In these cases the man or woman was infected, while he or she did not deserve such punishment, and syphilis must then be considered as a non-venereal disease. Syphilis, through the lymph and blood vessels reaches any organ and any tissue of the human body, and remaining in the system, is capable of bringing about so peculiar an appearance of the features of the individual that it is easily discovered by the eye of a skillful physician. This was pointed out by Ferdinand Hebra as ein ganz speciiisches Gesicht. If this is true of the general appearance of the body and especially of the face, it must also be so of the general mental condition of the person affected, for syphilis does not spare the delicate structure of the nerve cells, especially those forming the gray matter of the brain, and we quite often see specific affections of the nervous system in all the periods of the evolution of syphilis. Just as syphilitic eruption leaves marks on the skin, any attack on the nervous system must leave traces which late in life will become more pronounced. Indeed, if a syphilitic child shows unmistakable signs of syphilis in his or her bones in a form of dactylitis, he or she must also show signs of affection of the nervous system, which may be revealed in its motor or psychical functions. It is not difficult to perceive anomalies in the motor function, but the psychical condition is frequently hidden and only those who are constantly in contact with such a person are able to perceive the alterations of the psychical sphere. It is, therefore, easily understood that all these questions per- taining to the syphilitic alterations in the man who becomes infected, and to all his relations to his wife, to his family and to society, form a vast and important sociological study, which we shall carefully con- sider in all its details. CONTENTS PART I ■ THE MEDICAL ASPECTS THE TRANSMISSION OF SYPHILIS CHAPTER PAGE I. Historical Sketch of the Search for the Causal Agent 3 II. Pathological Process of Infection 14 III. Modes of Infection 22 THE EVOLUTION OF SYPHILIS IV. Primary Syphilis 28 V. Constitutional Syphilis 38 Affections of the skin 41 The skin appendages 52 Late syphilis of the skin 54 Other tissues and organs 56 Oro-pharyngeal cavity 60 Alimentary tract 65 The respiratory tract 6j The heart and blood vessels J2 The liver, spleen and kidneys 79 The male genito-urinary organs 84 The female genito-urinary organs 89 The bones and joints 90 The muscles and bursas 101 VI. Syphilis of the Nervous System 105 The brain 105 The spinal cord 112 General syphilitic affections of the nervous system 116 ix x CONTENTS CHAPTER PAGE Locomotor ataxia 121 General paralysis 123 Syphilis of the organs of the special senses . . 127 VII. The Nature of Syphilis as Influenced by Other Conditions 136 Causes of malignancy 136 Mixed infection 138 Tuberculosis 140 Alcohol 140 Tobacco 141 Other disease causes 142 Individual dangers from syphilis 143 VIII. Parasyphilitic Affections 152 IX. Influence of Syphilis Upon Other Diseases . . . 158 X. The Treatment of Syphilis 171 External treatment 177 Internal treatment .183 Injection treatment 189 Inunctions 195 Fumigation 202 Physiological action of mercury 205 Mercurial poisoning 211 Thermo-mineral baths 212 Iodides 213 Individual prophylaxis 223 XL The Transmission of Syphilis to the Offspring . 229 Direct transmission 229 By conception 235 Germinative infection 238 Congenital and hereditary syphilis 240 Maternal heredity 245 Maternal heredity alone 250 Sterility from syphilis 251 Syphilitic immunity 254 Symptoms and consequences of congenital and hereditary syphilis 264 General treatment of congenital syphilis . . .271 Constitutional treatment of congenital syphilis . . 273 Prophylaxis 275 Retarded hereditary syphilis 284 Latency of inherited syphilis 293 Syphilis of the third generation 299 CONTENTS xi PART II THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS CHAPTER PAGE I. Syphilis and Marriage 317 Syphilis as an impediment to marriage . . . . 317 Syphilis as cause of divorce 321 Damages in cases of syphilis 324 The medical secret 329 Professional ethics and syphilitic patients . . . 336 In reference to marriage and to family .... 338 II. Syphilis in Relation to Degeneracy 343 Degeneracy 352 Physical signs of degeneracy . . . -. . . 366 Syphilis and the decadence of populations . . . 370 Syphilis as a predisposing cause of crime . . . 392 Syphilis and sexual perversion 405 III. Syphilis and the Public Health . . . .. . . 412 Syphilis and life insurance 425 Public prophylaxis in regard to prostitution . . 439 Prostitution of minors 448 Causes of prostitution 452 Proxenetism and procuresses . . . . . . 456 Sanitary consequences 459 Prevention and coercion . . . . . . . . 463 Juvenile courts 465 Industrial schools 473 IV. The Regulation of Prostitution in the Public Prophylaxis of Syphilis 480 ILLUSTRATIONS PLATE F CING PAGE I Trypanosoma lues . . . . . . .12 II Syphilitic roseola. — Roseola annularis . . . .42 III Large papular syphilide, hypertropic type. — Papulosqua- mous syphilide four years after infection . . 46 IV Circinate syphilide of diffused type .... 48 V Pigmentation left by hemorrhagic papular syphilide . 50 VI Syphilis ulcerosa . . . . . . 52 VII Papular syphilide with gangrenous spots . . .56 VIII Phagadenic syphilitic ulcer with elephantiasis of the anus and vulva ........ 60 IX Large papular syphilide. — Circinate papular syphilide . 64 X Syphilitic cutaneous gummata, ulcerated. (Syphilis tuberculo-ulcerosa). — Ulcerated gumma of the nose. — Destruction of the septum nasi and portion of superior lip from syphilitic gumma . . .68 XI Ulcus perforans. — Multiple ulcerated gummata . . 72 XII Twin boys from syphilitic parents, one infected and the other healthy ....... 250 XIII Examples of Congenital Syphilis : Large papular eruption. — Rupioid form ; child died of pneumonia. — Diatrophy of right hand and left arm; child died of eclampsia . . . . . 268 XIV Diatrophy of the fingers in a heredo-syphilide. — Ulcerated gummata in a heredo-syphilide .... 306 XV Leon F. Czolgosz. — Stigmata of degeneracy in a criminal 402 XVI Francesco Gioli ........ 406 Xlll PART I THE MEDICAL ASPECTS PART I THE MEDICAL ASPECTS THE TRANSMISSION OF SYPHILIS I HISTORICAL SKETCH OF THE SEARCH FOR THE CAUSAL AGENT It is indeed astonishing to find authors who have denied the existence of the syphilitic virus, and others, like Brussais in France and Huber in Germany, who have even denied the existence of syphilis. There is no one to-day who could for a moment have a doubt con- cerning the contagiosity of syphilis and the inoculation of a healthy person by an infected one. Although until lately science had not positively discovered the exact nature of the syphilitic virus, yet by its contagiosity, course, and symptoms, it was always believed to be due to a living germ. Many investigators had searched in the blood and in the secretions of syphilitic patients, they had often referred to the discovery of a peculiar living organism, but later on it had been found to be not at all characteristic of the syphilitic affections. All the observations of this kind made before the founding of the science of modern bacteriology have remained as mere historical curiosities without scientific importance. To this category has to be referred the vibriolineola of Mueller and Donne, the micrococci of Hallier, Klotzsch, Salisbury and Bruhlkens, and the peculiar bodies of Losdorfer, which he claimed to have found in the blood of syphilitic persons. Observations afterwards made in the light of modern bac- teriology also remained unsuccessful. It would take a long time to mention everyone who has believed that he has seen the syphilitic germ, and has tried to demonstrate its existence, from Klebs, 1879, to Petrone, Barduzzi and Marcus, 1884. Their results were unsatis- factory and contradictory; no one has succeeded in showing a con- stant form of micro-organism in the inflammatory productions or in the blood of syphilitic persons, neither have they succeeded in a 4 THE MEDICAL ASPECTS positive inoculation of a culture in the lower animals. It was about the end of the same year, 1884, that Lustgarten x in a preliminary communication announced that he had detected a special bacillus in the syphilitic tissues by means of a peculiar method of staining. In the following year 2 he gave a more detailed description of this bacillus ,and of the staining method. Doutrelepont 3 and Schiitz fol- lowed in claiming the discovery of the bacillus of syphilis by a method of staining nearly identical to that of Lustgarten, and De Giacomi, Gottstein and Baumgarten stated that they had succeeded in finding bacilli in an initial lesion. Lustgarten examined sixteen cases of different lesions, such as indurated chancres, mucous patches and gummata. The bacilli were found in very small numbers, and attempts at cultivation were not successful, while the last mentioned authors with the decolorizing method succeeded in detecting bacilli in an initial lesion, which with the Lustgarten method could not be found. At this point Cornil 4 communicated to the Academy of Medicine of Paris that Alvares and Tauel had found in the smegma taken from a healthy person, bacilli, which reacted in the same manner with aniline dyes as the bacilli described by Lustgarten. Furthermore, the above named authors did not find the Lustgarten bacillus in scleroses and mucous patches of the mouth, and of a gumma of the lungs, but they found the organisms in the secretions of chancres, gummata, mucous patches, as well as in three cases of soft chancre, in the fluid of vesicles of herpes preputialis and in pemphigus vulgaris on the genitals of both sexes. In the smegma taken from the prepuce, from the large and small lips of the vulva, and from the region of the anus, the same bacilli were found which gave a similar reaction to those described by Lustgarten. The same results were obtained by Klemperer, who at a meeting of the Berlin Medical Society confirmed the observations of Alvares and Tauel, giving in this way a blow to the specificity of these bacilli. It would be a long and difficult task to mention all the observers and authors who have worked in this direction, men of great scientific ability, such as Dutrelepont, Matterstock and Bitter. Disse and Taguchi, Lingard and Eve, Andromico, Habercorn, Marcus, Man- surow, Leloir, Babes, Koeniger and Fordyce, 5 all believed they had 1 Wiener Med. Wochensch. 1884. 2 Wiener Med. Jahrbucher. 1885. 3 Doutrelepont. " Bacillen bei Syphilis," Deutsche Med. Wochensch. No. 19. 1885. 4 Cornil. Gazette des Hopitaux, No. 90, 1885. 5 John A. Fordyce. " A System of Genito-Urinary," etc., edited by Prince A. Morrow, p. 47. SKETCH OF THE SEARCH FOR THE CAUSAL AGENT 5 succeeded in finding a peculiar bacillus in a few cases of syphilitic scleroses or in the tissues of the mucous patches. Lately Jullien communicated to the Academy of Medicine of Paris the results of his investigations made with the co-operation of Dr. Delisle in the Pasteur Institute. He demonstrated the presence of an aneroid bacillus in the blood of syphilitic patients. He was able to cultivate the bacillus in blood serum, and to inoculate different lower animals, finding that frogs and pigs showed great sensitiveness to this poison. Max Yon Niessen 6 had also described a bacillus which he claimed to have found in the blood of syphilitic persons, which grows on nutrose agar, the color of which changes into yellow and yellowish green. It is colored by the staining method of Gram Nicolle. He claims to have found the same bacillus in all stages of syphilis. He inoculated monkeys and pigs with the cultures of this bacillus. The monkeys soon died after the inoculation, some showing diffuse erythema and inflammation of the lymphatic glands. In one monkey which remained alive for some time, a form of hepatitis developed with hypertrophy of the capsule of the liver and under the microscope the blood-vessels showed the same appearance as in man. Another monkey after a certain time was affected with epileptiform attacks. He spoke of papular eruptions, sclerosis, gummata and also of periostitis de- veloped in the pigs. Although the observations were of great interest, and the article was beautifully written, yet it was severely criticised by Ludwig Walsch of Prague in the Archiv fur Dermatologie und Syphilis, July, 1901. Walsch showed a lack of proof in Von Niessen's findings, premature conclusions from the results of his inoculations, and inconsistency of his projected therapeutics. Max Joseph 7 made a communication to the Berliner Medisin- ischen Gesellschaft, with illustrations, showing some peculiar bacilli found in the sperma of syphilitic patients at the height of the infectious period. The work was done in Dr. Piorkowski's Bacteriological Institute in Berlin, and was followed by another lengthy communica- tion by Dr. Joseph at the meeting of the Deutscher Natur-f or sellers und Aerzte in Karlsbad, September 24, 1902. Joseph started with the idea that a man who has been infected with syphilis, after two or three years, while apparently well, having sexual intercourse with a healthy woman, does not communicate the disease to her. But when the woman is fecundated, then the fetus is infected and communicates the disease to the mother. As a consequence he 6 Von Niessen. " Beitrage zur Syphilis Forschung," Wiesbaden. 1901. 'Joseph, Max. Berliner Klinische Wochenschrift. No. 13 and 14. 1902. 6 THE MEDICAL ASPECTS concluded that the syphilitic virus remains longer in the semen than in other secretions of the organism. He used sperma of syphilitic persons for inoculations, and as a culture medium pieces of sterilized placenta, which were inoculated mostly on the maternal side, and were kept in an incubator at the temperature of 37 C°. After twenty-four to forty-eight hours he could see on the inoculated places small points, grayish in color, which were colonies of micro-organisms which he recognized as bacilli. He compared these bacilli with those of diph- theria, and they were easily stained with carbolfucsin and gentian violet. He claimed to have found these bacilli in many cases of syphilitic persons five years after infection, although they had under- gone several treatments. He found the same bacilli in the tissues of the hard chancre, but he never could find them in the chancroid, or in simple erosions of the genitals. The bacilli were also present in ulcerated mucous patches of the scrotum, of the vulva and of the mouth. He claimed to have obtained positive results from the inocula- tion of pieces of inguinal glands, which had been removed from the groins of syphilitic patients under the strictest asepsis. Joseph bases the specificity of these bacilli on their peculiar shape, and on their peculiarity of vegetating only on the placenta as a culture medium. The cultures of these bacilli were inoculated on rabbits and guinea pigs without any results, but it seems that in a pig, several days after inoculation, an erythematous eruption appeared around the genitals, with ulcerations. The pig died and the lymphatic glands were found greatly hardened and swollen. But on the other hand another pig inoculated with different cultures proceeding from syphilitic tissues did not show after several months any perceptible alterations. He showed many preparations of the bacilli and explained the method of staining, which is a combination of Ziehl-Neilsen's method. The specimens first imbedded in paraffin are cut in thin sections and are placed in xylol for twenty-four hours, then in seventy per cent, and in absolute alcohol. The section is placed on the glass slide and dried with blotting paper, and kept for four hours in a solution of diluted carbol-fuchsin, then it is placed in a mixture of water and alcohol with three per cent, nitric acid. It is dried again and stained with Loffier's methyl-blue solution for a few minutes, then washed, dried and mounted in Canada balsam. In the examination of the lymph glands he claims that the bacilli are very numerous in the middle, in the lymph spaces, and very few towards the periphery. This announcement of having found the so much searched for bacillus of syphilis caused the same objections among the scientists as SKETCH OF THE SEARCH FOR THE CAUSAL AGENT 7 in the ether cases. Delbanco 8 referred to the observations made by H. Pfeiffer in fifteen normal urethrae and in twelve affected with gonor- rhea, by means of preparations on the cover glass, and by means of culture. In these preparations he found a large number of bacteria belonging to the group of pseudo-diphtheritic bacilli. Not one of the men furnishing the material for examination was syphilitic. The mor- phological appearance of those bacilli was exactly the same as that of those described by Joseph and Piorkowski as syphilis bacilli, and yet they are only an innocent kind of parasite, which have been mixed with the sperma while passing through the urethra. The only part difficult to be explained was the presence of the bacilli in the swollen syphilitic glands, found by Max Joseph in two instances. Paulsen, 9 at the biological section of the Medical Association of Hamburg, had already demonstrated bacilli having a great resemblance to those of diphtheria in cultures of the blood taken from the forearm of a man covered with syphilitic roseola, and once from the lymph taken from the swollen lymphatic glands of the groins, while the initial chancre was still present. The bacilli, although showing great likeness to those of diphtheria, have many characteristics which differ- entiate them. Paulsen limited himself to announcing the fact without deducing any conclusion. In 1884 Loffler, while treating the subject of diphtheria in calves, referred to a bacillus which he had obtained by inoculating rabbits with products from syphilitic lesions. This bacillus is morphologically similar to that of diphtheria of calves. From his experiments he con- cluded that, on the raw surface of mucous patches, parasitic bacilli find a good ground for their development. When in September, 1902, at a meeting of the Carlsbad physicians, Joseph and Piorkowski read their second communication, " Weitere Beitrage zur Lehre von den Syphilis-bacillen," Walsch spoke of his observations of the presence of the v. Niessen bacillus. He found this bacillus in six instances in the blood of syphilitic persons during the secondary period and also a yellowish diplococcus, which he had found three times. He had obtained the same bacilli in the culture of the serum taken from the inguinal glands removed from syphilitic patients. The blood taken from healthy people, and from syphilitic persons in the tertiary stage remained negative. From the blood of patients affected with syphilitic roseola, which had been inoculated on organs taken from the pig, bacilli were ob- tained, which had been described by v. Niessen, and had afterwards 8 Delbanco, Ernst. " Einige Notizen zu dem Aufsatz von H. Pfeiffer: Ueber Bakterienbefunde in der normalen mannlichen Urethra mid den Syphilis Bacillus von Max Joseph." Monatsh. fur Prakt. Dermatologie. 1903, No. 5. 9 Paulsen. Munch. Med. Wochenschr. 1902, No. 9. 8 THE MEDICAL ASPECTS been found by Adrian, Holzhauser and Hiigel. Walsch considered the bacilli found by himself, and those found by Joseph" and Piorkowski as pseudodiphtheritic bacilli, which so far do not throw any light on the obscure etiology of syphilis. Delbanco maintained the same opinion, and he believes that the bacilli alleged to be the cause of syphilis are only pseudodiphtheritic bacilli, which ought to be called bacilli found in syphilitic persons. We must not forget that in syphilis the initial lesion is usually ulcerated, the moist papules are ulcerated, and all are open doors for the entrance of secondary bacilli, which are taken in by the lymphatics and carried into the glands, and are also brought into circulation in the different parts of the system. The same order of secondary bacilli is found in lepra. The claim of Joseph and Piorkowski to have found the bacillus causa proxima of syphilis, falls to the ground and the bacilli that they have demonstrated are the very same found by Pfeiffer, Paulsen, Walsch ; only a kind of diphtheroid bacilli, which are found in syphilitic patients as secondary bacilli. Max Schiiller 10 described a peculiar form of round or oval bodies in the tissues of the syphilitic sclerosis, which he describes as forms of spores which appear closed in capsules. He finds that they are capable of some movements and compares them to a kind of sporozoa. In our pathological studies we have met with these peculiar forms, which are very visible when stained with Bismarck brown, made up of round bodies, which are nothing else than thrombi made up by an accumulation of leucocytes inside of the small lymphatics. We have already pointed out these conditions of the lymph-vessels in an article read to the meeting of the Fourteenth International Medical Congress in Madrid, 1903. We have found that the lymphatic vessels are affected by an inflammatory process, their endothelial cells are enlarged and in some places detached. The lymphatic vessels starting from the initial sclerosis are also enlarged and show irregular dilations during their course in the form of cul-de-sacs. They are filled with mononuclear leucocytes, which occlude the lymphatic vessels. The syphilitic virus seems to possess an agglutinating power on the serum and the leucocytes easily stick to the endothelial lining, so that the lymphatics are at times plugged up with lymphatic thrombi. We there- fore refer the peculiar appearance in the form of stars composed of round bodies, to a thrombosed condition of the lymphatic vessels, cut in transverse section. The question still remained sub judice. Everybody believed syphilis to be a disease of bacillary nature, and nobody doubted that the bacillus 10 Schiiller, Max. " Mitteilung iiber die protozoenahnlichen Parasiten bei Syphilis." Dermat. Zeitschrift, 1903, Heft 4. SKETCH OF THE SEARCH FOR THE CAUSAL AGENT 9 would be found. One of the difficulties was that the syphilitic virus had not yet been successfully inoculated in animals, and in consequence was also refractory to inoculation on artificial culture media. In reference to the bacilli, which were claimed to be syphilis bacilli, and then shown to be smegma bacilli, Pizzini was of the opinion that they were probably tubercle bacilli, which if in a dormant state are easily aroused by the syphilitic virus. The morbid symptoms produced in animals by the inoculation of these cultures were in all probability only the result of acute tuberculosis. In these last years a new era in the study of syphilis has begun, which indeed promises to cut asunder the veil which has enveloped the cause of the disease. Metschnikoff and Roux 1X announced the discovery of the suc- cessful experimental transmission of syphilis in the monkey, and not much later the finding of the pathogenic agent in a form of spirillum by Schaudinn and Hoffmann was announced. Inoculation of syphilis in apes occurs in those of the anthropomorphous kind, as it was con- firmed by Lassar 12 in a chimpanzee in the Aquarium in Berlin, and later by Neisser. From the experiments it was found that the chim- panzee is susceptible to infection with syphilis just as man. Twenty- two animals were inoculated, all with positive results. In any place where the inoculation has been done a characteristic syphilitic initial lesion has developed. The regions more often inoculated have been the brow or the eye-lid, which are more easily watched. The initial lesion has appeared between fifteen and forty-nine days after the inoculation, giving an average of thirty days of incubation. The initial lesion is not different from that which is seen in man, being in form of a small, hardened papular knot, bluish red in color, which soon is excoriated and then ulcerated, and covered with crust. After one or two months the lesion heals, the hardness gradually disappears and only a super- ficial cicatrix remains, stained with a brownish pigmentation. The anatomo-pathologic alterations of the lesion in the monkey is just the same as in man, as was shown by Lassar, Arnal, Salmon, Thibierge and Ravau. These consist in an infiltration of small mononuclear leucocytes surrounding especially the blood and lymph vessels, and in some cases true peri- and endoangioitis. After the onset of the syphilitic initial lesion the lymph glands are hard and enlarged, at first near the lesion, soon after of the whole body. In sixty-six per cent, of the inoculated animals, in from twenty 11 Metschnikoff and Roux. " Ueber die experimentelle Syphilis.'' Ref. Berlin Klin. Wochenschr. No. 52, 1903. 12 Lassar, O. " Ueber Impfversuche mit Syphilis am anthropoiden Affen." Derm. Zcitschr. Bd. xi. 10 THE MEDICAL ASPECTS to forty days from the first local lesion, general symptoms occur in the form of ulcerated papules of the genitals, of the chest, in the form of excoriated mucous patches of the mouth, papulo-squamous syphilides of the palms and soles. In the chimpanzee these symptoms, perfectly identical with those of man, are not so severe, are less extensive and of shorter duration. After three to four weeks they undergo an involutive process and disappear. In one instance only the eruption was of malig- nant form, of a rupioid nature, with extended ulcers ; the animal showed deep cachexia and soon after died. Visceral complications in the animals such as a hypertrophic con- dition of the spleen and nervous disturbances, and paresis of the posterior limbs, with abolition of the knee jerk were found. So far, no symptoms of late syphilis have been observed in the inoculated animals, because not one has lived more than thirteen months after the infection. Death has been caused in nearly all cases by infectious broncho-pneumonia. Experiments were repeated in other kinds of apes, as in the gorilla and ourang-outang, but after the appearance of the initial lesion no general symptoms have followed. In the same way experimental inoculations were made in the macachous rhesus, speciosus, cynomol- gus, cynocephalus, cercopithechus, fuliginous and ruber, in many dif- ferent countries, with the same results. In every case the initial lesion has appeared, but no general cutaneous manifestations have followed. The glands surrounding the initial lesion have become enlarged, show- ing that the virus does not find an appropriate soil and soon is attenu- ated and dies. We owe to the experimental researches of Neisser the confirmation of the knowledge already acquired from clinical observations, that the initial lesion and the mucous patches, as well as the cutaneous papules, are capable of transmitting the disease. He proved, furthermore, that the lymph glands and the serum from a bulla of syphilitic pemphigus in an infant with congenital syphilis could inoculate the disease. It seemed that other organs, spleen, liver, marrow of bone, cere- brospinal fluid, had given negative results, but in successive inocula- tions in Batavia, Neisser succeeded in inoculating apes with these organs taken from other syphilitics. In April, 1905, Schaudinn (unfortunately so soon lost to science and to humanity), then director of the laboratory for the study of the protozoa in the Berlin Institution, together with Hoffmann, lecturer on syphilology, announced the discovery of a micro-organism in the syphilitic products, which had never been described, belonging to the spirilla variety, difficult to stain, and from this peculiarity of taking little of the stain when treated with Giemsa's azur and eosin. they SKETCH OF THE SEARCH FOR THE CAUSAL AGENT n called it spirochaeta pallida. Schaudinn and Hoffmann in their first note expressed themselves guardedly in reference to the significance of their discovery, but in their second publication insisted on the duality of the spirochaeta^, the spirochaeta refringens and spirochaeta pallida, the former of a relatively large size, wave shaped, easily stained, the second, found only in syphilitic products, much smaller in size, cork- screw shaped and only stained by special stains. Although the discovery was at first accepted with a great deal of skepticism, within a few weeks after this announcement many re- searchers confirmed the fact brought out by the two discoverers. Metschnikoff and Roux read a communication to the Paris Academy of Medicine, May 16, 1905, in which they recognized the spirochaeta pallida of Schaudinn and Hoffmann as the germ-producing syphilis. The spirochaeta which has been referred to the class of trypano- soma, either prepared with azur and eosin (Giemsa stain) or with nitrate of silver and pyrogallic acid (Levaditi method), appears as a filament from four to ten /*, and one-half ^ thick, with narrow spirals in the form of a corkscrew, perfectly regular with pointed ends. In the spirochaeta^ and connected with them have been described small round or oval bodies, which according to Herxheimer are prob- ably terminal centrosoma. or initial forms in the development of the spirochaeta. When examined in a hanging drop the spirochaeta is in motion forward and backward, or in a kind of trembling movement, or in the form of elongation or of a shortening of the whole filament. They are usually found isolated, but often are found in groups. The method of staining is that of the Giemsa stain. A cover glass or a slide is rubbed on a mucous patch or on a chancre, or better the lesions are gently scraped with a curette and the mucous secretion with the detritus is taken on the glass slide. When perfectly dry in a film, it is hardened with alcohol for a few seconds and then dried again. The Giemsa stain is poured on and covered with a glass cover. After twenty-four hours it is washed, dried, and examined in cedar oil. The true spirochaeta takes a light rose-violet color, while the sp. refringens takes an intense blue coloration. With the method of Levaditi, the staining is done in the whole mass of the syphilitic product, so that it can be cut into sections and the spirochaeta is then seen in the midst of the tissues. The prepara- tion is as follows : A thin piece of mucous patch or suspected tissue is kept twenty-four hours in a ten per cent, solution of formalin, then twenty-four hours in a ninetv-five per cent, alcohol, then is left for a 13 Neisser. " Versuche zur Uebertragung der Syphilis anf Afferi." Pruts. Med. Woch. 1906, No. 13. 12 THE MEDICAL ASPECTS short time in distilled water. It is then left for three days in a solution of one and one-half per cent, of nitrate of silver, at a temperature of 38 C, and one day in a solution containing two per cent, of pyrogallic acid and five per cent, of formalin. Blaschko, 14 who has used this method quite extensively, cautions against local anesthesia in removing the piece of tissue by the infiltration with Schleich solution, on account of the salt which causes a precipitate with the nitrate of silver. Levaditi's method in our hands has given good results, as can be seen in the photomicrograph, Fig. I, which was taken from a hyper- trophic mucous patch of the vulva in a colored woman. Spirochaetae have been found in every tissue and in every fluid of the human body affected with syphilis, and not only on ulcers and on ulcerated patches, but also in parts far removed from them ; in the circulating blood, in dry papular lesions, in the spleen, liver, kidneys of children who had died in consequence of congenital syphilis. Mercury seems to have a powerful action upon the spirochaetae, so much so that after the use of this remedy only a few or none at all are to be found in the local lesions. This fact suggested to Metschnikoff and Roux 15 the idea of the prophylaxis and cure of syphilis, by demonstrating that the inoculation of syphilitic virus can be made harmless to man. A few hours after inoculating monkeys with syphilitic virus the points of inoculations were treated with a salve containing thirty per cent, of calomel, and in thirteen experiments the development of the syphilitic lesions failed. This experiment was repeated in a student who bravely volunteered to be the subject of the experiment. With virus from a hard chancre the student and several monkeys were inoculated at the same time. A few hours later the place of inoculation in the student and in one of the monkeys was treated with the thirty per cent, calomel salve, and the others were left as a control. In the student and in the monkey where the puncture of inoculation had been treated with the calomel ointment there were no signs of syphilitic lesions, while the other monkeys showed an initial chancre. In late syphilitic manifestations of the skin spirochaetae are not easily found. Spitze found spirochaetae in gummata and in sclerotic tissues, Rille in small cutaneous gummata, and we could find them in the sclerotic tissues of syphilitic elephantiasis of the scrotum. In the skin, according to Burnet and Vincent, they are found abundantly in the connective tissues, the lymph spaces, and in the af- 14 Blaschko. " Ueber spirochaeten Befunde in syphilitisch erkrankten Gewebe." Med. Klinik, 1906, No. 13. 15 Metcshnikoff and Roux on the prophylaxis and cure of syphilis. French Academy of Medicine. Med. Record, July 7th, 1906. Plate I Trypanosoma Lues Lymph space of the skin from an excised papula full of spiro- cnaetae objective SKETCH OF THE SEARCH FOR THE CAUSAL AGENT 13 fected tunics of the blood-vessels. Levaditi found them in the epi- dermis, in the tonsils, in the endothelial layer of the blood-vessels, in the liver in groups surrounding the blood-vessels and in the proto- plasma of the hepatic cells. Spirochaetae were seen to continue in their movements in the hang- ing drops for a few hours. In the cadaver of an infant who had died with syphilis, seven hours after death spirochaetae taken from the liver maintained their lively movements. After twenty hours there could still be seen some slight undulation. Cultures on human blood were made by Soura with negative results. Metschnikoff and Roux are very enthusiastic over this discovery, and they tend toward the opinion that syphilis is a chronic spirillosis. Indeed, if the spirochaetae were only ordinary saprophytes they would be found only on the surface and could not be found in internal organs, as has been the case with the spirochaeta. The objection that the culture of the micro-organism has not been successful, does not dimin- ish the value of the discovery. Many other morbid agents, although demonstrated beyond any shade of doubt, have not yet been cultivated, as the bacillus leprae, the plasmodium, and the spirillum of recurrent fever. If syphilis has been transmitted by means of inoculation from the blood in man by Pellizzari, and in the chimpanzee by Hoffmann, this is enough proof that spirochaetae live in the blood as a natural culture medium. The beneficial results which this discovery will bring to suffering humanity, and to society in general, can already be foreseen. It will solve questions of doubtful diagnosis, and will clear up a great many problems connected with hereditary syphilis. The celebrated Colles and Profeta laws will be explained. Treatment will be established upon more scientific ground, and the choice of intermittent or continuous treatment will find its true scientific explanation. The power of ag- glutination, of phagocytic action, of immunity in syphilis, will be established on a solid basis, and very likely we will possess preventive and therapeutic means in the use of a specific serum. II PATHOLOGICAL PROCESS OF INFECTION Syphilis is a contagious disease, which is inoculable through the secretions of the pathological products for a certain limited period. It is in the nature of a fixed contagium, for the reason that the virus must be conveyed and placed directly in contact with an excoriated surface of the skin or of the mucous membrane of the healthy person. At the point of entrance of the virus local changes in the tissues take place, which gradually become noticeable in the form of the char- acteristic initial lesion, or hard chancre, which in due time will give place to general symptoms of a specific character. The virus is re- produced in the diseased organism for a limited period of time, retain- ing its contagiosity, which ceases when the disease is dying out. The disease at a late period is no longer inoculable from the diseased to the healthy person, but it is still transmissible by heredity, and as we shall see later, from the developing fetus it is communicable to the healthy mother. The manifestations of syphilis go on in a continuous progressive evolution, and they may last for months, or for years, or even for a lifetime. The symptoms are not constant, but they appear in the form of relapses, so that the progression of the disease is interrupted by periods of latency, when the patient is apparently well. Some symp- toms are more persistent than others, and in the different cases the symptoms vary according to the different organs and tissues affected. In a few cases the manifestations are very obstinate, but in most of the cases, especially under a well-directed treatment, syphilis dies out after a certain period. When the syphilitic virus has come into contact with a scratch, or a fissure, or an erosion, or possibly has found its way into a follicle of the hair, in a word, has been placed in contact with the lymphatic spaces, from that moment the inoculation has taken place, and in that locality this recently discovered living organism goes on repro- ducing and multiplying. If the virus has been inoculated with other micro-organisms, there soon appears an ulceration or an inflammation as the result of the other cocci. It is clear that if together with the syphilitic virus the virus of a chancroid has been inoculated, this will soon develop as a chancroid, and only after three or four weeks H PATHOLOGICAL PROCESS OF INFECTION 15 the chancroid which was in the way of reparation, appears hard, and soon is changed into a hard chancre. The germs of the syphilitic virus require time to proliferate, taking two, three or four weeks to form their nest, which shows up at the end of the mentioned time in the form of the initial lesion. This time which elapses between the inoculation and the appearance of the chancre is the period of incuba- tion. The word has been well chosen, indeed it is in the nature of a culture. The virus inoculated in an infinitesimal part is there incu- bated, proliferates in the lymphatic spaces of the skin, around the blood- vessels, or under the mucous membrane. The living organisms which constitute the virus produce an irritation, which calls in the presence of migrating cells ready to reinforce the fixed cells and exercise a phagocytic role. The syphilitic germ, however, is too virulent to be overpowered by the cells, and they cannot hinder its multiplication. It develops its noxious toxins, which cause the subsiding of the reactionary phenomena of the cells to end in a proliferation. The cells are in the nature of lymphocytes in an embryonal state and form an infiltration which is the base of the hardness of the initial syphilitic lesion. The form and shape of the chancre depends on the layers of the derma or of the mucous membrane affected by the virus. If only the superficial lymph spaces of the papillary layers are affected, the chancre will be superficial in the form of a diffused erosion, chancre parchemine ( Fournier) or in the form of a lentil, papula. But when the lymphatic spaces and the vascular net of the whole corium is affected, then the chancre will be deep, cup-shaped, with thick edges, the classic Hunterian chancre. The migrating cells, however, are not able to stop the development of the infectious germ, the blood-vessels and the lymphatics surround- ing the area of induration already show pathological changes ; their tunics show an infiltration of cells, while their endothelium shows a proliferation of its cells. In the lymph spaces and inside of the lymph- vessels the virus has an agglutinative power on the lymph, which nearly closes the lumen of these vessels, and causes a chronic inflam- matory process. The virus, consequently, does not remain limited or enclosed in the area of the induration, but has already proceeded and spread to the surrounding lymphatic vessels, which by a skillful finger can be detected to be already hard and infiltrated. The general system is not yet aware of that which is developing in the lymphatics : in consequence the infected individual is apparently well. No pain and no disturbance has so far occurred, nor can any alteration of nutrition be detected. Meanwhile the virus is unrelentingly increasing and its evolution is continuously progressing and always along the lymphatic 16 THE MEDICAL ASPECTS channels. Here it finds the lymphatic glands, which act as a fortress planned for the purpose of preventing the progress of virulent microbes. But the same process which has caused the induration in the place of the inoculation, occurs in those glands. They become hard infiltrated, enlarged, somewhat swollen, but not usually painful, for the reason that the inflammatory process is very slow, the reaction is very feeble, and the presence of the virus produces an infiltration, the cells having lost their phagocytic power. Indeed, the enlarged glands of the groins are called bubo, and when resulting from syphilis, syphilitic bubo. The differential characters of the syphilitic bubo from the ordinary bubo of chancroidal origin are the sluggishness and the tendency not to suppurate. In some cases we also find that the syphilitic bubo may show signs of inflammatory reaction and suppuration. But in these cases the inflammation and the following suppuration are the result of other irritating germs, which have been accidentally inoculated together with or after the syphilitic infection. The glands which are first affected are those which are the nearest to the chancre, so that if the chancre is on the genitals the first glands to show the induration are the inguinal glands ; if the chancre is on the lips, the submaxillary glands will be the first to be affected. The time elapsing from the appearance of the chancre to the time when constitutional symptoms of syphilis appear has been called the second incubation. It is a period which we cannot call one of latency of the virus, because the virus is constantly reproducing, is advancing every day, is already forming its toxins, which display their noxious effects on the blood and on the tissues, but it is more a quiescence, the virus is not ready to show up w r ith the character- istic eruptions of the syphilitic erythema. When we shall know the entity constituting the syphilitic virus and its biochemistry, then we may be able to establish the exact influence which it has upon the affected organism; so far we must content ourselves with noting the changes which are produced in the tissues of the infected system. The virus deposited in the tissues of the skin or of the mucous membrane excites a cellular proliferation and infiltration in the point of infection, which makes the characteristic induration. This cellular infiltration, the product of the irritation of the virus, may for a certain time act as a kind of barrier preventing the virus from proceeding. In other cases the virus may be free in the tissues, and this may be the reason explain- ing the earlier or later appearance of constitutional syphilis. We have already had occasion to call the attention of practitioners to the fact that the manifestations of the constitutional symptoms will sometimes come a few days after the appearance of the chancre, while in other cases it will appear several weeks later, when the chancre has PATHOLOGICAL PROCESS OF INFECTION 17 nearly healed up. We find the reason in the difference in the length of time of the second incubation, in the origin of the virus. When the virus inoculated is the secretion emanating from a hard Hunterian chancre, the infection will proceed slowly with a long period of second incubation, while when the virus is the result of a humid papula, or mucous patch, the initial lesion will be of a papular form, small, and rather superficial, but more virulent in its nature. Indeed, we have observed in a large number of patients that the appearance of this small chancre is soon followed by a roseola, and the constitutional symptoms seem to be more severe in character. This is easily explained by the greater or less virulence of the infecting secretion, when we think that the hard Hunterian chancre is a place of elaboration of the virus, where the bacilli are proliferating, and the virus is in progress of elaboration and has not yet reached the ripe point. The secretion of a mucous patch contains a virus which has already been elaborated in the system, which contains toxins already formed, and also secondary septic bacteria of the pus and of the putrefaction. In this condition we believe that the explanation of the difference is found in the viru- lence of the secretions producing syphilitic infection. The constitutional symptoms occur only when the virus reaches the blood circulation, and we can assume that the virus can reach the blood, either by means of the lymphatic channels or by being intro- duced into the circulatory system directly from the infected point. When carried by lymphatic ways the virus proceeds slowly and the appearance of the eruptions is somewhat delayed, but when it is carried through the blood-vessels then the secondary eruptions are found nearly contemporaneously with the appearance of the initial lesion. It is necessary to remark, however, that at the period of the chancre the man is not constitutionally syphilitc, but he will become so when the virus will have reached the blood circulation. This has been shown repeatedly by the post T initial infections, which have been made either accidentally or for the purpose of experiment. Haslund, Ullmann and Lasch have referred to cases of individuals who, being already affected with an excoriated chancre and having had pustules on the body from scabies in the vicinity of the chancre, have shown other consecutive initial syphilitic chancres as the result of secondary inoculations. Pontoppidan experimentally obtained positive results by inoculating the secretion of an excoriated initial lesion on the arms and abdomen. These facts are apt to prove the views of Lang 1 on the possibility of a regional migration and of a post-initial infection. And they also prove beyond a doubt that a man affected with an 1 Lang, E. " Acquired Syphilis." " Twentieth Century Practice," Vol. xviii, P- 39- 18 THE MEDICAL ASPECTS initial chancre, although the lymphatic glands are involved, is not necessarily constitutionally syphilitic. And he will be so only after the virus has reached the general circulation. By means of the blood- vessels the syphilitic virus is transported to all parts of the body and no organ or tissue is spared, as the syphilitic pathological products are found in everyone, especially in the blood vessels. Although the syphilitic virus affects every tissue of the organism, yet it shows some preference for one or another organ or tissue. In this way we find that one patient is troubled with continuous eruptions of the skin, while another has scarcely a sign on his body and yet is constantly annoyed with ulcerated patches on the tonsils or tongue. Other patients who have scarcely shown signs of roseola on their body will quickly show symptoms affecting the nervous system, while others will be affected with syphilitic periostitis and osteoperiostitis. There is no law according to which syphilis attacks one part or another of the body, neither is there any established law that syphilis must run its periods in succession as set forth in the text-books. But we can say that in the generality of the cases there is a certain order of symptoms showing an irritative character in the first period of con- stitutional syphilis, while symptoms of a proliferating or of an infiltrat- ing nature mark the later period of the disease. Ricord established the division of the periods of syphilis into sec- ondary and tertiary. Although it has been severely criticised, yet it is based not only on the chronological order of the symptoms, but on the physiological and pathological conditions. Rinecker 2 showed the faculty possessed by secretions from secondary syphilitic lesions of reproducing the disease when inoculated in healthy persons, and the apparent non-inoculability of the tertiary manifestations, by means of experimental inoculations. This forms the basis for the distinction from a physiological point of view. The pathological distinction was at first pointed out by v. Barensprung 3 that the secondary syphilitic manifestations were the result of hyperemia and of a simple exudation, while the tertiary forms consisted of infiltrated nodules. In this way the distinction of Ricord, which was believed to be based only on a supposed chronological order of symptoms, became solid on a scientific basis and as a consequence a simple exudative iritis, orchitis, periostitis, and even superficial cutaneous ulcers, were dis- tinguished from gummatous affections, which have found their place among the tertiary lesions. In constitutional syphilis besides the symptoms of irritation, in- 2 Annalen der Charite, vi, p. 56. 3 Virchow, R. " Ueber die Natur der constitutionell-syphilitischen Affect." Virchow Arch, fiir path. Anat. u. Phys. 15 B. PATHOLOGICAL PROCESS OF INFECTION 19 flammation and proliferation, there is an order of alterations revealed in the nutrition of the organs and tissues in the form of marasmus in syphilitic cachexia. Ricord found the explanation of this condition in the diminution of the blood corpuscles resulting from a quicker destruction of them through the deleterious action of the virus, and in a diminished faculty of the hematopoietic organs in the formation of new corpuscles. Oligocythemia can be considered the result of the altered condition of the lymphatic glands. In connection with syphilitic cachexia there have been found in- durations in different organs of a lardaceous, waxy, or amyloid de- generation by Rayer, Rokitansky, Dittrich, Meckel and then proved by Virchow with the iodin reaction. The secondary stage begins with the first cutaneous erythematous manifestation, which is preceded by a prodromic period, which makes syphilis resemble exanthemata. Indeed, patients complain of rheumatic pains affecting different joints, together with general malaise, dull feeling of the head, pains in the chest, no ambition to pursue their occupations : some have insomnia and at times also neuroses. Under these conditions fever often appears, which we consider as syphilitic fever, because it is the result either of the chemical products emanating from the metabolism of the syphilitic micro-organisms, or from prod- ucts of disintegration of the blood or of the tissues, which in the general circulation are liable to produce this peculiar pathological symptom of general reaction. It seems that the syphilitic virus which has been formed in the initial lesion, and from there has been stored into the lymphatic glands, enters the blood circulation in small quantities and in successive issues, so that the general system, although affected, yet shows no reaction on account of the small quantities of the virus. From this we see that in some cases the syphilitic eruptive symptoms are preceded and also accompanied by fever, while in other cases the eruptions are ushered in without pyrexia. It is difficult to say whether this high temperature of the fever exerts any influence on the bacilli in increasing or in diminishing their virulence, rendering the course of syphilis milder or more severe. In our last term in the hospital we had occasion to see a man who entered the institution on account of acute rheumatism, but, still having a chancre on his glans penis, in the way of reparation he was referred to our ward. He was confined to his bed, as he could not move a joint on account of excruciating pains which had attacked the whole body. The joints, however, although extremely tender, did not show any perceptible swelling, such as we find in cases of acute rheumatism, nor could we find any perceptible exudation in the serous membranes of 20 THE MEDICAL ASPECTS the joints. The fever was remittent in character, the temperature ranging between ioo° to 103 ° F., increasing towards night time, when the pain also became more intense. The administration of the salicylate of sodium did not relieve this condition, and as the roseola in large patches was appearing on his chest, back, arms and thighs, we resorted to deep injections with one per cent, solution of sublimate, and to a saturated solution of potassium iodide internally, in doses of ten drops every four hours. In a few days the patient was able to leave his bed. The treatment was continued with sublimate injections, stopping the use of the iodide, and in a short time the roseola disappeared, leav- ing a mild erythema on the soft palate and tonsils. The patient was feeling well and asked to be discharged to return to his occupation. He was instructed to continue his treatment of liquor VanSwieten for some time longer, and in case of a new eruption to call at the clinic, but he did not come under observation again. In this case we found that syphilis which had produced so deep and a severe general symptoms as to cause high fever and a severe attack on the serous membranes of the joints, had exhausted its strength and in a short time had yielded to the treatment. This observation is in accordance with the experience of Lang, 4 who claims to have frequently observed that intercurrent febrile diseases, such as pneumonia, erysipelas, smallpox, typhoid fever, or acute articular rheu- matism, occasionally exert an extraordinarily favorable influence on the syphilitic process. This fever, which marks the first constitutional symptoms of syphilis, is the true syphilitic fever, which has nothing to do with fevers arising late from gummatous ulcers, or from osseous complica- tions, due to the action of the common pus cocci. The idea of the syphilitic virus being emptied into the circulatory system in a large quantity, thereby causing feverish reaction and putting to work all the resources of the organism to free the system from it, finds another comparison with the whole phenomenological course of syphilis. In fact, patients who have suffered with severe manifes- tations on the skin and mucous membranes, in ordinary circumstances do not show cases of severe cerebral syphilis. And the contrary has been remarked by neurologists that severe cases of spinal and cerebral syphilis are found in patients who had suffered from very mild cases of syphilitic eruptions. In these cases the syphilitic virus would reach the blood only in a very small quantity, remaining latent in the system until it produced the most distressing alterations in the deeper organs and tissues. Returning to this fever, which we consider as the invasion fever of 4 " Twentieth Century Practice," Vol. xviii, p. 42. PATHOLOGICAL PROCESS OF INFECTION 2 I syphilis, we cannot fail to recognize a peculiar type, which makes it resemble malarial fever. Indeed, patients affected with secondary erup- tions have been quite often referred to malaria before the eruption had taken place, and we have often seen patients take quinine for this fever under direction of their family physician. Fever does not accompany all cases of syphilis, in many cases the patient has had no fever whatever, and he is aware of the presence of the roseola when the physician invites him to undress. In the cases, however, where the fever is marked, we find that it makes its appearance from six to eight weeks after the infec- tion. The fever rarely begins with a chill, but usually is noted by such a heavy headache, malaise, general depression and rheumatoid pains, that the patients take to their beds. It has a remittent type, so that the temperature is lower in the morning and higher in the evening, some- times reaching, according to Lang, 105 ° F. It lasts two, three, or four days, rarely longer, and after a couple of days the skin shows a diffused faint redness, which in a few hours gives place to the roseolar erup- tion. After the eruption has made its appearance the fever soon sub- sides, leaving, however, the general symptoms, which only gradually disappear. We have shown how a man who had been infected with syphilitic virus, which had proliferated, found its way through the lymphatic channels, reached the blood, reproduced the entire syndrome of the syphilitic exanthema. We now know beyond any doubt that the man or woman is syphilitic, that they have acquired syphilis, but we do not know what will come later. We do not know how they have become infected, whether by guilt or by accident. It is quite interesting for the physician to know the origin of the infection, and establish the point of entrance of the syphilitic virus. In order to reach this knowl- edge, we must consider the different ways in which the inoculation can take place. Ill MODES OF INFECTION Syphilis is transmissible from a syphilitic person to a healthy one by direct contact of the secretion exuding from ulcerations of syphilitic inflammatory products, or from his secretions (sperma), or from his blood inoculated on a scratch, or on an abrasion, or on a wound in the healthy individual. In this case the syphilitic virus produces at the place of entrance its initial lesion in the form of a hard chancre, as stated above. The large majority of cases of syphilis are acquired during coitus with a syphilitic person, and the seat of the initial mani- festation is usually the genitals or their vicinity in the form of genital or paragenital initial lesions. As a consequence we find the hard chancre in the man on the inner surface of the prepuce on the sulco- balano preputiale, on the frenum, on the free edge of the prepuce — on all those parts where the thin epithelium is liable to be torn or scratched. Not infrequently the initial lesion is found on the skin of the penis dorsi, and on the inferior region just at the point of juncture with the scrotum. In the woman the initial lesion often has its seat on the nymphse or on the internal surface of the labia majora, on the four- chette and at the ostium vaginae. The initial lesion besides the genitals is found quite frequently on the mouth, on the lips, on the tongue, on the tonsils. The virus has been deposited there by kissing, or by using some article which had been in the mouth of a syphilitic, such as pipes, stumps of cigars, glasses, spoons, forks, etc., or through unnatural contact with the genitals. An initial lesion is also found on the lips of children who have been kissed by syphilitic persons, or of infants who have been nursed by a syphilitic woman and has, vice versa, been found on the breast of nurses who have suckled syphilitic children. An initial lesion has often been found on the eyelids, sometimes on account of kissing, and at other times on account of foreign bodies being removed from under the eyelids by licking the eyes, as is cus- tomary among Russian peasants. We have seen three cases of hard chancre of the chin, in two the virus had entered through a scratch from a razor in shaving, and in one 22 MODES OF INFECTION 23 the virus had entered into the follicles of the hair. In all the three cases, the face had been besmeared with the saliva containing secretion from mucous patches or from the blood oozing from the excoriated patches on the lips of a syphilitic woman. In another case of chancre of the chin the inoculation resulted from a pair of tweezers used by the barber to remove a hair growing under the epidermis. Initial lesions in the mouth have been the result of inoculation of syphilitic virus from surgical instruments, especially those for dental operations. Vice versa, we have had occasion to see numerous cases of hard chancre upon the last phalanges of the second finger of the right or of the left hand of dental students, and of dentists, acquired while performing dental operations. We have quite often had occasion to give professional attention to physicians, midwives and nurses, who had accidentally become infected in pursuing their duties. As a conse- quence, when a patient comes before us, he has been infected with syphilis either by his own fault, exposing himself to the contagium by coitus, or by accidental infection. In one way or the other he has acquired syphilis, but in one case the responsibility rests with himself, and in the other it is entirely foreign to his will, having been inoculated by accident without any suspicion. In the case of a guilty one, there are two classes of infected per- sons. One is the street rowdy who is accustomed to carousing and is almost certain to get syphilis. Such libertines ought to be confined in a hospital, as prostitutes are, in order to prevent them from spreading the disease. They belong to the lower classes, without principles of morality, who are addicted to the abuse of alcoholics, which makes their syphilis of a malignant nature. Deteriorated by debauchery, weakened by the use of alcoholics, their system is an easy prey to the tertiary symptoms of syphilis. Their dissipated lives and immoral customs find severe punishment in syphilis. They form the popula- tion of the venereal wards and are subject to the severest ravages of the gummatous period of syphilis. This class of patients frequently comes before the Judge of Police Court, and they are the tough cus- tomers of the workhouse. Another class of patients we find belonging to guilty ones, who with the best education, with the best moral principles, have forgotten themselves in an unfortunate moment. They have been infected with syphilis by coitus. They remember that moment as the darkest spot of their life. They long to go back of that moment, and feel that they never will be guilty again of such an indiscretion. They find themselves infected with a loathsome disease, and are disgusted with themselves. Uusally they are intelligent patients, well educated, and are made despondent over the occurrence, and see the future before 24 THE MEDICAL ASPECTS them dark and full of dismay. They see the danger of hideous eruptions on their faces, which are noticed by everybody, and they fear that on their foreheads may appear that horrible corona veneris, by which everyone may read their guilt. They understand the danger of inoculating others, and especially the danger of inoculating the wife in case of marriage. They foresee, too, the horrible inheritance which will be transmitted to their offspring, and they feel the remorse, fear the consequences, and subject themselves to the most exact and thorough treatment. They are the most obedient patients, they quit the use of tobacco and of any stimulants, and will- ingly submit to any remedy in order to recover from their syphilis. In many cases they become neurasthenic from great worry over their unfortunate accident. In the daily papers we sometimes read of suicides, or of the disappearance of individuals without any special cause ; frequently the cause is given as financial distress. Syphilis is never thought of nor mentioned, but on many occasions it is undeniable that it may be a cause, if not the principal one, for the disappearance or the suicide. It plays a great role in domestic dramas, of which the solution usually remains a secret. Fournier has already referred to a dozen cases of suicide committed on account of syphilis. A gentleman in high professional standing, with a splendid scien- tific education, of an irreproachable moral character, on not feeling well, sent for us professionally. He called our attention to a small, hardened point in the sulcus balano-preputialis, which was diagnosti- cated as a hard chancre. Our poor friend was thunder-stricken, he looked at us in the hope that we had made a mistake, but after a more careful examination the diagnosis was confirmed. He was to get married in a few weeks, everything was ready, the cards already printed, what could he say? what excuse could be found to satisfy the curiosity of his acquaintances? It was a question of breaking off the engagement, or postponing the marriage, until when? The following dilemma arose, either break the engagement, or give his wife a case of pox as a wedding present. What horrible nights he was passing, nights which were as long as eternity. The light of day, the ordinary occupations distract the mind from continuous thought ; but when night came, the darkness presented the most distressing scenes to his mind. Sleep was impossible, and if, for a moment, he began to doze, he was awakened by the most frightful dreams. Yet the end of the trouble was rather satisfactory. The only constitutional symptoms were limited to a mild roseola, and a few superficial patches on the tongue, which, with a vigorous and well di- rected treatment soon disappeared. The marriage, which had been MODES OF INFECTION 25 postponed on account of ill health, was celebrated over two years after the occurrence, nearly sixteen months after that no more symptoms had reappeared. We never heard of any further trouble on this account. In the case referred to, we find an act of misguided conduct which had produced bad results, and for which he paid the penalty of his imprudence. It is true that each individual case must be judged by a charitable regard for the preceding and subsequent conduct, but in those cases we find that the moral responsibility is greatly diminished. We have another series of cases of syphilitic inoculation, where the individual has no idea of exposing himself to the possibility of being- infected. This is the case of a woman who has married a syphilitic husband and she is infected with syphilis without knowing it. This subject is of vast importance, and will be treated separately in the article referring to marriage. Other modes of infection are possible without any knowledge. We were asked to see a lady for a so-called abscess of the nipple. She had given birth to a healthy child, but fearing she had not a sufficient quantity of milk to feed it, the child had been given to a wet- nurse. After several weeks the baby developed a sore mouth. The mother still wanted to nurse her child. A physician had seen the child and failed to make a correct diagnosis, in consequence the mother kept on suckling her babe. After a few weeks, the mother developed a sore nipple, which was taken for an abscess and for which our advice was sought. This sore nipple was a hard chancre of the classical type, and a roseolar eruption was already perceptible on her chest and back. It was a case of unmistakable syphilis, and it was, therefore, not diffi- cult to trace the origin of the inoculation. The sore mouth of the babe consisted of mucous patches on the lips, and an examination of the nurse revealed the whole history of the transmission of syphilis. The fault of the contagium in this case rested only on their family physician, who had been called to examine the nurse before having her give her breast to the babe. His examination had not revealed to him the presence of syphilis in the nurse, and this threw on him all the blame for the infection of the whole family. We have had occasion, in another instance, to see just the reverse in the syphilitic infection. To a healthy nurse was given a syphilitic babe for nursing, without anything being mentioned concerning the existence of this disease in the family. The nurse became infected, and after a few months was allowed to return to her native village. Her husband became infected, and a small epidemic of syphilis started in that country place which was traced to her. In small proportions it recalled that which happened on the first appearance of syphilis among the European populations, when syphilis became almost epi- 26 THE MEDICAL ASPECTS demic. In that case, although the origin was in a guiltless person, yet the following cases were equally in the guilty and not guilty, without distinction. We cannot leave this subject without referring to an experience which we had only a few months ago. We were called in consultation to see a babe four months old, which was suffering with supposed eczema. The child was covered with a papular eruption from head to foot; on the face, around the nose and mouth, and alsd around the genitals and the buttocks, the papules had been excoriated and in con- sequence were covered with thick crusts. There was no doubt that the case was one of a papular syphilide, the only question was to trace the origin. The child had been nursed by the mother alone, and she was apparently in splendid health. The father, although in apparent good health, admitted that he had a small chancre before his marriage. The sister of the mother came to help her in taking care of the babe, which she did with good will and self-denial. Not long after she sought our advice for an ugly pimple which had appeared on her right cheek. It was a hard chancre, which she had contracted from the babe of her own sister, and she has had all the manifestations of con- stitutional syphilis. Here we have a case of infection directly due to a good heart and to altruism. The cases of accidental syphilitic infection can be multiplied to the infinite, and this has caused the authors to form a class of cases of this disease which has been called Syphilis Insontium, because the infected is entirely innocent in the acquiring of syphilis. L. Duncan Bulkier * has given great consideration to this subject, and after a careful study of the literature, shows that the disease has been acquired innocently in a vast number of instances, and in ways and means which could hardly have been suspected. Fournier stated that nearly twenty-five per cent, of females with syphilis met in his private practice had ac- quired the disease in a perfectly innocent manner. Bulkley produces long statistical tables of initial lesions of syphilis observed in genital, perigenital and extragenital regions. In all these tables the frequency of the accidental infection through the mouth, fingers and vaccination is remarkable. Nearly every year Bulkley refers to cases of this kind, illustrating this important subject, and such work ought to change the idea of syphilis among the laity and the profession. Everyone, in his practice, has occasion to refer to cases of syphilis acquired in the exercise of one's profession, cases which may be called professional syphilis. We have already had occasion to report three cases of hard chancre on the lips in three workingmen employed in a 1 Bulkley. " Syphilis Insontium : A Clinical and Historical Study of Syphilis Innocently Acquired." New York, 1893. MODES OF INFECTION 27 glass factory. They had been infected by using the blow tube to blow the melted glass and make bottles. Nearly every year we meet with cases of intial lesions of syphilis, in the fingers and hands of physicians, dentists and midwives. The introduction of the fingers into the mouth and the vagina for examination is the most dangerous feature in our profession, on account of the possibility of being infected. In these cases we find that the unfortunate occurrence of taking syphilis has been the result of altruism, either in being useful to others or in the performance of duties connected with one's occupation. It is an act of self-denial which leads to sufferings and to physical en- feeblement, and which may be of disastrous consequences for his wife and offspring also. The syphilitic infection in many cases may weaken a wide-awake mind and the constitution of a vigorous body, which will diminish the happiness of his descendants, who, having inherited a syphilitic taint, are bound to undergo sufferings which diminish the pleasure of living, In fact, a well-preserved life shows itself in over- flowing spirits, becomes a source of pleasure to all around, while a constitution weakened by the presence of the syphilitic virus, or by the fear of being syphilitic, brings depression to him and to his family. In conclusion, we have seen that a young man may expose himself to the danger of infection from syphilis on account of his indiscretion, and for this he has to bear the blame and the penalty. This indiscre- tion, however, has no connection with a deterioration of his moral character, although he has been late in determining that he will never do it again. We have seen many others infected with syphilis in complying with their good and charitable nature, or with the duties of their profession, and this class of patients ought to be considered as sufferers on account of their humanitarian altruism, rather than have a suspicious look cast on them because of their being infected with syphilis. THE EVOLUTION OF SYPHILIS IV PRIMARY SYPHILIS The different ways in which syphilis may be acquired make a dif- ference in its reflex upon the morality of the infected, but with refer- ence to the evolution of the disease, do not change at all the virulence of the infection and the consequent manifestations. Neither does this exclude the fact that every individual infected is a possibility for spreading the disease among others, for the virus taken in any way will produce the same results in the newly infected. In a person free from syphilis, when the syphilitic virus comes in contact with an abrasion, scratch, puncture, or finds its entrance in a follicle, there the initial lesion is formed, which is nothing else than a culture of the syphilitic germs. The initial lesion, in the form of a so-called hard chancre, appears only after a certain period of time, which is called incubation, and it is truly an incubation of these germs (spirochaetse), which takes an average of from three to four weeks to show its work. In the event that, together with syphilitic virus other germs of a different kind and virulence are inoculated, we have some difference in the manifestation of the chancre. But when syphilitic virus contains no other virulent germs, then after the mentioned time a circumscribed infiltration is noticed just at the place of entrance of the virus, which is marked by a slight redness and sharply defined borders, hard to the touch, accompanied by a slight sensitiveness. This is the classic in- durated chancre, or the Hunterian chancre. At other times the chancre is much more superficial, little elevated about its edges, which seem to be nearly encased .in the normal tissues, chancre parchemine, initial papule. The difference is only in the depth of the tissues involved in the process ; the alterations are found in the lymphatic and in the blood vessels of the affected skin or mucous membrane. These altera- tions are to be found in all local syphilitic manifestations, beginning with the initial sclerosis, and persisting in the infiltrated gumma of the late manifestations. The chancre histologically is the result of an infiltration of cells into the lymph spaces around the connective tissue fibers of the mucous 28 PRIMARY SYPHILIS 29 membrane or of the derma. Macroscopically it appears like a granular amorphous substance, and from the fact that it takes a reddish color with iodine, von Barensprung thought that the exudation forming the base of the specific induration was different from other inflammatory products, and to be identical with those exudations, constituting in- filtrations in the organs in consequence of constitutional syphilis. But Virchow proved that degenerations are present in many pathological processes, and they show nothing characteristic in syphilis. In the first moments after the inoculation, the syphilitic virus germinates into the lymph spaces as the parts which offer the soil adapted for the development of the germs. In some specimens of the initial sclerosis, greatly enlarged lymphatic vessels surrounded by a large quantity of infiltrating cells have been found. The lymphatic vessels are affected by an inflammatory process, their endothelial cells are enlarged and in some places detached. The lymphatic vessels start- ing from the initial sclerosis are also enlarged, and show irregular dilatations during their course in the form of a cul-de-sac, and are filled with mononuclear leucocytes. The inflammatory condition of the lymphatic vessels is very perceptible, and clearly shows that the indur- ated edema, which often accompanies the initial sclerosis, is due to the occlusion of the lymphatic vessels. The infiltration which forms the body of the hard chancre seems to be circumscribed in a focus, as it is limited by a strong layer of elastic fibers ; the process, however, has a tendency to spread through the lymph vessels. In the further development of the chancre, the blood vessels too are involved in the infiltration, and their walls show a process of chronic inflammation with an enlargement and thickening of their stroma. These pathological changes are found in the arteries as well as in the veins, and it forms the characteristics of all syphilitic lesions. In the sclerotic part the new cells are forced towards the surface and the epithelial stratum appears thinner, and gradually the affected part appears deprived of its epithelium (eroded chancre) ; or it breaks down entirely (ulcerated chancre). In an old chancre there have been found giant cells like those in a gumma. The infiltration takes place in the papillary layer, extending sometimes to the subcutaneous tissues. The papillae are usually somewhat more elongated and enlarged, with an interpapillary ingrowth of epithelium. The syphilitic chancre occurs as an infiltrated place from the size of a lentil to that of a twenty-five cent piece, encased in the skin or in the mucous membrane, with its edges projecting somewhat above the level, and of reddish blue color. The anatomical structure of the part where it has its seat is the cause of its different shape. When it is on 30 THE MEDICAL ASPECTS loose skin, as on the prepuce, it has that plate-like extension, and it is easily recognized when taken between the thumb and index finger, as a cartilaginous induration. When near the sulcus balano preputiale, on turning the prepuce, the mucous membrane appears yellowish and bloodless, like the conjunctiva on the tarsus, when the eyelids are turned. The chancre can have almost any shape or form, circular, semi- circular, cylindrical, beanlike, but always gives that hard, well-defined sensation of its edges which constitutes its character. In more resist- ant tissues and in less accessible parts, the diagnosis of the hard chancre is not so easy ; but from its symptoms and surroundings it cannot be mistaken. The hard chancre gradually shrinks and heals up, sometimes leaving an indurated place, which lasts for years. At other times it undergoes a rapid retrogression so that there remains of it no more than a whitish atrophic scar. It is on account of the mildness and of the triviality of the symptoms that it may pass entirely unobserved, and that the patient, in good faith, denies the existence of an initial lesion. The chancre, sometimes on account of the pyogenic cocci, soon becomes ulcerated, and the ulcer assumes large proportions. In the ordinary cases it has only erosive or ulcerative characters, and the secre- tion is rather scanty, shiny and containing detritus. The ulceration is always limited by the induration, and for this reason the edges are adherent, and the ulcer is deeper in the middle. In some cases we have a true gangrenous process extending over the indurated chancre, which is explained by the presence of endoarter- itis, the result of the syphilitic process. In one case of an old man over seventy years of age, who contracted a hard chancre, it was soon changed into a gangrenous eschar and invaded nearly the whole penis, with fatal results. Cleanliness has a great deal to do with the ulceration of the hard chancre. It is easily understood that when a purulent secretion re- mains between the mucous membrane and the chancre, it will increase the irritation, and the inflammatory process will soon increase the necrotic process. It will also lead to complications of lymphangitis, erysipelas, swelling and redness of the contiguous skin. Quite fre- quently in the hospitals we meet with cases of phimosis caused only by the inflammatory process of the prepuce on account of the lack of clean- liness on the part of the patient. The ulcerated chancre, if improperly treated, may be filled with exuberant granulations, and, in some cases, they may attain such pro- portions as to form true condylomata, or venereal warts. In some cases the syphilitic virus may be mixed with other bacteria besides those of the pus, as occurs when, with the syphilitic secretion, PRIMARY SYPHILIS 31 there is mixed the secretion from a chancroid. This case has gfiven origin to the theory of the unicity of the virus, and it has taken years of constant work to dispel these ideas from the mind of the syphilol- ogists. This case was well explained by Rollet, with the mixed chancre, which was strenuously denied and fought until the bacterio- logical works of Ducrey and Unna, have shown beyond a doubt the peculiar dumb-bell bacillus to be the cause of the chancroid. In this case the virus of the soft chancre works on its own account, producing the chancroid after a very short period of two or three days' incubation, and assumes its course as a true chancroid. But when the process of reparation begins and the ulcer is healing, then the syphilitic virus shows up its work, with the characteristic induration around the healing surface of the chancroid. These cases are not rare, and they do not reflect much credit upon the physician when he has made a diagnosis of chancroid and it finally has turned out to be a hard chancre. In some cases when the chancre is in the sulcus balano preputiale, and is accompanied with lymphangitis and consequent phimosis, the diagnosis cannot be easily made ; but the presence of a hard point inside of the preputial sac will give the idea of the presence of an ulcerated hard chancre. When the initial lesion has its seat in the urethra, it can also be discovered by pressing the urethra with the fingers. An encio-urethral chancre does not form very deep in the urethra. It usually extends from the meatus to the fossa naviculars, or a little above the fossa navicularis. It is soon eroded and discharges a mucopurulent fluid, which would lead one to think that he had to do with a case of gonorrhea, although it is found to be too long after the exposure, and lacks the ordinary symptoms of gonorrhea. But the fingers will dis- cover a hard point inside of the urethra of an oblong shape, which gives the impression of a cylindrical or spindle-shaped hardening of the urethra. Many kinds of initial lesions have been described ; but so many dis- tinctions pertaining to the same thing, instead of contributing to the clearness of the subject, will rather make it obscure. Before leaving these few remarks on the initial lesion, we wish to consider the other kind of initial lesion, which we have pointed out as the initial papule. This form of initial lesion is somewhat rarer than the other, and it ap- pears after a period of incubation in the form of a small, sharply defined nodule the size of a ten-cent piece ; at other times it spreads somewhat more. The edges, however, are always projecting - and can be felt hard as parchment. The different anatomical regions occupied by the lesion are the cause of giving it a different appearance. In a dry part of the skin, it will appear as a flat, dry, circumscribed, bluish red livid nodule. 32 THE MEDICAL ASPECTS somewhat hard, its epithelium, macerated by moisture, becomes dry and with some little exudation forms a crust which covers its surface. When it has its seat on parts of the skin which are usually humid on account of physiological or pathological secretions, then the epithelium covering the papule soon becomes macerated, and remains like a dirty mass of detritus adherent to its surface. On the mucous membranes the papule is little elevated above the normal mucosa and the epithelium appears like a whitish scab, which, when detached, leaves a red slightly bleeding surface. In any place, it has a tendency to break down and leave an ulcerated papule, which always becomes more inflamed through uncleanliness or misdirected treatment. When properly treated, an initial papule heals up, like the other initial sclerosis, the infiltration is reabsorbed, the redness diminishes in intensity and is changed into a brown pigmentation. This after a while disappears and the healed surface shows a whitish atrophic scar, which in most cases remains for the whole life, producing, however, no per- manent traces of destruction in the affected parts. The question arises whether the hard Hunterian chancre and an initial papule come accidentally or through some reason. We had al- ready noticed in our practice that among a large number of patients, some affected with a typical Hunterian chancre, showed symptoms of constitutional syphilis much later and somewhat milder than another affected with an initial papule. It is true that syphilis, like any other disease, is often modified in its symptoms and its course, and in its periods of evolution by different circumstances. Climate, age, physical condition of the patient, incidental diseases, use of intoxicant liquors, timely and convenient ad- ministration of therapeutic means, have great influence on the develop- ment of the constitutional symptoms. But the source of the infection plays a role in the consecutive manifestations of syphilis. 1 The virus from a hard chancre needs a solution of the epidermis in order to be inoculated, while that which oozes out of the mucous patches can find its way in the follicles also. In the case of a hard chancre, the result of the virus taken from another hard chancre, the initial lesion is the place of elaboration of the virus ; while in the case of the initial papule the virus has been already elaborated, and is much more quickly absorbed into the system. Any virus passing through the animal system is modified in its intensity and its effects, and by analogy syphilitic virus is susceptible of important changes. The mucous patch, papula Immida, is a char- acteristic eruption of syphilis, which appears at its acme, and contains 1 Ravogli, A. " The initial lesion in relation to the constitutional symptoms." Cincinnati Lancet-Clinic, Nov. 24, 1894. PRIMARY SYPHILIS 33 the virus in all its intensity. While at a late period syphilitic mani- festations, such as broken-down gummata, have no longer the faculty of inoculating the disease, although the affected person is still immune. The virus, at the time of the secondary eruptions, is in the full strength of its toxic power and the mucous patch, which constantly accompanies all the secondary period, is the most dangerous eruption for the trans- mission of syphilis. According to our observations the symptoms following the inoculation of the virus from one lesion, or from another, show some difference in the development, course and severity of the manifestations. From our observations we believe that the virus of an initial chancre taken from another chancre remains hidden a long while in the lymphatic system, where it is elaborated until it is ready to produce systematic troubles ; while the virus from mucous patches, which is the result of secondary lesions, is more readily absorbed into the general system, producing quick and marked symptoms of the constitutional disease. Marston, Low, Paget, and LIutchinson are of the opinion that the more extensive the initial sclerosis is, the more severe and stubborn the secondary symptoms that follow. But this assertion does not find confirmation in our observations, as we have seen large diffused chancres, and sometimes two or three chancres in the same patient, followed by mild secondary symptoms which easily yielded to treat- ment. On the other hand, we have seen a small initial lesion in the form of an initial papule, followed by severe constitutional symptoms. Our observations are supported by those of Ed. B. Bronson, 2 that in the malignant forms of syphilis the symptoms are generally precocious. The period of incubation in severe cases of syphilis is usually shortened, and the constitutional manifestations hastened. In those cases where the secondary symptoms are much delayed, these are usually of a mild character. Consequently we are justified in regarding a prolonged primary period as a favorable element in the prognosis, and a short duration of this period as an unfavorable one. The origin of the virus may have some influence in the severity of the following symptoms. This, however, must not be considered in an absolute way, but must be regarded as subordinate to all the patho- genetic causes, which render the system of the patient more or less susceptible to the action of the virus. It has been pointed out as an important characteristic of the initial chancre that it is single, but it is not rare to find two or even three chancres, sometimes in the vicinity of one another, sometimes widely separated. At the moment of the inoculation of the virus 2 Bronson, E. B. " Primary Syphilis. A System of genit. urin.," etc. Prince A. Morrow, 1893, P- 97- 34 THE MEDICAL ASPECTS several places may have been abraded, excoriated, ready for the ad- mission of the virus, and in this way the inoculation may be effected in different places. It is also possible that the syphilitic lesions are genital and paragenital, and in this way occur a double inoculation of the virus at a distance from one another, as has been referred to by Jonathan Hutchinson, Ohmann-Dumesnil, Lang, and others. Most of the cases of infection take place during sexual connection, for this reason cases of genital chancres are more frequent. But, as any part of the body having an excoriation exposed to the absorption of the virus can be inoculated, so the occurrence of extragenital chancres is also equally frequent. Infection through the mouth, bv kissing, by using pipes or stumps of cigars has quite often shown initial lesions of the lips, corners of the mouth, tongue, tonsils and also the face. We have often found chancres on the hand, fingers, and several times under the finger nails. We have quite often seen chancres on the nipples, cheeks, chin and once on the left nostril. In one instance, a hard chancre was on the region of the glabella, and fol- lowed a wound with a broken glass. Subjective symptoms accompanying the hard chancre are greatly influenced by the anatomical region and its functions. A chancre of the lips or of the tonsil will be painful during eating or in the act of deglutition. A chancre under the finger nail is always painful on account of the distention of the tissues, and is often mistaken for panaritium. The initial lesion, either in the form of sclerosis, chancre or initial papule, is always the first symptom of the inoculation of syphilis, and we can say that it never fails. However, we find ourselves in the presence of cases where the initial lesion has been so slight that it has passed entirely unobserved. In women infected by the semen or by conception, the initial lesion is not found, and in these cases very likely the syphilitic virus has been readily introduced into the blood without a chancre or an initial lesion. In many cases the initial lesion is accompanied by a peculiar edema which keeps the affected region hard and swollen. This edema was pointed out by Sigmund as edema indurativum and by Fournier as cedeme sclereux. This condition quite often occurs in cases of hard chancres of the labia majora, where the affected labium was edematous and swollen, and also on the prepuce, causing phimosis, and swelling of the whole penis. The skin so swollen is reddish dark in color and the borders of the affected skin are usually neatly marked off from the healthy skin. The skin so swollen, when examined, produces under the exploring finger the sensation of hard strings, which are the inflamed lymphatic vessels. Indeed, the infiltration. PRIMARY SYPHILIS 35 which forms the body of the chancre or of the initial papule, although seemingly circumscribed within a focus, has a tendency to spread through the lymphatics. It is an every-day observation to find under palpation a few days after the appearance of the syphilitic chancre on the penis, hard, sluggish, but tender knotty cords from the thickness of a thread to that of a string, as the affection of the lymphatics, which run towards the lymph glands. The infiltration is but the result of the vital reaction of the cells opposing the invading virulent germs, and it can be considered as any other inflammatory process. The progress of the infection takes place through the lymphatic paths, and in the lymphatics is noted the presence of the virus. The virus seems to possess an agglu- tinating power on the serum, and the leucocytes easily stick to the endothelial lining, so that the lymphatics are at times plugged up with lymphatic thrombi. This condition of the lymphatic vessels on the dorsum penis was first described by Basserau, and has recently been studied by Xobl 3 and Neumann, 4 who have attributed the induration entirely to the specific alteration of the tunics of the lymph vessels. In fact, they are much enlarged and they show rings of infiltrating cells, in their endothelium the elements are multiplied and their spaces are studded with polynuclear leucocytes. Abundant infiltration is found also in the tissues surrounding these vessels. The endo- lymphangitis is the cause of more or less complete obstruction of the lymph vessels. Their endothelial lining in some instances has gained the centre of the vessel, which is not entirely obstructed. The connective tissue layers forming the external tunics of the lymphatics are involved in the inflammatory process, and are thickened by infiltration of cells, which also extends to the surrounding tissues in the form of perilymphangitis. The connective tissue fibers are also enlarged on account of the irritation and their hyperplastic con- dition shows a proliferating tendency. The indurated edema is caused by the infiltration and obstruc- tion of the lymphatic vessels, which prevents the progress of the lymph in the lymphatic spaces. The syphilitic virus contained in the lymph vessels causes the cell migration through chemotaxis. The small lymphatics remain filled up with a large quantity of mononuclear lymphocytes. The edema usually remains limited to the labium, or to the prepuce, so that it but rarely reaches the mons veneris or the scrotum. There is only a tenderness, but no sensitiveness, and in a very few 3 Nobl, G. " Etiologie et Anatomie pathologique des Lymphangites." Comptes Rend., p. 445. 4 Neumann, I. " Specielle Pathologie und Therapie, herausgegeben von Nothnagel." Wien, 1896. 36 THE MEDICAL ASPECTS cases it may wind up with suppuration in some limited portion. It continues for a long time, but under treatment gradually disappears without leaving any traces. The process of the specific inflammation which we have seen in the lymph vessels passes to the lymph glands, which soon show specific alterations. They are rapidly affected by the syphilitic in- fection, and from their development, and from the intensity of the infection, an idea of the degree of the virulence of the disease can be obtained. The process which affects the lymph glands, producing the syphilitic bubo, is entirely different from that of the venereal bubo. It consists of a slow inflammatory process of the follicle of the gland, with proliferation of the connective tissues, causing a hindrance to the normal flowing of the lymph, and an enormous production of small young leucocytes, which fill up the alveoli of the glands. In the first or second week after the appearance of the chancre, the nearest lymphatic glands become enlarged and at the same time show some tenderness. This tenderness after some days disappears. Some- times it is one, usually it is several glands which are affected and enlarged to the size of a hazel-nut or that of a plum, remaining in that condition for months. When the chancre has its seat on the genitals, the first affected glands are those of the groins, and accord- ing to the side occupied by the chancre and to the anastomoses of the lymph vessels, they are more on one side than on the other. In the case of an extragenital chancre, the lymphatic glands near the lesion are first affected ; for a chancre on a finger the epitroclear gland ; for a chancre on the nipple, the axillary glands ; for a chancre on the tongue, the sublingual glands will be first enlarged and swollen. In the case of a patient acquiring both a genital and extragenital initial lesion Lang has found not only the glands of the groin, but also those of the extra-genital region enlarged. In the groin, although three or four glands are affected, one is much more felt, corresponding to the initial lesion. Usually they are only tender and for this reason the affection is called an indolent bubo; but there are cases ending with suppuration. This occurs only as a complication when other injurious germs are acting together with those of syphilis. Consequently when the initial lesion is ulcerated, and is not kept clean, or when together with syphilitic chancre, the virus of a chancroid has been inoculated at the same time, we find that the syphilitic bubo ends in suppuration. We believe that the syphilitic bubo, when suppurating, can be dis- tinguished from the ordinary bubo of the chancroid. The latter is greatly inflamed, swollen, and soon fluctuates, while the former has a sluggish course, slowly suppurates, and the pus comes from the inter- glandular spaces, producing sinuses between the glands. For this PRIMARY SYPHILIS 37 reason in the treatment of a suppurated bubo, we find it necessary to remove all the enlarged glands. The adenopathy in the evolution of syphilis follows the chancre, accompanies the mucous patches, and the superficial ulcerative lesions, but is independent of them, and is the result of the progressing disease. In the tertiary period the lymph glands are no longer enlarged, they have shrunk, but are still hardened like kernels, this condition being due to the sclerotic condition of the connective tissues forming their stroma. The extended chain of the lymphatic glands represents the bar- riers placed to keep virulent germs carried by the lymphatic vessels from entering the system. Their swelling and their inflammatory reac- tion represents the struggle between the leucocytes and the germs, or better the defense of the normal tissues against the invading micro- organisms. However, in the syphilitic glands the struggle is rather unequal ; the leucocytes are unable to cope with the virulent germs, the germs conquer, and the young leucocytes, destitute of any phago- cytic properties, increased in quantity in the alveoli of the gland, serve as a culture medium for the development of the virulent germs. Jullien 5 maintains the same views in regard to the lymphatic glands. He believes that the inflammatory process of the glands is followed by inertness and impotency; the resources of the organ are exhausted, the rushing of the polynuclear cells either impeded or insufficient, and in this way they become a kind of hiding place for the virulent germs. The same glands, offering a propitious culture medium to the germs for their development, also become a place adapted to their preservation during the period of latency, confirming the asser- tion of Virchow, that syphilitic germs are not preserved in the blood, but in the depth of the lymphatic system. 5 Jullien, L. " Sur le role des ganglions lymphatiques dans les diatheses tuberculeuses et Syphilitiques." Bui. et Mem. de la Societe, 1900. V CONSTITUTIONAL SYPHILIS In the preceding chapter we have already expressed our opinion, that the initial lesion is a purely local process. It is a place of elabora- tion of the virus from which general infection will take place. Yet there are some syphilologists who still believe that soon after the entrance of the virus into the abrasion an alteration of the general system takes place, and that the initial lesion which is formed at the point of entrance of the virus is a symptom of constitutional syphilis. It was difficult to demonstrate the correctness of our opinion, so long as the syphilitic germ and its biochemical functions were not known. But from the recent studies on the spirochaetae, and in the resulting pathologic alterations in the infected, we may assert that the virus produces a cellular infiltration at the point where it has been inoculated, and forms the so-called initial sclerosis. For some time the virus remains enclosed in the tissue cells, but it is finally carried along by the lymphatics and by the blood vessels. , The same cells, which for a time have acted as a barrier, begin to migrate and carry the virus into other parts of the organism. The ordinary way of spreading the infection is by the lymphatics, as already pointed out, and by this way the virus enters the general circulation after a certain period of quiescence. It is also possible that it may enter the blood current by the way of the blood vessels, which is not usually the case ; but this explains the occurrence of some cases, where a rapid spreading of the infection is noted. Another form of extension, noted especially by Lang, is through the interstices of the tissues and shows thick super- ficial syphilitic lesions spreading around the initial lesion, and from the time and place they appear as a regional infection. We have had occasion to notice this peculiar regional infection in the. case of a chancre of the nipple, where the whole mamma was, before any other general eruption, covered with thick small papules coalescent in groups. In this way the virus of syphilis, before the disease becomes constitutional, can reach localities not only by the lymph channels, but also by regional migration. From the post-initial infection (when an individual already having a chancre is inoculated at a distance with another chancre), we can 38 CONSTITUTIONAL SYPHILIS 39 conclude that this person was not yet constitutionally infected. In fact, a person after being inoculated, having a hard chancre, and an involvement of the neighboring lymphatic glands, has not yet the constitutional infection of syphilis. The constitutional effects of syphilis appear at the moment when the virus or its toxins reach the blood in the general circulation and it is carried to every organ and tissue of the body. The blood is the first to show a decided effect produced by the syphilitic virus in a form of leucocytosis. Stoukoven- koff, Biegaski and d'Amore were able to prove that under the influence of the syphilitic poison there occurs a rapid decrease of hemoglobin and also of the number of red blood corpuscles, with an increase in the white blood elements, especially of the lymphocytes. Ernest Becker x made the object of his studies the morphological condition of the blood in syphilis so as to determine the quantity of erythrocytes and leucocytes. In two cases with roseola and marked adenopathy he found a well- pronounced leucocytosis, with a predominance of the lymphocytes. The relation of the polynuclear to the lymphocytes was 65 : 30, rep- resenting in a cubic millimeter 3000 lymphocytes instead of the normal 1200 to 1500. These observations confirm the views of Virchow, that in syphilis the general swelling of the glands goes with the lymphocytosis. In a patient affected with the initial sclerosis, without constitutional symptoms, the blood was found in a normal condition. We have already expressed our opinion 2 that the alterations of the lymphatic glands are the causes of the leucocytosis in syphilis. The hypertrophy of the connective tissues, which fprm the follicle of the gland, together with the altered condition of the tunics of the blood vessels, prevents a greater elaboration of the white elements of the blood, which in large numbers remain accumulated in the alveoli of the glands as mononuclear lymphocytes. This accumulation of lymphocytes in the cavitary system of the gland is not the result of an active exudation but rather of a passive exudation, caused by the difficulty which the lymphatic elements find in going through the affected glandular tissue. The enlargement of the lymphatic glands at this period of syphilis has been considered as an argument of prognosis for the consequent manifestations of the disease. Auga- gneur 3 advanced the theory that the lymphatic glands when active in their functions, by their phagocytic power must modify the infectious elements, and, as a consequence, an intense adenopathy would be a 1 Becker, E. " Haematologische Untersuchungen." Deutsch. Med. Woch. } 1900. 35. 2 Ravogli, A. " A few notes on syphilitic bubo." The Medical News, New- York, July 26, 1902. 3 Augagneur. " Seance de la Societe Franchise de Syphilographie et Dermat- ologie," Feb., 189s. 40 THE MEDICAL ASPECTS favorable symptom in syphilis, showing the defensive power of the organism. Although this assertion seems quite reasonable theoretically, yet it is entirely against the ordinary clinical experience. T. De Amicis 4 stated that a great enlargement of the lymphatic glands usually accompanies severe cases of syphilis. Mild cases of syphilis show mild adenopathy, so that sometimes the diagnosis remains in doubt if other symptoms do not show the presence of syphilis. In these cases we find that the phagocytic power of the lymphatic glands is no longer of any value against the syphilitic infection. At the end of this period, which is also called second incubation, some patients begin to complain of various disturbances in the form of rheumatic pains, especially in the extremities, malaise, no ambi- tion, disturbed sleep, dull headache, etc. It seems that the virus already circulating in the blood is capable of causing irritation in the tissues, and with its toxins acts as an irritant on the central nervous system. Not rarely do we see attacks of convulsions in delicate neurotic girls precede the eruptions of syphilis. In some cases, however, the syph- ilitic eruption is ushered in without any prodromes, and the patient does not notice the roseola unless the physician calls his attention to it. We .have already spoken of a syphilitic fever, which is the fever of invasion, resembling that of the contagious exanthemata, the result of the spirochaetae and their toxins circulating in the blood. It is possible that the virus enters into the general circulation in some cases in a large quantity, producing a general febrile reaction, in other cases in small quantities and at successive times, so that the general system is not greatly affected. Fever, when present, has a peculiar type of intermittence, which has quite often prompted physicians, ignorant of the existence of the chancre, to consider it as malarial fever, and treat it with quinine. When studied carefully with the thermometer, it usually shows a remittent character. Usually syphilitic fever is not accompanied by a chill, but comes in with a headache, general depression, weakness of the knees, rheumatoid pains, loss of appetite, sometimes vague neuralgic pains. These subjective symptoms are somewhat more aggravated towards night, and then the temperature rises to 103 or 104 F., with remission towards morning, the temperature nearly reaching the normal. The fever lasts from three to four days, and at this time the cutaneous surface shows a diffused bluish discoloration, noticeable when the patient is divested of his clothes. This condition has been called cutis variegata. 4 De Amicis, T. " Sul preteso potere difensivo fagocitico," etc. Giorn. Intern, delle Scienze Mediche. Anno XXIII. CONSTITUTIONAL SYPHILIS 41 SYPHILITIC AFFECTIONS OF THE SKIN The eruption is soon replaced by the true erythematous eruption, roseola, or macular syphilide, which is the earliest and the mildest of all the cutaneous manifestations. It is the first visible proof of the general contamination of the system, and, in cases of doubt, is the confirmation of the diagnosis. In some cases it is very mild and presents only a few lesions, while in others the spots are thick and apparent. The eruption consists of rounded hyperemic spots, usually with ill-defined borders, seldom raised above the level of the normal skin, and then but slightly. The roseola spots vary in size from that of a lentil to that of a finger tip. Their redness is vivid only in the early period, showing a bright pink-rose-red, which does not entirely dis- appear under pressure, and leaves a yellowish skin. After some days trie spots assume a dark dirty brownish color and remain for some time in this condition. The roseolar spots are distributed over the body, but not always in the same way. The trunk is most usually so affected, so that chest and abdomen are the first regions to show their presence, then the upper portion of the extremities and the neck. The eruption is more pronounced on the flexor surface of the limbs than on the extensor. The palms of the hands and the soles of the feet are often the seat of the eruption, but their dorsal surface is usually spared. The scalp shows spots of roseola, the face is usually spared, only in rare instances is it affected. In some cases roseola occupies by preference the anterior, in others the posterior half of the body. In one of our cases, after having removed all the affected inguinal glands, a few spots of roseola appeared on the lumbar and on the gluteal region only. Roseola is accompanied by an erythematous affection of the mucous membranes of the throat, which is a good characteristic symptom on which to base a differential diagnosis from other eruptions of an erythematous character. Roseola is the first objective symptom of constitutional syphilis, it causes the least marked changes on the skin, and it represents the first stage of other efflorescences. In fact, the pathological lesions of syphilitic roseola are made up by an increase of cells around the capillaries and in the lymphatic spaces. The blood vessels show important changes in their tunics, consisting in an infiltra- tion of cells and in a proliferation of their adventitial elements. Some exudation is also found around the hair follicles, sebaceous glands and sweat glands. When roseola is left to itself it persists for some time. and its brierht color remains for nearlv two weeks. Then the infiltra- 42 . THE MEDICAL ASPECTS lion gradually diminishes, its color assumes a dirty yellowish or a dirty grayish hue, and disappears leaving in some places a mild pig- mentation. In the regions of the skin which contain a great quantity of sebaceous follicles, there sometimes appears a peculiar seborrhea ac- companying the roseola. This peculiar seborrheic condition is re- vealed by a yellowish dirty brown color of the skin which is dry and scaly especially around the nose and mouth, in the naso-labial fold, the hairy scalp, along the borders of the forehead and neck and sometimes around the genitals. The hair begins to get loose on account of an increased quantity of the epidermic elements in the follicle of the hair and to fall off in spots corresponding to the roseola lesions, producing that character- istic alopecia which has been called diradaris. Alopecia is usually noticed on the scalp, but not infrequently the hair of the eyebrows, axillae, pubis, etc., also fall out in the same way. Roseola may form the only eruption of the whole evolution of syphilis, and in this case syphilis may show its activity in successive eruptions in the form of recurrent roseola. Usually the spots of the recurrent roseola are much larger, livid, and somewhat more deeply infiltrated, seated on the shoulders, on the chest, or on the abdomen, more often on the anterior or posterior folds of the axillae. When those patches are reabsorbed in their center, the edges remain some- what more prominent and form circular lesions, which have been described under the term of roseola annularis, gyrata, figurata, etc. We will not dwell on the differential diagnosis of the syphilitic lesions, because it is our sole purpose to give an idea of the evolution of syphilis in the infected rather than to teach syphilology, and so we will proceed to consider briefly the other eruptions. Papular syphilide is the next eruption, which in some rare in- stances is formed by the roseola spots, which on account of an increased infiltration assume the papular shape. In other instances papules begin to be mixed among the roseola spots, forming that mixed eruption which we call maculo-papular syphilide. Usually after the macular eruption has disappeared there is a short period of quiescence, which is followed by this eruption. In this case the eruption may be preceded by some reactive feverish attack, and two or three days later hyperemic spots, brownish red in color, from a pin-head to a lentil in size, make their appearance all over the body. The papules in some localities lie very close together, in others they are discrete and only a few in number. W r e can say that the papule is the true eruption of syphilis, which represents an infiltration arising from the connective tissues, and especially from the walls of the vessels. In this stage of syphilis Plate II < j 3 W ■si O Oh < O o CONSTITUTIONAL SYPHILIS 43 the vessels are affected with inflammation and the arteries, affected with a true angitis, cause edema and infiltration of small leucocytes into its limited district, which was called by Renaut 5 cone arterielle. • The infiltration affects not only the papillary layer but the deeper layers of the cutis. In some cases the infiltration forming the papules is found more dense around the hair follicles and the sweat glands. The infiltration also penetrates into the mucous layer of the epidermis, which is the initial step to the breaking down process of the larger papules. The color of the papules is red only during the first days, for it is soon changed into a mixed shade of dark blue or dark brown. The papules consist of a circumscribed nodular elevation, firm and solid to the touch, varying in size from that of a pin-head to that of a lentil, or even greater than a quarter of a dollar. The anatomical region of the skin has great influence on the appearance of the papule, which takes on different characters according to whether it is situated in a dry region or in a place where it is constantly macerated by the perspira- tion or by physiological secretions. On the trunk, in the extensor surface. of the extremities, the papules usually do not grow much, are slightly scaly and remain dry ; upon the hairy scalp they appear scabby, and where the skin is in folds the papules are moist, the desquamation is replaced by viscid secretion and the papules take on an exuberant development. On the palms and soles where the epidermis is thick and hard, they assume a peculiar scaly form, which has given origin to the misnomer of psoriasis palmaris and plantaris. When a dry papule begins to undergo the process of retrogression, the red color and the infiltration disappear and desquamation takes place, and the papule totally disappears. When the hyperemia and the infiltration have lasted for some time, then on the place of the papula there remains a reddish brown or a grayish discoloration, which is due to a pigment, the result of the effused coloring matter of the blood in the meshes of the tissues. This pigment after a while is also reabsorbed and, disappearing, leaves the stratum Malpighi also des- titute of the normal pigment, forming, especially in a delicate skin, light spots which are designated as leucoderma. From the size of the papules the eruption has been divided into several varieties, as, small and large papular syphilide, or miliary papular syphilide and lenticular papular syphilide. Usually the larger papules present themselves as such of a large size already formed : sometimes they are the result of small papules increasing in size, at •times also they are developed from roseola spots. 5 Renaut, J. " Snr la caraateristique anatomo-pathologique de la syphilis." Revue Pratique dcs maladies cutances. Janvier, 1903. 44 THE MEDICAL ASPECTS The eruption has a rather benign course, and in a few weeks a lenticular papular eruption is under involution and disappears. It lasts for months when it is left to itself without regular treatment. In some cases the papular eruption consists of large papules from the size of a bean to that of a quarter of a dollar, of a dark reddish color like that of boiled ham, or the crust of bread, few in number, scattered irregularly on the body. They usually make their appearance on the forehead, on the hairy scalp, on the body and extremities. From their size they are called giant papules, and an eruption of this kind, especially in the beginning of the constitutional eruption, is always considered of unfavorable prognosis for the later evolution of syphilis. The small papular syphilide or miliary syphilide is also a stubborn eruption, and it is usually a sign of a deep syphilitic infection which will show up after a while with severe symptoms. In this form the papules are small and scarcely reach the size of a millet seed ; they are of a dirty brownish red color, aggregated in groups, covering large portions of the trunk and extremities. This eruption persists much longer than the ordinary lenticular papular syphilide, and in one pa- tient six months after the appearance of this eruption it could still be seen on his body. The lesions of this eruption are deeply seated, and after they are involved and reabsorbed there remain small super- ficial atrophic points in the skin. It is not one of the first eruptions of syphilis. It sometimes makes its appearance after the roseola, but is oftener one of the recurrent eruptions, and is accompanied by a few scattered large papules. This miliary papular eruption is constantly accompanied by severe syphilitic symptoms on the mucous membranes, and the general condition of the patient is run down, with a marked pallor and defective nutrition. It occurs, and not very rarely, that either on account of the acute invasion of the papular eruption or on account of an abundant exuda- tion, the papules are surmounted by vesicles. This has been called vesicular syphilide, and, on account of its likeness to varicella, has been called syphilis varicellaformis. These cases, at the time of a smallpox epidemic, are likely to give us trouble with the city authori- ties or with the hospital officers, on account of their resemblance to variola. The vesicles soon dry up and are converted into crusts, which are more frequent on the hairy scalp, the face and the legs, in that form of syphilis called papulo-crustacea. The possibility of mistake in the diagnosis of variola is only for a short time, because by a careful study of the development and disposition of the papules, and of the accompanying symptoms on the mucous membranes, the error will soon be dispelled. CONSTITUTIONAL SYPHILIS 45 On account of the thick epidermis on the palms of the hands and on the soles of the feet, the syphilitic papules of these regions are not raised up, but are flat, with a very slight elevation: They soon begin to desquamate, and are covered by dense epidermis in the form of white adherent scales, which are partially detached and replaced by new scales, the desquamation being formed by old and new scales. This form of syphilitic papules have a tendency to frequent recurrence. Their appearance is usually at an advanced stage of syphilitic evolution, and they are quite obstinate under the best treatment. The papules of the palms and soles appear at first in the form of reddish circumscribed spots from the size of a pea to that of a finger- nail in the center of the palms and extend in a circular manner towards the periphery. After they have remained some time covered with scales, the central scales are lost, and the papule remains as a large patch of a bright red color, smooth in the center and surrounded by a border of scaly, hard epidermis. The patches sometimes coalesce and extend in a serpiginous way, involving the whole palm, with an active thick desquamation. In case of deep infiltration the skin is apt to crack and form fissures, which cause a great deal of pain and inconvenience. The chronicity of the syphilide in this region is mostly due to the fact that the lesions are constantly exposed to friction and to pressure, causing a continuous irritation. On the soles of the feet, although the eruption has the same character, yet it is not so stubborn as on the hands, as it is somewhat more protected from external injuries. Papules also afTect the fingers on their flexor surfaces, and the toes, on the concave portion of the plantar region, being subject to motion, easily crack and form painful fissures. The nails are affected by papules either around the fold containing the nail, or inside in the nail bed : in the first case they appear like a flat reddish papule covered with a thin desquamation ; in the second under the nail, like a round, yellow, brownish spot, raising the nail somewhat. The nails become dull, fissured, and scaly. It is worthy to be mentioned that a papular infiltration at the edge of the heel or on the plantar surface of the foot, on the ball of the big toe, in the places where there is thick epidermis and it is ex- posed to continuous pressure, sometimes assumes quite peculiar char- acters. The skin covered with a papule shows a round area of nearly half an inch in the form of a callus. On account of maceration from perspiration, the epidermis is lost in the center and the papular infiltra- tion covered with a thick epidermis remains at the periphery, giving the appearance of a crater. The crater begins to ooze and forms an ulcer which resembles the perforating ulcer and has no tendency to 46 THE MEDICAL ASPECTS heal up on. account of its callous borders. Similar ulcers are often seen on the hands of patients who had thick callous formations in these regions. . Papules situated in an anatomical region- exposed to continuous moisture change their appearance so much that they have been dis^ tinguished by some authors from the ordinary papules -and have been considered as the characteristic eruption of syphilis. Under the name of plaques muquciises, tubercules muqueux, moist papules, papulae Jutmidcc are considered papular efflorescences, which being constantly wet with perspiration, urine, or other secretions, become quickly macerated, denuded of their epithelium, and show a moist surface. They are usually found on the external genitals, in the genito-crural fold, in the perineum, around the anus, the depression- of the navel, under the breast of woman, under the axillae, in the spaces between the toes, in the' auditory canal, the angle of the mouth, and in any place soiled by urine or feces, especially in children who are not kept scrupulously clean. In some cases the mucous patches form all the syphilitic symptoms, by their persistent relapsing. The moisture of the place, and warmth, seem to favor the develop- ment of the moist papules, so that when an ordinary dry papule has reached the size of a millet-seed, and does not exceed that of a split- pea, the moist papule attains the size of a ten-cent piece and even greater. It begins as a flattened elevation, round or discoid in form, and from this appearance it has also been called flat or condylomata lata. The larger patches present a depression in the center and the edges are somewhat elevated over the normal level. They are usually grayish red in color, succulent and soft, and, after some time, take on a dark bluish color. The epidermal covering macerated by the moisture becomes grayish, and is easily rubbed off as a pellicle, leaving a flesh raw patch oozing abundant serum which causes a nauseous odor, hence the name of pustula fcetida, of the old authors. The irritation of this secretion, together with the saline reaction of the perspiration, produce an irritation on the papillae, which rise in points above, the whitish pellicles of the macerated epithelium, which gives to the lesion an appearance similar to a raspberry. The same condition of moisture, warmth and dirt, with the con- tinuous irritation, and probably through a local infection, cause the patches' to multiply to such an extent around the labia majora, the anus and their vicinity, that these parts are densely covered by them and almost no normal skin left between them. The papules surround- ing the anus look like red, swollen folds entering the anal orifice and are seen as ulcerated patches by distending the sphincter. In fact, when the papules remain moist they break down, causing Plate III Papulosquamous Syphilide Four Years After Infection CONSTITUTIONAL SYPHILIS 47 a loss of substance. In this way they become ulcerated and the ulcer may extend deeper and replace the papule entirely in its extension. The ulcer usually clears up and cicatrization begins, leaving a super- ficial scar. Mucous patches frequently recur, and they are present when all other symptoms have disappeared. They are the most dangerous lesions for spreading the contagion to well people who are brought into con- tact with a syphilitic individual. It is one of the most persistent lesions. It is often a relapsing lesion, which is usually seen during the first two years after the infection, but they are sometimes found after four and five years. In regard to the eruptions of papular syphilides there is to be noted that the early eruption has a tendency to spread all over the body in a symmetrical disposition ; but later on in their successive recurrences the number of papules is limited to a few scattered irregu- larly on one region of the body. In this case the papules have no longer a symmetrical disposition ; they are grouped together and often arranged in a circular or in a semicircular form. In a patch formed by syphilitic papules we see in the middle old papules in the way of involution ; some partially healed up, others covered with scales and the new papules along the periphery showing the peripherical growth of the syphilitic lesions. The dry papules produce no subjective symptoms in the patient, only at the time of desquamation do they cause itching sensations. The moist papules are usually troublesome, being accompanied by an itching and burning sensation; they cause fissures and ulcerations, which are very painful, especially near the anus. On the toes, on the palms and soles, the papular eruption may become so painful on account of the fissures as to prevent the use of these parts. With this eruption there are many other concomitant affections. Alopecia, affections of the mucous membranes of the mouth, nose, pharynx and larynx, iritis, and general enlargement of the lymphatic glands are constantly present. Sometimes neuralgia, paresis and oc- casionally symptoms affecting the central nervous system are found along with this eruption. It is also found in association with syphilitic inflammation of the periosteum, of the joints, of the muscles, of the tendons, of the synovial sacs, and it is not out of the range of possi- bility to find it accompanied by a gummatous infiltration of the skin or of some other organ. It is very easy to establish the diagnosis of papular syphilide by the form of the eruption, its location and distribution, the accompany- ing symptoms, and much more so when we are able to demonstrate the presence of the initial lesion or its scar. But there are some cases 48 THE MEDICAL ASPECTS where the diagnosis is quite difficult on account of possible confusion with similar eruptions. At the period of desquamation, in cases where the papular eruption has lasted a long time, it may be confused with psoriasis vulgaris, or also with tinea tonsurans of the body. This error, however, can be easily avoided by a careful study of the symptoms already mentioned above. Lichen planus may offer some points of similarity to a papular syphilide and much more on account of the tendency of lichen planus to attack the mucous membrane of the mouth and tongue. But the study of the lesions of lichen, their waxy, shining papules with a central depression, their tendency to arrange themselves in groups, the long standing of the papules, the intense itching accompanying the eruption, are characteristics which are suffi- cient to dispel any possible error. Mucous patches are so characteristic that when once seen there is no possibility of mistake, and indeed in some doubtful cases, the appearance of one of these papules is sufficient to confirm the diagnosis of syphilis. After a papular eruption has left the skin, some pigmentation remains on the places of the papules in the form of pigment spots, which give to the skin a marbled appearance. This peculiar form of pigmentation has been considered by some authors as an independent syphilitic eruption, which has been called syphilis pigmen- taria. But the careful study of the patients has shown that the remain- ing pigmentation is the result of the syphilitic lesions which have been on the skin, and according to all appearances the pigment spots are connected with the antecedent eruption. It is in the form of spots at times of the size of a lentil or of a ten-cent piece, 'at times larger, where the pigment had diminished or has entirely disappeared. These white spots make a distinct contrast to the normal skin which, retaining its pigment, is seen in the form of darker stripes. This discoloration has been very properly called syphilitic leucoderma. It appears more frequently in women and it is more apparent on the neck, although it can be seen on the upper portion of the chest, on the trunk and on the extremities. After the involution of the first macular or papular eruptions of syphilis on the regions named, there remain small round or oval whitish spots, which touch each other. The normal skin appears more deeply pigmented, and the whole looks as if the neck had not been washed. The leucoderma disappears very slowly, dimin- ishing gradually in its intensity in the interval of from one to two or even four years. The treatment has no influence whatever on its involution. Although many authors claim that leucoderma is found preferably in individuals with dark complexions, we find that on the contrary it Plate IV ClRCINATE SYPHILIDE OF DIFFUSED T VPE CONSTITUTIONAL SYPHILIS 49 is much more frequently found in individuals with white, thin and delicate skin and blond hair. In a large number of syphilitic patients we have found this leucoderma on the sides of the neck, only excep- tionally in men, while in the female ward we find it quite often, in its various degrees. Syphilitic leucoderma is so characteristic that once seen it cannot be mistaken for other discolorations of the skin. It is a sure sign of syphilis, although it is not a syphilitic eruption, as Hardy called it syphilis pigmentaria. Furthermore, it is a sign of syphilis already progressed ; it appears only after the eighth or twelfth month from the infection. Syphilitic virus by itself is not capable of producing pus, and when pus is formed on the syphilitic lesions it is due to the cocci of pus, which transform the papule into a pustule. The pus cocci are found everywhere, and free on the surface of the skin they enter into the syphilitic lesions by artificial cultures, as has been proved by Campana 6 and by Lang, 7 who found staphylococci within the tissues at a great distance from the border of the pustules. We have already seen that, on account of a large quantity of exudation, the apex of the papule in some cases is raised in the form of a vesicle, the fluid after a while is dried up, leaving a scab surmounting the syphilitic papule. When, however, the staphylococci enter into the exudation of the vesicle, it becomes purulent, the pus soon dries up into a scab, giving place to an impetiginous eruption, which has been called syphilis papu- lo-pustulosa, or syphilis papulo-crustosa. These pustular eruptions are more frequently found on the hairy scalp, on the lower extremities, and not infrequently on the face. If we remove the thick dark greenish scab, w r e will find an ulcerated surface covered with pus, and when the whole papule has suppurated, the ulcer begins to granulate, showing a raw surface, which after it has healed up leaves a superficial cicatrix, corresponding to the original lesion. When a pustular eruption afTects the scalp or the part of the face covered with the beard, the follicles of the hair are involved and as a consequence the hairs get loose and fall out. Pustular syphilides are always found in individuals run down in general health, whose nutrition has failed on account of the syphilitic process, and much more on account of their systemic conditions and hygienic surround- ings. In these cases it happens that the infiltration of the syphilitic eruption is turned into suppuration, forming pustules of different varieties. Syphilitic pustules have characteristics of their own, which dif- 6 Campana, R. Fra Castorius. 7 Lang, E., 1. c, p. 6S. 50 THE MEDICAL ASPECTS ferentiate them from an ordinary pustule. This latter has an acute course, the epidermis is readily raised by pus, is surrounded by an inflammatory halo, soon breaks, and the pus is dried, forming a scab which drops off leaving a surface covered with new, normal epithelium. The syphilitic pustule, on the contrary, has a slow course on account of the fact that the infiltration but gradually undergoes suppuration. The epithelial covering, which contains the pus, remains for some time on account of lack of pressure on the part of the fluid. The first quantity of pus is already converted into a dry crust, and the suppura- tion continues underneath, so that the crust is pushed somewhat higher by the fluid and forms thick, bulky crusts. So long as infiltration remains, suppuration continues, and on account of the formation of a heavy thick edge around the pustule the process is maintained by the renewed infiltration. In this way we must see in a syphilitic pustule an ulcerative process, which is not very deep, involving only the upper layers of the skin. When the infiltration has disappeared the ulcer clears up and the process of reparation takes place, always healing with a superficial cicatrix. Sometimes the infiltration and suppuration progress on one side of the lesion, while the other side is healing. Thus the ulcer takes a semilunar appearance. This ulcer progressing in this way is called a serpiginous ulcer. The scar which retains this peculiar shape re- mains there to indicate the existence of a pustular syphilide. In the ulcerated base of a syphilitic pustular lesion papillary growths may take place, which, resembling reddened granulations, are elevated above the ulcer, oozing purulent matter, partially covered with dirty crusts. This condition of the ulcerated, pustular syphilide is found especially in the hair and the beard ; it resembles sycosis and has been called syphilis framboesioides. Pustular syphilides, like papular syphilides, in the early period have a tendency to affect a large area and to assume a symmetrical distribution. In the late period the lesions are much deeper, are isolated and scattered in a few places only of the cutaneous surface. The pustular eruption may be preceded by an attack of fever, which sometimes continues, according to the quantity of suppuration. From the size of the pustules, pustular syphilide has been called syphilis varicellaformis, and also acne syphilitica, when it results from small pustules distributed with certain regularity, recalling the distribution of varicella. When resulting from large pustules scattered on the body, it is called syphilitic ecthyma. Very large pustules, the size of half a dollar or more, developing slowly, with thick, elevated crusts resembling the shell of an oyster, have been called syphilitic rupia, from (pi'Tros) which means filth. Plate V Pigmentation Left by Hemorrhagic Papular Svphilide CONSTITUTIONAL SYPHILIS 5 1 The course of a pustular syphilide is rather long, because it takes time for the lesions to heal, and while they are healing new ones are coming, prolonging the affection indefinitely. In rupia we always find a superficial ulceration of the skin, af- fecting a place about the size of a half dollar or larger. It begins in the form of a blister, of which the over-lying epidermis is flaccid and wrinkled, containing only a moderate quantity of sanious purulent fluid, which dries up, forming a dark-brown scab. Under the crust at its periphery fresh suppuration takes place, which gradually raises up the first crust, forming a second one, which looks like a ring. The process of disintegration is repeated and the crust grows on account of the new concentric rings formed by the continued suppuration. When the crust is removed an ulcer is exposed, oozing a thin sanious pus. Its edges are infiltrated, and when the infiltration fades the ulcer is repaired. The process of cicatrization takes place first in the center of the ulcer and then in the periphery, sometimes showing ulcerated rings. The cicatrix is in the begining of a bluish red tint, which slowly grows paler until it becomes a brilliant white color. It is lower than the level of the normal skin and it appears thin and atrophic. Syphilitic rupia is found in an advanced stage of syphilis. The lesions are sometimes thickly spread on the skin, but are ordinarily limited to only a few, and sometimes to only one pustule, which shows the existence of constitutional syphilis. Before leaving the subject of pustular syphilides, it is worthy to mention the resemblance which a small pustular syphilitic eruption has to a case of varioloid. We have already said that at the time of a smallpox epidemic some of these cases are capable of causing much trouble with the health officers. The resemblance is so striking that the eruption has been called syphilis varicellaformis, and there are some cases where it is rather a difficult task to decide at first glance whether we have to do with a case of varioloid or with one of pustular syphilide. It is stated that the eruptive fever is somewhat more intense in smallpox, but we also find fever preceding the syphilitic eruption, and sometimes a very mild fever at the beginning of a smallpox case. It is very rare that a pustular syphilide is not accompanied by other syphilitic lesions, especially on the mucous membranes in form of moist papules. Syphilitic pustules have a much slower course and last for weeks ; while in smallpox the pustules dry up in a few days, as the whole process runs its course in a shorter time. So when we have to deal with pustular syphilides, the pustules last for some days : some are still in the form of papules when others already show a formed crust. 52 THE MEDICAL ASPECTS This is different from the appearance of smallpox, where the eruptive lesions show nearly the same condition. Other affections may also be mistaken for pustular syphilide ; such as acne varioliformis (Hebra), acne necrotica (Boeck), acne cachecti- corum; but the error will easily be dispelled by considering the other syphilitic symptoms, which are constantly found present in syphilitic diatheses. In some cases of deep syphilitic infection papules of a late syphili- tic eruption have shown necrotic process. The papule is connected in a small dry gangrenous patch, black in color, which gradually is detached and is replaced by a scar. SYPHILIS OF THE SKIN APPENDAGES During the evolution of syphilis the hair is affected in different ways, showing that it is not spared by the poison any more than the other tissues of the body. Everybody knows that when syphilis breaks out the hair begins to fall. The following also constitutes a symptom of syphilis ; if, when passing our hand over the head of the patient, we close at the same time our fingers, a few hairs remain between them. After the first appearance of roseola or somewhat later, the hair becomes dry, loses its brilliancy and becomes loose in its follicles. The hair falls out in small areas, reminding one of the distribution of roseola or papular lesions. When the patient has his hair cut short, the bald areas show very prominently, and the scalp looks as if it were eaten by moths, alopecia diradans. In some cases the thinning out of the hair increases to a total baldness, and it also affects the hair of the body, eyebrows, beard, axillae, pubis, etc. With this alopecia there are no signs of disease of the scalp, no lesions, no desquamation. In the first instance of alopecia the hyperemia and the exudation around the follicles of the hair forming the roseolar or the papular spot, are accountable for the loosening of the root of the hair from the papilla, and for the shedding of the hair. In the second form of alopecia, it forms a symptom by itself and is probably due to a tropho- neurotic condition induced by the syphilitic toxins. Syphilitic alopecia occurs more commonly during the first year of the infection, and usually shortly after the first general eruption. The hair is lost mostly on the sides of the head, the temporal and occipital regions first show the thinning of the hair. In cases where very little treatment has been given to the patient, the loss of hair may occur at a later period. Syphilitic alopecia is always temporary; it will cease after weeks or months and new hair will grow out, but the growth of the new hair will not be so luxuriant. Permanent baldness is of but very rare occur- Plate VI < w O w u CO CONSTITUTIONAL SYPHILIS 53 rence. It does happen, however, when syphilitic infiltration destroys the papillae of the hair or impairs its follicles, and in these cases we have a resulting scar which is destitute of hair on account of complete destruction. After gummatous ulcers, after pustular extended ulcera- tions and sometimes also after deeply seated papules, scars remain which are destitute of hair. The nails are also affected by syphilis in its different forms. They lose their brilliancy, assume a matt color, and easily split and splinter, as results of the nutritive changes in the matrix of the nails. These alterations of the nails rarely show up alone, for they usually accom- pany cases of papulo-squamous syphilides of the palm or soles, or of the volar and plantar surface of the fingers and toes. Although the erup- tion has disappeared, the altered condition of the nails persists un- changed for a long time in that form described by Fournier as onyxis craquele. The nails have not only lost their luster and become yellow- ish and dull, but are marked by parallel lines or ridges. The edge of the nail cracks and breaks easily, leaving ithe edge unequal and irregular. This form of onyxis is often associated, or better, is pro- duced by a form of dry paronychia. Usually several nails are affected at the same time. Paronychia has been divided into several types, which can be called dry, inflammatory and ulcerative paronychia. The varieties depend entirely on the infiltration and the period of the syphilitic affection. It may be the result of an initial lesion, of a papule, of a pustule or of a gumma, with the resulting change in the severity and nature of the paronychia. In paronychia the syphilitic deposit is found in the matrix or in the lateral furrows which contain the nail. In the case of a superficial papule the paronychia may remain dry ; but in the case of an initial lesion, of a pustule or of a gumma suppura- tion occurs and this leads to ulceration. The nail in this case is thick- ened, infiltrated and ulcerated towards the edges of the ulcerated fur- row. On account of the resistance of the tissues, the pathological process of syphilitic paronychia is accompanied by pain, which persists until the absorption of the infiltration and the healing of the ulceration takes place. When the process affects the bed and the matrix of the nail this is nece'ssarily lost and the new nail is commonly thick, chalky and deformed. In some cases of old syphilis the nail plate assumes a form of hypertrophy in length and in volume to resemble a claw, which has been called onychogryphosis. 54 THE MEDICAL ASPECTS LATE SYPHILIS OF THE SKIN When syphilis has reached the period of maturity, the true syphilitic product is the gumma. Unlike the other syphilitic products already considered the gumma is subject to disintegration, for although it may come to the most favorable end, that of reabsorption, yet signs of destruction will remain in the affected places. It forms a more serious affection than the other lesions, which are of an irritative and resolutive character, and do not imply destruction of the tissues af- fected. The process of gummatous infiltration affects the connective tissues or their equivalents, bone, skin, etc., through which the elements of the tissues, pressed by the interstitial growth, become at first hyper- trophic, then atrophic, necrobiotic, and must finally die. According to the tissues involved, it sometimes causes intense pains, which increase at periods, especially at night, and are described as tearing and boring pains ; at other times, when affecting the subcutaneous tissue, the patients have cutaneous gummata for a long time, without being kept from their occupations. Gummata occur in a double form ; some are superficial and others are deep. The superficial gumma is just the same as that which many authors call tubercular syphilide. Indeed, they admit that between the tubercle and the gumma there is a striking analogy ; they possess identical histological characteristics, the difference is only in the size and depth of the infiltration. The syphilitic tubercle is an intradermal lesion, while the gumma is extended to the subcutaneous tissues. It is more practical to consider all under one nomenclature, gummata, and dis- tinguish them as superficial and deep. Superficial gummata appear on the skin in the form of roundish flat nodules, of a brownish red or copper color, varying from the size of a pea to that of a bean, and having their seat in the derma. They are sharply defined in the form of small tumors, hard, resistent and elastic in the beginning; but softer later on. Gummata in general make their appearance only in the later stages of syphilis, from three to four years after the infection, and sometimes not before the tenth, fifteenth or the twentieth year. ' In exceptional cases they may show up earlier, so much earlier, indeed, that they may exist along with lesions of secondary nature. Their early occurrence always shows a grave and anomalous type of syphilis. Gummata are usually found in association with pigmentation, cicatrices, and dis- colorations left by former syphilitic eruptions. While superficial gummata may develop on any portion of the body, yet they are usually limited in number, and have a tendency to CONSTITUTIONAL SYPHILIS 55 affect the face, the back of the shoulders, arms, thighs and legs. They are essentially chronic in their course and may undergo reabsorption, but in most of the cases they soften and ulcerate. The central portions of the gummatous nodules are more often affected, and there the pro- cess of disintegration begins, which is very slow and causes the lesion to remain for a long time. When the syphilitic infiltration forming the gummatous nodule undergoes reabsorption, it diminishes and flattens, and the epidermis is thrown off in scales. Its bluish color is changed into a rusty brown, the center is depressed, and the skin is changed into a whitish atrophic scar, which remains surrounded by heavy brownish pigmentation. The pigment resulting from the long-standing hyperemia and the effusion of the coloring matter of the blood is gradually reabsorbed in the upper portions of the body, but on the extremities it remains through life. When the superficial gumma breaks down, an ulcer is the result, which upon the drying up of the purulent secretion, is soon covered with thick heavy crusts, strongly adherent. When the crusts are re- moved, a sharply defined ulcer is discovered with a yellowish bottom and steep edges, somewhat undermined and involving the whole thick- ness of the skin. The ulcer progresses as long as the borders and the base remain infiltrated and soiled with detritus. When the infiltration diminishes, the bottom of the ulcer clears up and shows the healthy granulations, which are soon covered by epithelium, forming a thin depressed cicatrix, at first heavily pigmented, then glistening white. Superficial cutaneous gummata have a tendency to come in groups, covering a large area of the skin. In some cases the nodules are so thickly pressed one against another that it is difficult to recognize the individual lesions. The skin presents in these patches all the different stages of the nodules from the bluish red infiltration to the scaly con- dition, and as the older ones have been already reabsorbed in the center of the patches, cicatricial portions are also found. When the gummata undergo disintegration, ulcers are formed, which last for a long time, healing slowly and leaving deep scars. When the gummatous infiltration has affected the skin which covers the cartilages, or superficial bones, like the auricles, the nose, the eye- lids, and the forehead, the ulcer may then denudate these parts and cause necrosis, with the resulting destruction of these organs. The ulcers usually appear in chains, interrupted by a cicatrix of old ulcers already healed up. New nodules arrange themselves around the old lesions, forming increasing circles, taking on a serpiginous appearance. In the same way ulcers are progressing, healing- towards the center, and extending along the periphery. This peculiar way the ulcer has of extending gives to it the shape of a kidney or that 56 THE MEDICAL ASPECTS of a sickle, which can be considered as characteristic of the syphilitic ulcers. The number of gummatous nodules of the skin is sometimes limited to a few, but sometimes they are spread over large areas, cover- ing one entire shoulder or the whole gluteal region, and lasting for years, especially when not properly treated. SYPHILITIC AFFECTIONS OF OTHER TISSUES AND ORGANS Since the time of Petit 8 the gumma has been considered as a collection of fluid, but in reality it consists of a mass of small round cells, which are only young mononuclear leucocytes. In the formation of a gumma the difference of the tissues affected, their compactness and their quantity of blood vessels have a great deal to do with its appearance. In every gumma the blood vessels are affected in their tunics by an infiltrating process, but the lymph vessels are also en- larged, obstructed and inflamed, showing that the formative process of granulation has started from them. In the gummata, together with the infiltration, there is also a proliferation of the connective tissues. In some gummata the infiltration and proliferation of cells is the main feature, and in this case the intercellular substance becomes softer, semifluid, and the melting mass gradually becomes purulent, breaks down, and ends in an ulcer. In the others the proliferation of cells remains circumscribed, the intercellular substance multiplies, their cells maintain their form, or assume a round shape, like that of the granula- tion cells, undergoing in their way a fatty degeneration. In the first case the process resembles a heteroplastic change, while in the second it is more like the hyperplastic alterations leading to a sclerosis. The difference between the cutaneous and the subcutaneous gum- mata consists mostly in the size ; in the latter the morbid product forms nodules of considerable volume. Tumors from the ordinary size of a bean or walnut may attain that of the fist, and even greater, in the form of a tumor, round, oblong, or flattened in shape, originally of firm consistency, and movable under the skin, or else fixed to the underlying fascia, according to whether they originate in the loose con- nective subcutaneous tissue or in that of the fascia. The skin covering a gumma has at first the same color and a normal aspect, but gradually, as the gumma increases in size, it is subject to important changes. On account of the distention produced by the growing tumor, the skin becomes whiter and glistening and, on account of the difficulty of cir- culation, shows an edematous swelling. The gumma remains for a long time in this condition, until it becomes softer in the center, and after a while in the periphery also, giving to the examining finger the sensation of a soft, elastic and fluctuating mass. 8 Petit, Louis. "Traite des maladies des os." Paris, 1735- Plate VII Papular Syphilide with Gangrenous Spots CONSTITUTIONAL SYPHILIS 57 If an incision is practiced on the gumma at this period, no pus will be found, only a small quantity of a sticky viscid fluid, resembling a solution of gum arabic, with a few pus corpuscles and a few drops of blood. From the presence of the mucilaginous fluid the tumors have been called gummata. The end of the gumma varies quite a great deal. In some for- tunate cases, after the infiltration has undergone fatty degeneration, the newly formed particles of tissues are changed into a granular detritus, which is gradually absorbed. The skin over the site of the original gumma remains depressed, thin, but not materially changed, though with some abnormal pigmentation. In other cases when the process has advanced so far that the skin covering the gumma has become bluish red, threatening to break down. the absorption of the deep-seated parts of the gumma is still possible. Then the bluish tint of the skin is changed into a faint red, remaining somewhat edematous. Gradually as the absorption takes place, the edema disappears and the gumma appears depressed, and is re j absorbed, leaving an atrophic scar to mark its seat. When the absorp- tion disposes of but a part of the contents of the gumma, those remain- ing undergo cheesy degeneration, which through irritation produces suppuration and is thus finally emptied and removed. In other cases the fluid part may be absorbed and the solid changed by calcareous degeneration into a hard mass, which, encapsuled by connective tissues, remains as a dead product of the process. The usual issue of the gumma is the ulcer. The skin covering the tumor becomes bluish red, infiltrated, edematous, and attached to the whole mass ; it becomes thinner and is perforated at the highest point of the tumor. A quantity of purulent matter, together with necrosed parts of the gumma are emptied, and an ulcer remains. It will extend according to the infiltration of its bottom and edges. The edges appear bluish red, thickened, neatly cut, undermined, while the bottom has a yellowish cover, due to the necrotic shreds and detritus, infiltrated without any tendency to granulations. The purulent secretion is usually rather thin, and abundant in accordance with the disintegration of the infiltration. When the in- filtration has been destroyed by suppuration, the ulcer begins to clear up, the edges become flat and slope toward the bottom, which begins to show red granulations ready to start the cicatricial process. The in- filtration of the edges disappears, and they begin to show a whitish line of good cicatricial tissue, from which place it extends till it covers the whole surface. On account of the irregular destruction of the underlying tissues the scar is often nodular and irregular and usually surrounded by a brownish pigmentation. 58 THE MEDICAL ASPECTS In some cases we may have the healing of the gumma on one side while the extension of the infiltrating process is progressing on another side, in a serpiginous way. In the deep gummata, however, this oc- currence is not so frequent as in the superficial one. The subcutaneous gumma usually affects the body one at a time, but we may also find several gummata at the same time. It frequently occurs on the forehead, neck, shoulders and legs. From the size of a hazel-nut, gumma may attain that of a goose egg and even greater, especially when seated on the trunk. In individuals debilitated, in poor health, or who have had im- proper treatment, the infiltrated gumma may undergo rapid disintegra- tion, which causes extensive ulcers, producing the destruction of the tissues and organs affected. In one of our cases the destruction of nearly the whole inferior lip occurred in a few days in a syphilitic in- dividual, eight years after the infection. These gummatous ulcera- tions, with such quick destructive power are accompanied by unbear- able pain, which prevents the sufferer from sleeping. In some cases gummata may be so numerous as to produce the destruction of the skin in large areas. When reparation is partially effected, the cicatrix draws and may cause a contraction of the joints. In one case a gumma of the knee joint had taken so large a develop- ment after a slight injury as to give the idea of an aneurism. Gum- mata, on account of the destruction of the lymphatic vessels, may be the cause of stasis of the lymph, which together with the altered con- dition of the periosteum and of the fascia, produces an elephantiasic condition of the legs, and of the affected organs. In some cases the gumma is rapidly converted into a gangrenous mass, gangrenous gummata. The change is very rapid and the destruction of the organ is the result. In a patient in the hospital, who had been admitted for phimosis, upon opening the prepuce the whole glans was found to be a gangrenous mass. In the same way gummata of the skin have changed in a few days into gangrene, which limited itself, sloughed off and healed up in a short time. In some cases when blood vessels are taken in by the destructive process, hemorrhage is the consequence. It sometimes occurs that a carcinomatous growth has found its seat on an ulcerated gumma. Hutchinson and Langebeck have referred to many cases of carcinoma in conjunction with ulcerated gummata, and Lang and Doutrelepont have often found carcinoma connected with syphilis. In this case the ulceration from syphilis is the door of en- trance for the cancerous germs, and the tissues, flabby and lacking in vitality, are a good ground for their development. In many cases tuberculosis is also associated with syphilis, and CONSTITUTIONAL SYPHILIS 59 both together cause the most hideous ulcers and extensive destructions. Although ulcers of this kind may be found in any place, yet we have very frequently met with extensive ulcers of the vulva in syphilitic patients who were also affected with tuberculosis. Extensive ulcers of the labia majora with a greatly diffused in- filtration and surrounding edema, are frequently found in prostitutes. The syphilitic infection in all such cases dates back several years. In one instance the hard palate was affected with extensive superficial ulcerations, which could have been referred to as tubercular. Cases of extensive ulcers of the vulva have been described by Huguier 9 and others as lupus of the vulva. Hyde 10 and Taylor " denied the idea of lupus, and claimed those ulcers to be the results of syphilitic infiltration. Taylor especially does not mention at all the possibility of tuberculosis acting together with syphilis. The existence of both diatheses together, according to our experience, cannot be denied, and we can say that when both exist in the same individuals one intensifies the other. In another case of a colored woman there were symptoms of pulmonary tuberculosis, to- gether with a marked syphilitic diathesis, and it was difficult to eliminate either one as causes of the destructive condition of the external genitals. It cannot be denied that the induration from the infiltration, and the following chronic edema, may become a cause of ulceration through lack of attention, together with chronic vaginal discharge and the presence of urine ; but in many cases it seems that the associa- tion of tuberculosis with syphilis is more plausible. This ulcerative process, associated with an infiltrated condition of all tissues, becomes so extensive and so destructive that it gradually removes large portions of skin and of the underlying tissues, sometimes lasting for years, until death relieves the patient. Such cases sometimes show a vegetating ulcer covered with granu- lations on both sides of the labia majora, extending down to the perineum and the anus. The vulva, edematous and infiltrated, may reach an enormous elephantiasic size. The edges of the ulcer may be neatly cut, made up by the agglomeration of hard, infiltrated nodules, showing a round disposition. The labia minora may be nearly all destroyed by the ulcerative process extending inside to the ostium vaginae. The process is slow and the antisyphilitic treatment is of little benefit, yet in some cases when the disease has not gone too far. curet- 9 Huguier. " Memoire sur l'Esthiomene, on dartre rougeante de la region vulvo anale." Paris, 1849. 10 Hyde, J. N. Jour. Cut. and Genit. Urin. Diseases, April and May, 1889, 11 Taylor, R. W. New York Medical Journal, 1890. 60 THE MEDICAL ASPECTS ting of the ulcer with local applications of a solution of I : iooo of bichloride of mercury has brought about recovery. We recognize that tubercular processes of the vulva are of rare occurrence, and are but rarely found in children, as a result of secondary uterine tuberculosis. In general these extended ulcerative processes must be attributed to syphilis, but in some cases it is easy to see that syphilis is associated with tuberculosis and one has an influence on the other, and both to- gether cause horrible destruction. Of course the gummatous syphilitic process has to be differentiated from tuberculosis, as both are entirely different processes. Indeed, we have a great many interesting differential points taken from the time of appearance of the disease ; gumma, as an expression of late syphilis, appears later in life, while lupus is seen much earlier. The course of the syphilitic process, although very slow, is yet more rapid than lupus. It is very rare at the time of the appearance of the gumma not to find some other signs of syphilis present, and also the therapeutic argument that a syphilitic gumma improves under specific treatment, while lupus does not show any sign of improvement. A gummatous ulcer should not be mistaken for miliary tuberculosis of the skin, which is rather a rare affection, and shows an acute process leading to disintegration. Its flat appearance, the yellow reddish color of its bottom, the nibbled condition of the borders, the presence of small whitish miliary nodules surrounding the ulcer on a red inflamed skin, will be important signs for differentiating miliary tuberculosis of the skin from syphilis. Then there has to be added that miliary tuber- culosis of the skin always comes when the process of tuberculosis is very much advanced, and the patient is greatly run down; it is then very easy to make the diagnosis. The onlv obscure cases remain when an individual affected with tuberculosis has acquired syphilis and both diatheses are found together. Svphilis at a late period is the cause of elephantiasis of the penis and scrotum in the man, and of the labia in the woman. In the man the skin of the penis takes on great proportions, so as to be increased many times its natural size. SYPHILIS OF THE ORO-PHARYNGEAL CAVITY It is frequently found that the initial lesion has its seat on the lips, tongue, mucous membrane of the cheeks, palate, tonsils. In such cases it is easily communicated in an innocent way by kissing, or by objects of ordinary use. The seat of the chancre, however, has no in- fluence on the secondary lesions which affect the oral cavity. After the period of the second incubation, or when the initial chancre has Plate VIII Phagedenic Syphilitic Ulcer With elephantiasis of the anus and vulva CONSTITUTIONAL SYPHILIS 6l lasted from four to six weeks, together with the symptoms of a general reaction, the mucous membrane of the mouth shows hyperemic patches in the form of erythema. Some are small patches the size of a penny, sharply defined, raised above the level of the normal epithelium, and are found on the lips, cheeks or tongue. A form of reddish, diffused erythema is found spread on the soft palate, faucial tonsils, and on the uvula, and has been called erythematous syphilitic angina. It makes its appearance at the time of the first breaking out of the roseola on the skin, and sometimes precedes the eruption a few days, and it is then the first constitutional manifestation of syphilis. It causes a very slight subjective sensation, so that many patients scarcely notice that they have any throat trouble. It is noticed at first as a sensation of dryness, and then an increased formation of mucus takes place. Syphilitic erythema of the throat sometimes lasts from six weeks to several months, and spreads over the velum palati. the palatine arches, the tonsils and the pharynx. In many cases it retrogrades, leaving, however, a red erythema on the arches of the palate. In other cases, it happens that the epithelium is lost in spots and superficial erosions remain, covered with some whitish detritus, showing a narrow area of infiltration, which is liable to make the move- ment of deglutition painful and laborious. Gradually the infiltration declines, the erosions become covered with epithelium and heal up, the bluish red color of the mucous membrane takes a rusty brown color, with enlarged blood vessels, which remain for a long time as a witness of syphilis. This condition of the throat appears also at the time of the cuta- neous erythematous syphilide, yet it runs its course independently of it. It frequently recurs during the first year, and sometimes also during the second year after the infection. The mucous membranes are affected by papules in the same way as the skin. The papules in the mucous membranes are flat, reddish elevations the size of a lentil or larger, sharply denned, slightly in- filtrated and very slightly raised above the surface. The redness soon gives place to an opaque dullness, the epithelium assuming a bluish white or a pearl-colored appearance, more or less loosely adherent. They are called mucous patches. Mucous patches are very frequently found on the free edge of the lips, on the mucous membrane of the cheeks, on the tongue, especially on the border, tip and sublingual surface, on the tonsils, soft palate, faucial tonsils, but rarely on the posterior wall of the pharynx. The mucous patches situated in parts where the mucous membrane is in continuation with the skin, have the appearance of the mucous patch on the mucous membrane and that on an excoriated papule on 62 THE MEDICAL ASPECTS the skin. After the mucous patch has lasted for some time, the thick epithelium is thrown off, and the place is left with a thin covering, while the whitish raised-up borders go down and disappear. When the mucous patches are neglected, they increase in size and in number, closely covering the tonsils, the arch of the palate or the border of the tongue, and on account of fissures or abrasions, become very painful. They also undergo a superficial necrotic process, forming painful ulcers. The irritation caused by the use of tobacco, either in smoking or chewing, is the cause of the ulceration of the mucous patches in the mouth. These ulcerated patches together with fissures which are pro- duced by the infiltration of the mucous membrane, cause such a swell- ing of the tongue and tonsils as to render the movements and functions of these parts exceedingly painful. In consequence of the suppuration of the ulcerated mucous patches of the pharyngeal cavity the lymphatic glands of the neck and of the submaxillary region become greatly swollen and painful and in some cases end in an abscess. In some cases of mild syphilis an eruption of a few papules in the oral and pharyngeal cavity are the only visible signs of the constitu- tional disease. In these cases the eruption of the few papules is pre- ceded by a slight feverish reaction, and they occur as an erythematous surface of the pharyngeal ring. When the mucous patches are kept clean and treated, they dis- appear in from two to four weeks without leaving any trace ; but when they have been ulcerated through the irritation caused by the use of tobacco, or by stumps of teeth, they remain for months and frequently recur. Mucous patches of the mouth and throat are stubborn syphilitic symptoms ; they recur very frequently during the first and second years after the infection, even when all other symptoms have subsided. The mucous patches in late recurrences are confined to a few whitish papules, which rapidly disappear, but are soon replaced by others in another locality. The patches at a late period are not very much in- filtrated, and are depressed in the center, showing a kind of annular shape, principally affecting the lips and the tongue. From the pres- ence of the patches in the oral cavity, the epithelium, especially that of the mucous membrane of the cheeks, undergoes a peculiar change in its appearance, forming a kind of diffused whitish patch, of different intensity according to the severity of the lesions. In some cases, from the angle of the mouth running back towards the last molar tooth, the epithelium is thick, hard and sclerosed, of a white mother of pearl color, with small elevations making the mucous membrane uneven. In some cases the epithelium is only superficially affected, showing a CONSTITUTIONAL SYPHILIS 63 whitish yellow discoloration affecting the folds of the mucous mem- brane ; at other times there results a kind of a whitish stripe running unevenly from the angle of the mouth towards the last molar tooth. This condition of the mucous membrane of the oral cavity is a nearly constant or a permanent one. We have pointed out these whitish patches of the cheeks as one of the constant signs testifying to the evidence of an old syphilis. The recurrent patches on the lips and tongue make the patient a constant danger to healthy people on account of syphilitic contagium. Of course kissing is the most dangerous act for the transmission of the disease, especially to children; but it is also possible that syphilis be inoculated through towels or by different utensils which have been used previously by the infected person. For this reason it is necessary to use great caution in employing people in the household, especially in the quality of cooks when there is a suspicion of syphilis. The Oral Cavity — The submucous tissue of the mouth is often the seat of gummatous foci. They appear as nodes the size of a pea to that of a bean or greater, bulging over with the reddened mucous membrane. At first they are firm and hard to the touch, but later they become soft, the mucous membrane is broken and an ulcer is formed. The ulcer, according to its seat and quantity of infiltration, assumes dif- ferent appearances ; but it is sharply defined and on a red bluish base. It remains at first stationary, covered with yellowish grayish detritus, then clears up and finally heals, always leaving a cicatrix. In some unfortunate cases, gummata of the mouth take an acute destructive character, as above stated, producing great impairment in its functions. The tongue is often affected with gummata, as firm tumors felt in its substance. They break down and leave ulcers, which produce great pain in the movements of the organ. We more frequently meet with gummata of the hard palate, and these lead to the exposure of the bone. The bone falls into necrosis and is perforated, leaving a com- munication between the oral and the nasal cavity. The soft palate is also easily destroyed by gummata on account of its thin and delicate structure. In our service in the City Hospital we have not rarely seen the destruction of the whole soft and of a large area of the hard palate, making deglutition very difficult and painful, and speech very nasal in tone. The tonsils and the pharynx are often affected with circumscribed gummata, which, breaking down, cause ulceration. The patient suffers great distress in consequence of dryness and rawness of the throat, which is relieved for only a short time by gargling. The diagnosis of the syphilitic affections of the mouth is not dif- 64 THE MEDICAL ASPECTS ficult. The only disease which deserves mentioning is the stomatitis mercurialis. The absorption of mercury for the treatment of syphilis, no matter how and in what form administered, in many patients will lead to the inflammation of the gums and of the mucous membrane of the mouth, with an increased flow of saliva (salivation). This causes swelling of the gums, with a grayish yellow edge where they are in contact with the teeth, swelling of the cheeks and, in advanced cases, also of the tongue, on which the teeth leave their imprint. The patient complains at first of a metallic taste, and soon gives off an offensive odor from his mouth, which increases with the production of the ulcers on the gums and cheeks. These ulcers are shallow, of a grayish white color from necrotic detritus, and surrounded by inflammatory redness. In these cases, if the use of mercurials is not stopped, it may lead to the necrosis of the tissues, and also of the jaw. In some cases, in the mucosa of the cheeks and of the lips, more rarely of the hard palate, are formed milk white spots, opaque, irreg- ular in shape, just as if the mucous membrane had been touched with a stick of nitrate of silver ; the epithelium is hard, thick, and wrinkled, and causes a sensation like tanned skin. Sometimes they also appear on the edges and on the back of the tongue. In these white places the tongue is smooth, deprived of its papillae, while the rest of the tongue is red, thickened and studded with red elongated papillae. It is the condition of the tongue which was described as keratosis Ungues by Kaposi, plaques lisses by Fournier, leucoplakia by Schwimmer. These patches are more frequently found in persons addicted to ex- cessive smoking, and, for this reason, they have also been called plaques des fumeurs by Buzenet. But according to many authors and to our own observation, these callosities of the mucous membrane of the mouth, if they are not the direct result of syphilis, they are surely greatly favored by it in their development. These patches are not influenced by antisyphilitic treatment and remain for years entirely unaltered. We will only mention the possibility in the oral cavity of lupus, which, like syphilis, leads to disintegration and loss of substance. It closely resembles syphilis and it requires some study to differentiate the two diseases. The ulcers from lupus are usually of a pale red color, granulating, and surrounded with nodular growths, which are lupus foci. In the ordinary cases lupus of the oral cavity is only a reproduction of lupus of the face, and the presence of lupus nodules on the face or of scars will facilitate the diagnosis. But we cannot for- get that in exceptional cases lupus begins on the mucous membranes. Miliary tuberculosis also affects the tongue, the palate and the pharynx in the form of tuberculous ulcers, which can be mistaken for , Plate IX An <| O 1 B M f PM PL. H < u CONSTITUTIONAL SYPHILIS 65 syphilitic ulcerations. Tuberculous ulcers sometimes are primary, but are often secondary to tuberculosis of the lungs or of other organs. The tubercular ulcers have a cheesy, lardaceous bottom, with under- mined sloughing edges, of a bluish-red color, studded with tubercular nodules. Tubercle bacilli are easily demonstrated in the discharge or in the substance of the nodules. Tubercular ulcers usually have their origin on the tonsils and on the vault of the pharynx, extending to the velum palati and to the back portion of the pharyngeal cavity, but they remain sharply limited at the beginning of the esophagus. They are accompanied by such extreme pain that the patient cannot take nourish- ment. Fever is often present, and symptoms of general tuberculosis will be easily found, so that the doubt between syphilis and tuberculosis cannot remain long, unless as we have already mentioned, both diatheses, are mixed together. The lips, the mucous membrane of the cheeks and tongue, are af- fected with carcinoma, and there may sometimes be doubt in the- diagnosis with reference to syphilis. In the beginning of the develop- ment of carcinoma it may be mistaken for an initial lesion of syphilis, but the condition of the enlarged glands will soon show the syphilitic lesion, while in carcinoma the glands are not affected until later. Gummata usually affect any one of these parts in several places, at the same time, while carcinoma usually begins as only one lesion. In cases, however, where the carcinoma or gummata have been for some time, and when the surface is covered with papillary growths, it is rather difficult to make a differential diagnosis between the two. Moreover, we have already mentioned that not rarely carcinoma has its origin in ulcerated syphilitic gummata of the mucosa of the mouth. In some cases we resort to the antisyphilitic treatment to see its in- fluence, and the kind of affection we have to deal with before perform- ing a radical operation. Many other affections which have no relation to syphilis may create some doubt concerning it. Some papillomata are often found on the gums or cheeks and may be ascribed to syphilis. In the same way a peculiar and rare affection of the tongue, glossitis cicatrisans, may also be mistaken for a syphilitic manifestation. SYPHILIS OF THE ALIMENTARY TRACT Although syphilis affects every organ of the body, yet we can state that syphilitic lesions of the esophagus and stomach in the secon- dary period are only exceptions. Cases of dysphagia are quite often the result of syphilitic ulcers of the pharynx or larynx ; and there have also been observed cases of dysphagia from paralysis of the esophagus. 66 THE MEDICAL ASPECTS in the course of syphilis, which disappeared under specific treatment. Cases of cicatricial obstructions of the esophagus have been referred to, which had been the result of ulcerated gummata. In these cases the symptoms of obstruction have appeared only late after recovery from syphilitic attacks. It is quite a rare thing to find syphilitic affections of the stomach, but not exceptional. In our practice we have met, in individuals who had suffered with severe symptoms of syphilis, cases of anorexia, pain- ful sensation in the stomach, vomiting after the ingestion of food, all of which have disappeared under the administration of mercurials and of iodide of potassium. There have oftener been observed and demonstrated syphilitic affections of the intestines produced by syphilis, and we very frequently have occasion to see cases of syphilitic enteritis in children affected with congenital syphilis. In the early period of syphilis we find cases of stubborn diarrhea, which are only relieved by the use of small doses of calomel. Cases of diarrhea, however, are found as the result of hydrargyrosis, and in this case it is necessary to stop immediately the use of mercurial medication. The rectum is a region which is often affected with syphilis, be- ginning with the initial lesion and passing through all the stages to the gumma. Mucous patches are found around the anus in the form of rhagades, which are very painful and bleed at the time of defecation. Mucous patches affect the inferior portion of the rectum, and on ac- count of the continuous irritation to which they are exposed, grow to a large size and may cause troubles resembling those produced by can- cerous stricture of the rectum. Gummatous productions of the rectum are also frequently found. They easily ulcerate and produce destruction of the mucous membrane of the rectum, leaving the muscular layer exposed, which is also riddled by the ulcers. In these cases the patient has involuntary stools, which are watery and bloody, accompanied by tenesmus. When the ulcers heal, stricture of the rectum is often the consequence. SYPHILIS OF THE RESPIRATORY TRACT If we consider the respiratory tract, we find, to begin with, the nose, which is sometimes the seat of an initial lesion. During the secondary eruptions it is often affected with irritative forms of syphilis, either of the erythematous or the papular form. This condition pro- duces a syphilitic nasal catarrh, which is noted for its obstinacy, lasting for months, with an abundant purulent secretion. The parts of the nose accessible to examination show a diffused CONSTITUTIONAL SYPHILIS 6 7 redness of the mucous membrane, and, in the vicinity of the nostrils, mucous patches are found, usually covered with a yellow grayish secre- tion. It is due to the syphilitic rhinitis that some patients complain of headache in the frontal region, which disappears when the rhinitis subsides. Superficial gummata affect the skin of the nose, which after ulcer- ating may produce destruction of the cartilage, with permanent de- formity of the alae of the nose. Gumma of the pericondrium of the cartilage, and of the periosteum of the nasal bones, causing destruction of the hard structure of the nose, has been of not infrequent occurrence in our observation. A gumma of the pericondrium may cause necrosis of the cartilages and bones, destroying all supporting parts of the nose. The lady who had been infected by marriage belonged to a class of cranks who believe they can have all diseases cured by prayer, and only when the nose was in the condition shown by the illustration did she decide to ask for medical attendance. The septum nasi is often perforated and even destroyed by a gum- matous process, causing both nostrils to coalesce in a large opening. Sometimes the nose, remaining without the support of the septum, sinks in the form of a small triangle. Sometimes a gummatous process affecting the mucous membrane and ulcerating deeply causes necrosis and exfoliation of the cartilages and bones. The first appearance of the gumma of the nose is marked by a dull pain, which is followed by a swelling which causes obstruction to the passage of the air. The nose takes on a brownish bluish color, and is greatly swollen at the bridge, and later becomes edematous. When the gumma breaks down from the inside a mucopurulent secretion comes out ; in some cases the secretion dries into a thick crust, which adheres to the wall of the nose. A new purulent secretion detaches these crusts, so that at times they are thrown off. The purulent secre- tion remaining in the coanae of the nose becomes decomposed and causes a foul smell. The bones are discovered to be necrotised and exfoliat- ing, and sometimes the patient on blowing his nose blows out small pieces of bone. If the affection is in the turbinates, the result is not of so great importance, but when the necrosis extends to a greater portion of the bony structure, the nose is deprived of its support, falls down, and deformity is the consequence. When, for instance, the per- pendicular plate of the ethmoid is destroyed, the nasal bones sink down, the bridge of the nose is bent down like a saddle and the tip is tilted upwards, causing a hideous deformity, which reveals the nature of the process which has taken place. In some cases the gummatous process spreads to the horizontal plates of the palatal bones, and produces a perforation of the hard 68 THE MEDICAL ASPECTS palate. In some cases the perforation which results may be so large as to enable one to inspect the cavity of the nose from the mouth. It causes distress in mastication and in deglutition, when the food enters the nasal cavity from the mouth. The adjacent sinuses are not spared and the gummatous process finds its way into the antrum of Highmore, into the sphenoidal and into the frontal sinuses. In this way on ac- count of the infection of the frontal sinus, we can explain the violent pains in the forehead which accompany syphilitic ozena. In reference to the olfactory functions, it is interesting to mention that in these cases of rhinitis the smell of which is noticed by others does not affect the patient, either on account of being accustomed to the continuous bad odor, or on account of the blunting of the sense of smell. In the first case the patient, although not noticing the bad odor of his nose, is still capable of noticing other odors ; but in the second there is complete anosmia. On account of the diseased condition of the upper portion of the mucous membrane of the nose, where the ramifications of the olfactory nerve are spread, the function of smell may be destroyed. In other words, anosmia may be only temporary, and it is the result of the swelling of the mucous membrane covering the middle turbinated bones, occluding the olfactory fissure between the middle turbinated body and the septum. When the swelling subsides and the permeability of the olfactory fissure is restored, the sense of smell will gradually return. The larynx is quite often affected by syphilis in the early and late stages. During the early period of syphilis, it is an erythematous af- fection of the mucous membrane in the form of a catarrh — catarrhal laryngitis. It is limited to a redness only, and a superficial swelling of the mucous membrane, which in some cases, on account of increased infiltration, may cause superficial abrasions, and, in some grave cases, infiltration extended to the muscles with resulting paresis. The erythema, in most cases, is diffused to the whole mucous mem- brane ; but in some it may be limited to single parts, such as the epiglottis, the aryepiglottic folds, false vocal cords, etc. As a conse- quence, the patient shows different degrees of hoarseness according to the process, which may lead to aphonia. The quantity of secretion causes the patient to cough and hack in order to get rid of the secre- tion. In most cases the laryngeal catarrh is one of the first symptoms of constitutional syphilis, and accompanies the erythema of the palate and pharynx. Sometimes it comes after the condition of the pharynx has improved, and is one of the relapsing affections, especially in per- sons who by their occupations are often exposed to the cold air. Mucous patches affect the larynx only in rare cases, to the extent Plate X 'J u o On i < M w 2 Oh ° CD U £ £ 9 CONSTITUTIONAL SYPHILIS 69 of three in one hundred syphilitic persons. The mucous patches in the form of small lentils appear on the free edge of the vocal cords, in a rather elongated shape, covered with grayish epithelium, or excoriated, or even ulcerated. They cause complete aphonia, as we had occasion to observe in two of our cases, lasting for seven weeks. Another fre- quent site of the mucous patches is the free edge of the epiglottis, ex- tending towards 'its posterior surface; sometimes the ary epiglottic folds and the mucous membrane of the arytenoid cartilage are invaded. In a case referred to by Armand Despres an ulcerated proliferated patch on the right vocal cord was the case of so severe a dyspnea that it was necessary to resort to tracheotomy. Mucous patches of the larynx usually terminate through involu- tion, and although they break down, they are easily healed. Like other organs, the larynx, too, at a late period of syphilis, is affected by gummata, which attack the vocal cords either in the form of small nodules or in the form of diffused gummatous infiltration. A man, thirty-five years of age, who had shown periosteal gummata of the tibiae, began to develop complete aphonia. On the right side of the rima glottis three little, round reddish brown nodules covered nearly the entire vocal cord, preventing the formation of the voice. The gummata frequently undergo suppuration, leaving ulcers, with neatly cut edges from the infiltration. The resulting ulcers in for- tunate cases usually heal up, but in some other cases the cartilages may remain uncovered, causing necrosis with extensive destruction of the organ and permanent impairment of the phonation. In some cases, on account of the defect of the epiglottis or of the imperfect action of the muscles of the larynx, fluids or particles of food enter the rim of the glottis during deglutition, with severe annoyance to the patient until he has gotten into the habit of preventing it. After cicatrization, the loss of substance may produce all kinds of disorders, according to the location and extension of the destruction. Small ulcers may heal up easily without leaving scars, but the vocal cords are so sensitive that any small superficial scar may impair nor- mal intonation. When the destruction has been of considerable extent, the result- ing cicatrix may cause adhesions of the vocal cords, leaving a small opening, or adhesions of the other parts of the larynx. Only rarely have syphilitic lesions been traced below the larynx into the trachea and bronchi, but it is more than probable that some cases of bronchial catarrh in the first period of constitutional syphilis are due to the irritative syphilitic process, similar to that which affects the soft palate, pharynx and larynx. Papules on the trachea have been described in a few cases by 70 THE MEDICAL ASPECTS Seidel and Mackenzie. But the lesions more frequently observed are gummata, not in the isolated nodules, but as a uniform infiltration. It gradually ulcerates, the cartilages remain exposed, necrosis takes place, and when detached, are expectorated in the form of small necrotic scales. In most cases the trachea is affected together with the larynx, and it seems that it is only the extension of the process ; but in a few cases gummatous infiltration of the trachea can be demonstrated independent of the larynx. Tracheal syphilis may have an easy termination, the infiltration may be absorbed, the ulcers cicatrized; but deformities of the trachea are often the consequence. If an entire ring has been destroyed, the trachea will appear shortened, but if only half of the ring has been destroyed, the trachea will be bent, and both deformities will be ac- companied with some narrowing of the lumen. Stenosis of the trachea may follow gummatous infiltration and ulcers independently of necrosis of its cartilages. The gummatous infiltration sometimes causes an evenly spread stenosis of the trachea from above downwards. Ulcers may cause uneven cicatricial tissue, running from one side to another, producing a kind of net-work in the trachea. In these cases when mucus remains there, some dyspnea is produced, which is only temporary. When ulcerations are present on the mucous membrane of the trachea, the muco-purulent secretion is always increased, and is accompanied by rales, cough, and sometimes pain behind the sternum. In consequence of tracheal syphilis the patients are exposed to a great danger resulting from possible perforations into the esophagus or into the large blood vessels, causing a fatal hemorrhage. Stenosis of the trachea is the result of gummatous infiltration and resulting ulcerations after their healing. They come slowly and are revealed by dyspnea, especially during the inspiration, and the voice loses some of its resonance. The lungs when affected by syphilis show gummatous nodules, which are rarely single, but usually multiple and on one side. The middle and lower lobes are more frequently affected, but the apex has also been found infiltrated with gummata. These are round, from the size of a pea to that of a walnut, and of a grayish red color. The surrounding pulmonary tissue is infiltrated on account of a chronic limited pleuropneumonia or bronchopneumonia, which is the result of the presence of the gumma. The inflammatory process produces either on the surface of the organ underneath the pleura, or around the small bronchi, firm callous foci of cicatricial nature, hard to the touch, consisting of sclerotic connective tissue. The hyperplasia of the connective tissues is plainly visible, start- CONSTITUTIONAL SYPHILIS yi ing either from the walls of the larger bronchi, or from the adventitia of the pulmonary vessels. In some cases it results in stenosis of the bronchial tubes, and in others in bronchiectatic cavities from cicatricial contraction. Pulmonary syphilis also affects the lungs in the form of a diffuse infiltration in one or in both. The pulmonary tissue, becomes firm, homogeneous, devoid of air, and of a yellowish red color. The process starts from the interstitial connective tissues and from the walls of the arteries and of the bronchi. This form is found mostly as a con- sequence of congenital syphilis. Another form attacks adults as catarrhal pneumonia in which an entire pulmonary lobe is found firm, of a pale reddish gray color, devoid of air, and at the cut shows a peculiar gelatinous appearance. In the symptoms we have no characteristics by which to decide whether a catarrhal form of the lungs is due to syphilis or not. The syphilitic symptoms present, together with a catarrhal condition of the lungs, of a stubborn and protracted course, will suggest the syphilitic origin of the pulmonary affection. We have had occasion to observe a few cases of pulmonary af- fections produced by syphilis. One occurred in an old gentleman who was suffering with a diffuse papular eruption eight months after the infection. He was taken ill with an acute pain in the right chest, dyspnea, cough and fever. This condition lasted for several weeks and, when the dyspneic condition was at its height, he expectorated a large quantity of pus, after which the symptoms gradually subsided and recovery was the result. Another case came under our observation four years after in- fection, and after undergoing very severe and persistent syphilitic symptoms. The pulmonary affection began with difficult respiration and a dry and obstinate cough, which was followed by enormous hemorrhages of the lungs. The condition of the lungs seemed more suggestive of a case of tuberculosis, but in the expectoration we could never find tubercle bacilli, and from the fact that the patient has recovered we have been inclined to maintain that the case was one of pulmonary gummata. The cases observed have been found in individuals who had suf- fered from syphilis for several years. The symptoms referred to are first difficult respiration, which reaches the point of a true dyspnea, when catarrh supervenes, followed by a cough, scanty expectoration and slight pain. This condition, which is worse in the evening and better in the morning, may last for some time. Gradually with the progress of the affection the respiratory movements of the thorax become impaired. The infiltration of the lungs is revealed on per- 72 THE MEDICAL ASPECTS cussion by a dull sound, weakened respiration, increased bronchial inspiration, and shortened expiration. The gummata undergo the destructive process and cavities are formed. Dyspnea, pain and cough increase, expectoration becomes abundant and purulent, and at times profuse bleeding is observed. The patient becomes weak, his appetite is lost, fever begins and a cachectic condition will finish the picture of the pulmonary phthisis. Children with congenital syphilis quickly succumb to pulmonary trouble. In adults, however, when they preserve their strength, there is the hope that with an antisyphilitic treatment they can be brought to recovery. The diagnosis between tuberculosis and syphilis of the lungs is sometimes difficult. It is necessary to remember that the syphilitic gumma affects the lungs in the middle, and the physical signs are found towards the angle of the scapula, and more frequently on the right than on the left side. The accompanying syphilitic symptoms, such as periostitis, and scars of subcutaneous gummata will be very valuable in enabling us to establish the differential diagnosis. Both diatheses may exist together, and in this case it is difficult to establish the differential diagnosis between a tuberculous and a syphilitic pul- monary affection. SYPHILIS OF THE HEART AND BLOOD VESSELS The same process which takes place in the skin may affect any other tissue and any other organ of the body, the only difference is the anatomical structure in which the syphilitic lesion takes place. It is not the cell of the bone, or the nervous cell, which is directly affected by syphilis; but from the blood vessels or from the lymphatics, as a consequence of an angioitis an accumulation of lymph cells is formed, which cuts off the supply of the nutrition to the cells of the tissues, and consequently they are affected with necrobiosis and die. In every gumma we find blood vessels affected in their tunics by an infiltrating process, and also lymph-vessels enlarged, obstructed and inflamed, showing that the formative process of the granulation has begun from them. The process, therefore, is always the same; the difference is in the tissues affected, and the way in which they react in the developing affection. Cases of affection of the heart in syphilis have been reported by Ricord, Lebert, Virchow, Wagner and others. Gummata are fre- quently found in all the muscular parts of the heart, in the walls of the ventricles, auricles, and septum and in -the papillary muscles. A syphilitic myocarditis, independent of gummata, produces Plate XT to CO — CO U 13 CONSTITUTIONAL SYPHILIS 73 fibrous cicatrices in its muscle with resulting partial aneurisms. Either gummatous or fibrous syphilitic myocarditis are associated with a sclerotic endocarditis, or with partial pericarditis. Endocarditis may attack the lining of the myocardium, or the valves near their insertion. In this case the valves are thickened or pushed aside by the developing gumma. Symptoms of insufficiency or of stenosis are the result of the deformity of the valve. The heart is affected by syphilis only at a late period, after it has existed for several years. In some cases the coronary arteries are affected by a sclerogum- mous arteritis, and in consequence the heart is affected with myo- malacia, and with callous formations of sclerotic connective tissues. In other cases the ganglia and the nerves of the heart, being involved in the sclerotic process, are the cause of different forms of angina pectoris. The course of the syphilis of the heart is usually latent. The disease lasts for a long time, until as a result of a violent effort or of an increase in the specific productions, a sudden change for the worse takes place. In most cases the patients die suddenly in consequence of paralysis of the heart, very rarely from the rupture of the muscle in the vicinity of the lesion. The symptoms, in general, are those of a chronic myocarditis, the patients complain of general weakness, palpitation of the heart, precordial pains; they often speak of a sensation of fear and oppres- sion in the chest and sometimes have dyspnea. Physical examination shows an increased cardiac dullness ; the heart sounds are in some cases normal, but are usually muffled and associated with a slight blowing murmur. The contraction of the heart is weak and unequal, with corresponding small and irregular pulse. The patient is pale and sometimes cyanotic, edema and dropsy develop and the urine con- tains albumen, but only rarely signs of insufficiency of the valves are present. The end of syphilis of the heart is usually fatal. Cases have been reported with a favorable termination after long and per- sistent antisyphilitic treatment. The syphilitic manifestations in the circulatory system have for a long time attracted the attention of pathologists as the part upon which the infectious influence of syphilis shows its deleterious action. The origin of the syphilitic lesions must be looked for in the vascular system, which forms a part in the intimate structure of nearly every organ and tissue. In the developed chancre the blood vessels already show the results of the attack of syphilis. Their alterations are no longer the result of a reaction, but the result of the infection in possession of the tissues. The nature of the lesions of the blood ves- 74 THE MEDICAL ASPECTS sels in syphilis is exactly the same that we find in the stages of its evolution, representing in the secondary period a hyperplastic inflam- matory process like a specific irritation, and another in the tertiary period in the form of a gummatous infiltration. After the classical works of Hiibner and Baumgarten on syphilis of the cerebral arteries, the question of the alteration of the blood vessels in syphilis has been entirely cleared up, and they justify us in maintaining that aneurisms are produced directly by syphilis. The process affecting the arteries is a true arteritis of a specific nature, which causes an infectious degeneration of the blood vessels. The specific inflammatory process affects the artery in its totality, its tunics are greatly enlarged by the infiltration between their cellular elements. It is scarcely possible to distinguish the adventitia from the surrounding tissues, as the infiltrating cells are accumulated with- out a line of demarcation. The muscular tunics seem to be smaller and compressed. The intima is thickened more than the other tunics ; it is woven with hyperplastic young cellular elements concentrically disposed, the endothelial lining is greatly increased, so that the lumen of the artery is much diminished, and has also changed its normal shape. In some transverse cuts it looks quadrangular, in others rhomboidal, and in those remaining round it looks like a tunnel. In some cases the intima is so thickened as not only to diminish the lumen of the blood vessels, but also to obliterate it. Many blood vessels are found plugged up with thrombi, such as we have found in the lymph vessels. In the secondary stage the in- flammation of the artery causes an edema and an infiltration of leucocytes in its limited district, which was called by Renaut 12 cone arterielle. The arteries composed of elastic and contractile layers depend on their own vasa vasorum for their nutrition, through the plasma supplied by them to the media. The internal layers and the epithelial lining of the intima, however, must take their nourishment either by the media, or by imbibition from the circulating blood, as happens in the capillaries, which are destitute of vasa vasorum. It seems that syphilitic virus affects the arteries in the beginning, through the lymph spaces, because we find arteries in the initial sclerosis, when no virus is circulating in the blood, but it is undeniable that in later manifestations it comes through the infected blood, affecting the intima. The irritating action of the virus upon the intima of the artery produces an exudation which spreads through the walls of the artery into the surrounding tissues, and with its agglutinating proper- 12 Renaut, J. " Sur la caracteristique anatomo-pathologique de la syphilis." Revue Pratique des maladies cutanees, etc. Janvier, 1903. CONSTITUTIONAL SYPHILIS 75 ties causes coagulation of the serum and formation of the thrombus. Virchow 13 demonstrated that the endothelial cells of the intima are susceptible of proliferation, and in certain circumstances are also sus- ceptible of neoformation. For the larger blood vessels, however, it is more plausible that the syphilitic inflammatory process starts from their own vasa vasorum, as we could demonstrate in the basilar and in the subclavian arteries. The arterial lesions are in great part to be held accountable for the syphilitic manifestations in every tissue, and in every organ of the system. If we stop to consider for a moment the skin, we will easily see that the affection of the arteries must be considered the factor of the eruptions, from the roseola to the superficial ulceration. Since the publication of the works of Hiibner, the purpura of the new-born has been referred to the syphilitic alterations of the blood vessels. In papular eruptions and mucous patches the influence of the endoarteritis is clearly shown by the circumscribed limits of the chronic infiltration of the derma and its fibro-formation, which is re- vealed by the elongation and hypertrophy of its papillae. In the same way in the ulcerative process, and also in the gangrenous superficial gumma, the endoarteritis is responsible for the resulting ulcerations. In some cases the arteries are so greatly changed as to show how deep the deleterious influence of syphilis is on the vascular system. The intima especially is so thickened with cellular elements and with endothelial proliferation as to cause the lumen to become nearly obliterated. The gummatous process affects the blood vessels as well as any other tissue, and it is really in the blood vessels that we find the best representation of the fatty degeneration of the gumma. We have had the opportunity to see gummatous infiltration in basilar, auriculo-temporal and popliteal arteries. The production of the aneurism is due to the pathological condi- tion of the artery directly induced by syphilis. Lancereaux has already described an aneurism of the subclavian artery, which improved under the administration of the potassium iodide. G. W. M. McNalty 14 observed in a soldier thirty-five years old an aneurism of the aorta which had made its appearance five years after the infection. He claimed that it was benefited by potassium iodide. The patient, how- ever, died and the post-mortem revealed numerous gummata in the heart and in the endocardium, with thickening of the aortic valves. The innominate artery and a portion of the arch of the aorta were converted into aneurisms. 13 Virchow, R. " Ueber die acute Entziindungen der Arterien." Archiv. fur Path. Anat. und Phys. B.I. p. 274. 14 McNalty. Quoted by Lang, 1. c, p. 148. 76 THE MEDICAL ASPECTS Langebeck demonstrated in four cases of aneurism of the aortic arch, and in many other cases of aneurisms of the aorta, that the patient had suffered from syphilis. In a colored man who was treated in the Cincinnati Hospital for an enormous aneurism of the popliteal artery, we have found exostoses in both tibiae, an unmistakable sign of an old syphilis. The infection in that case had taken place nearly eleven years before the aneurism appeared. Cases of popliteal aneur- isms in syphilitic persons have been reported by James O'Grady, Hey- berg and others, as a result of syphilitic arteritis. According to our observations the principal cause of the rupture of the arteries causing aneurism is due to the sclerotic condition of the media. The media is, like the other tunics, infiltrated at first, its delicate muscular struc- ture compressed by the cellular infiltration becomes atrophic, inelastic, and therefore the pressure of the blood easily breaks its fibers, causing the aneurismatic sac. In many other cases, however, the syphilitic arteries are subject to an infiltration and hypertrophy of all the tunics so as to constrict the lumen of the artery and cut off or diminish the supply of the blood to the peripheral parts. We are indebted to the kindness of Dr. Greiwe, director of the Pathological Laboratory of the City Hospital, for the use of a specimen of the basilar artery affected with syphilitic arteritis at its point of division. It was enlarged in the form of a small olive, whitish outside, hard and solid to the touch. In the section, the artery was nearly closed, showing the lumen to be about the size of a pinhole with thick and infiltrated walls. The whole alteration consisted of a gum- matous tumor which had taken up the entire wall of the artery. To the microscopical examination the gumma of the basilar artery showed the infiltration mostly in the adventitia and intima, with a few fatty degenerated elements in a yellow mass, contained in a fibrous fundamental substance. The adventitia is thickened with an enormous infiltration, and also with proliferation of the corpuscles ■of the connective tissues, which contain the round emigrated cells. Few scanty foci of fatty degeneration are present, scattered through the external tunic. The media is also infiltrated, but is so compressed and crowded that it is smaller and looks nearly atrophic. In the intima the elastic layer is greatly enlarged. Elastic fibers appear between the hyperplastic tissues and between them a thick infiltration of small cells with granular necrotic centers and with some giant cells in their midst. It is a true gummous arteritis, which has been regarded by Baumgarten as a form of syphilitic arteritis, histologically specific. In our specimens we could demonstrate that the gummous infiltration CONSTITUTIONAL SYPHILIS 77 does not spare any layer, the adventitia and the intima being more frequently affected. In the retrogressive process of the gummatous infiltration, sclerosis takes place, which leads to cicatricial changes of the arterial walls. In the affected blood vessels it is easy to distinguish a gummous periangioitis, and a productive endoangioitis. The periarteritis is very likely the result of an infiltration, which arises from the lymph- spaces surrounding the vessel, and causes the enlargement and the thickening of the external wall, while the endoangioitis is marked by an infiltration of the elastic elements, and a production of large endothelial cells, with a tendency to restrict and diminish the lumen of the vessels. In consequence of some exudation from the intima, in many small vessels and also in vessels of medium caliber, the blood is coagulated, forming a thrombus which sometimes entirely closes the lumen of the vessel, at other times only partially. This condition of the blood vessels explains the hemorrhagic af- fections in hereditary syphilis and the effusion of the coloring matter of the blood in all syphilitic lesions, which, although in the secondary period, leave a pigmentation lasting for a long time. The vasa vasorum of the affected arteries show the same process of peri- and endoangioitis as we have found in the other tissues. In hereditary syphilis the blood vessels likewise show alterations. At the place of ramification of the placenta Hennig 15 found extravasated blood, calcification, edema, infiltration, in a word a true gummatous product, which he carefully described as masses surrounding the arteries of the placenta. Infiltrations have been found by Zilles around the umbilical veins, and also around the blood vessels of the chorion in luetic subjects. The same pathological alterations of the blood vessels are found present in new growths proceeding from syphilitic lesions. In a carcinomatous" production growing out of a syphilitic ulcer of the inferior maxillary bone, we have found the blood vessels infiltrated, and affected in the same way as in the ulcerated syphilitic patches on which it was implanted. The condition of the blood vessels in these growths positively shows the characteristic luetic angioitis, which recalls the fact that the cancerous stroma is implanted on syphilitic ground. The veins are not spared by the same inflammatory process. Small veins under the microscope appear in the same condition as the arteries, their walls show an infiltration of cells, the connective tissues are enlarged, the shape of the vein is elongated, and in many instances they are obstructed with thrombi. 15 Hennig, K. " Beitrage znr Anatomie, Physiologie und Pathologie der Placenta." Leipzig, 1873. 78 THE MEDICAL ASPECTS Mracek 16 found the same alterations in small and medium sized veins in cases of purpura in children affected by hereditary syphilis, so that he has attributed this affection to the alterations of the veins. Proksch 17 has given the most elaborate and complete history of the syphilitic affections of the veins, collecting a large number of cases from all authors who have written on this subject. The pathological alterations in the veins in consequence of syph- ilis consist in an irritative, hyperplastic, inflammatory process, and in a gummatous infiltration at a late period. The veins like the arteries in all their ramifications from the smallest to the largest are liable to undergo the same pathological alterations. Edwin Klebs 18 described an annular induration affecting the lumen of the vena porta produced by a gumma seated in the vicinity of the vena cava. Cases of syphilitic phlebitis of the vena saphena interna have been reported by Girdwood, Greenhow, Gayrand, Lang, Breda, Charvot, Mauriac, Cautra, Gosselin, Mendel and Thibierge, in many cases under the knee, and in a few cases above. Cases of phlebitis of the saphena externa have been reported by Gosselin, Hutchinson and Dittrich. Karl Huber found thrombosis of the same vein and Langebeck referred to a case of gumma and thrombosis of the femoralis, which reached the iliac externa. In the City Hospital we have had occasion to treat cases of syphilitic phlebitis of the saphena externa affecting the whole region of the leg under the knee, which gradually subsided under the use of mercurial ointment. In another case we found phlebitis and peri- phlebitis of the vena femoralis, which was surrounded by an enormous gummatous infiltration. The syphilitic lesions of the veins like those of the arteries are of different natures according to the stage of syphilis. In the early stage the inflammatory form is that of a syphilitic phlebitis, while in the late period it has a gummatous nature. The lesions sometimes involve the intima, sometimes the media ; but they more frequently start from the adventitia. The point from which the infiltration starts seems to be that of the vasa vasorum. The connective tissues surrounding the veins in some instances are involved in the inflam- matory process and in these cases we find periphlebitis. Syphilitic affections of the cerebral veins have been described by Birch-Hirschfeld, to be of the same character as those described by Hiibner in the syphilitic arteries of the brain. 16 Mracek, F. " Syphilis hemorrhagica neonatorum." Arch. f> Derm, und Syphilis. Wien, 1887. XIX, p. 117. 17 Proksch, I. K. " Ueber venen-syphilis." Bonn, 1898. 18 Klebs, Edwin. " Handbuch der pathologischen Anatomie," 1. 1st Abh., p. 447- CONSTITUTIONAL SYPHILIS 79 Syphilitic alterations of the ramifications of the vena porta in the parenchyma of the liver have been described by Rokitansky, Dit- trich and Virchow; and Arnold Beer, in 1867, showed that the hyper- plastic interstitial inflammation of the ramifications of the vena porta are the cause of the syphilitic alterations of the liver. It is scarcely necessary to say that the symptoms connected with the syphilitic affections of the blood vessels are different according to the location and extent of the disease, the size of the affected ves- sels, and to the importance of the organ whose circulatory region is the place of the affection. The blood vessels lose their elasticity and become greatly thickened. Their lumen in some cases is enlarged, but is usually narrowed and in some cases obliterated, being unable to perform their functions of the nutrition of the tissues in the normal way. The thickening and the infiltration of the vessel tunics, and also the disposition to the formation of the thromboses, makes the blood vessels liable to break, producing capillary hemorrhages with arrest or, at least, an impairment of the nutrition of the tissues. The blood vessels, thickened and narrowed with gummatous production, and also obstructed by thrombi, prevent the circulation of the blood in the different organs and tissues, with resulting necrobiosis. The blood vessels affected in their stroma and in the arrangement of their tunics by the syphilitic virus may be recognized as the cause of serious dystrophies and malformations in the developing embryo. As a result of the diseased condition of the umbilical and placental vessels the fetus dies in utero. Foci of softening of the brain, ulcers of the skin, etc., are the result of prevented circulation of the blood through occlusion of the blood vessels. Hemorrhages are often caused by the rupturing of the blood vessels as the result of the syphilitic inflammatory process of their tunics. SYPHILIS OF THE LIVER, SPLEEN AND KIDNEYS Proceeding in the consideration of the organs as they are affected by syphilis we find that the spleen is frequently the seat of syphilitic manifestations. It is subject to those alterations revealed in the nutri- tion of the organs and tissues, called amyloid degeneration, which is found with marasmus and syphilitic cachexia. Virchow distin- guished two forms, a flaccid and an indurated one, the latter being more like the amyloid form. The gummata of the spleen are rare. Haslund had occasion to have post-mortems done in forty-four cases of adults who had died of acquired syphilis in the Commune Hospital in Copenhagen. He found that twenty-seven presented hyperplasia of the spleen, and three amyloid degeneration, but none showed gummata of this organ. 80 THE MEDICAL ASPECTS Moskuleff 19 reported cases of pseudoleukemia produced directly by syphilis. He found in a woman affected with secondary lues the spleen enlarged, with a swollen condition of the lymph glands, and consequent leukocytosis. All symptoms disappeared after a strong mercurial treatment. Lang, in his clinic, has had the spleen examined in all syphilitic cases. In thirty cases of recent syphilis the spleen was found to be enlarged eight times its original size, it being necessary to note the fact that in four cases the patients had suffered previously with malaria. In one case he found a diminution in the size of the enlarged spleen, when the syphilitic symptoms began to diminish in intensity. In advanced syphilis, involvement of the spleen may be frequently seen. The liver, the spleen, and more rarely the pancreas are affected with syphilis, in the form either of a diffused chronic irritative inflam- mation or in the form of circumscribed gummatous nodules, with disastrous results to the functions of the organs and to the life of the patient. Syphilis as an infectious disease affects the kidneys in the same way that it affects the whole body, showing at times its bacterial action, at other times its bacteriotoxic influence. Nephritis occurs in different forms which can be grouped as acute nephritis, chronic diffused nephritis, chronic indurated nephritis, and as gummata of the kidney. From the records of la Charite, Spiess collected 220 cases of post-mortems done in subjects who had died from syphilis. In 147 cases affections of the kidneys were present ; among them 42 cases were found with amyloid degeneration, and 7 affected with gummata. Thirty-four cases were of congenital syphilis, of which 10 showed kidney disease, and 3 amyloid degeneration, gummata not being found. E. Wagner, from the records of 63 cases of affected kidneys found in the post-mortems of syphilitic subjects, reported 3 cases of gummata, 35 of amyloid degeneration; and of the other cases, 8 with acute and 4 with chronic nephritis, 7 of granular kidney, and 6 with unilateral atrophy of that organ. H. v. Bamberger tried to establish the relation of Bright's disease to the other diseases, and in 1623 post-mortems he was able to determine in 49 cases syphilis as an etiological factor. Indeed, the characteristic product of syphilis is the gumma, and the other condi- tions of nephritis are common to any other nephritis caused by en- tirely different morbid agents. As a result it is difficult to say whether nephritis is accidentally accompanied by lues, or whether it is caused 19 Moskuleff. Journ. fur haut und ven. Krank. Heft 4, 1902. Ref. in Dermatolog. Zeitschr. B. X., Heft 1, 1903. CONSTITUTIONAL SYPHILIS 8l by lues. In the same way the amyloid kidney, although found in syphilitic cachexia, occurs in consequence of tuberculosis, of tuber- cular affections of the bones, protracted suppurations from caries, etc. Of course nephritis from syphilis does not vary in its symptoms from nephritis arising from other infections ; but the presence of constitutional syphilis will show the syphilitic origin of the affection of the kidneys. It was believed that nephritis occurred only at a late period of syphilis, but it has been found with the earlier symptoms. E. Wagner referred to a case of acute Bright's disease, which appeared only six weeks after the infection and disappeared with the other symptoms after specific treatment. Indeed, there are luetic albuminurias which are only the first degree of a mild true nephritis, which can be considered either as the result of an attack of the bacteria, or as a parenchymatous degenera- tion of the epithelium from the syphilitic toxins, which produce morbid alterations in the secreting elements of the kidneys. Karvonen 20 has tabulated a large number of cases of nephritis from syphilis at all stages of the disease, showing that the kidney is affected quite often during its course, and is influenced by the anti- syphilitic treatment. One-third of the cases of acute nephritis have developed quite early, two months after the appearance of the initial lesion, some three months ; but after one year acute nephritis is only a rarity. This shows that nephritis cannot be the consequence of mercurial treatment which may act as an irritant substance affecting the epithelium of the segregating organs of the kidney, when in the first appearance of syphilis the patients had not yet been subjected to any treatment. But it is also possible that other causes favor the noxious influence of syphilis on the kidney, such as the abuse of intoxicants, the use of so-called antigonorrheal remedies, balsams, etc., which cause irritation of the kidneys. The pathological altera- tions which have been found in the acute syphilitic nephritis show that it may appear as parenchymatous, or as interstitial, but it oftener begins as interstitial nephritis. The symptoms of the acute luetic . neohritis are not different from those accompanying an ordinary /< nephritis and they especially resemble nephritis after scarlatina. It comes gradually, and as Fournier has remarked, it begins with a mild albuminuria, the patient maintaining his general condition unaltered. There is also another form which begins with stormy symptoms, enormous albuminuria, edema, etc., which is the result of a typical degenerative inflammatory nephritis. 20 Karvonen, J. J. "Die nieren Syphilis." Dermatologische Zeitschrift. Berlin, 1900, p. 55. 82 THE MEDICAL ASPECTS In the first of the interstitial type, the urine contains only a small quantity of albumen, with many leucocytes, a few hyaline and granular cylinders, and also, once in a while, a few red blood corpuscles. In cases where the interstitial alterations have gone very far on account of the compression of the canaliculi, and of the edema of the kidney, we find clear, scanty urine, with little albumin, few hyaline and granu- lar casts, many leucocytes and no epithelium. The glomerulonephritis, which is of a much more toxic nature, has symptoms altogether like those of any other parenchymatous nephritis. In these cases the patients are very pale and tired, often complain of a chill, which is not followed by fever, and pain in the renal region, which is increased by the slightest pressure. The urine is very scant, sometimes there is anuria. It has a high specific gravity, is turbid, sometimes contains blood, and always large quantities of albumin. It contains cylinders of all kinds, mostly epithelial, renal epithelium, red and white blood corpuscles and urates. The patient early shows some edema of the face, especially of the eyelids, and soon after some edema of the feet, which spreads to the whole body, invading the serous cavities also. Other organs will enter in as complications, so we may see nausea, vomiting, diarrhea, or bron- chitis and pleuritis, or nervous symptoms in the form of nervous headaches, or a true uremic condition. On account of the weakness of the heart or other complications the patient is liable to die. Yet in most cases, under a well-directed treatment, the symptoms subside and the patient may recover. Relapses of acute nephritis may occur, just as an acute form may terminate in chronic nephritis. In the chonic diffused nephritis, on account of the obscurity of their etiological moments, it is not so easy to recognize the syphilitic origin, because the symptoms have nothing characteristic, and the diagnosis will be based solely either on the history of syphilis or on the accompanying syphilitic symptoms. Not even is the microscopic examination capable of revealing syphilitic chronic nephritis, because the alterations of arterio-sclerosis and of amyloid degenerations are the same as those found in subacute mercurial nephritis, revealed by necrosis and calcification of the epithelium, glomerulitis with edema, and infiltration between the canaliculi. In the same way we must also take under consideration a certain degree of alcoholism, which is quite often the cause of chronic nephritis. We can, therefore, state that a chronic diffused nephritis has no characteristic point to be referred to syphilis, such as we see in an acute nephritis, on account of the multiplicity of causes and of the slight difference between them. In most cases, it seems that the gen- eral specific treatment, especially in the first year, had been greatly CONSTITUTIONAL SYPHILIS 83 neglected. Nearly all the cases had shown symptoms of a tertiary nature in the skin, bones, periosteum, nervous system, etc. Its ap- pearance at a late date, its tendency to attack the whole organ, its alterations of a degenerative nature, point it out as being syphilitic nephritis of a toxic origin. As a consequence, characteristic symptoms of syphilitic nephritis do not exist, and under the circumstances we must follow the advice of Gubler. When a patient shows all the symptoms of a nephritis, either acute or chronic, and the etiology is doubtful, it is necessary to think of the possibility of syphilis and begin a specific treatment. If the patient shows signs of syphilis on the skin or in other organs, this will confirm the diagnosis of syphilitic nephritis. We must not forget, however, that an old syphilitic is also liable, independently of syphilis, to get an ordinary nephritis from any other cause. The yielding of the disease to the specific treatment will be, in these cases, a good argument in favor of a syphilitic affection. The kidney is also the seat of the gummata. Virchow had found in the kidneys partial, circumscribed cicatrices, which he regarded as the result of the reabsorption of a syphiloma, but a true gumma he did not find. Lancereaux found the syphiloma of the kidney which he described in his " Traite de la Syphilis." Gummata of the kidneys is a very rare occurrence, unless the partial cicatrical condition sometimes found in the kidney is considered as the result of gummata. They appear in the kidney in the form of round tumors, from the size of a lentil to that of a cherry. In some cases they are superficial in the cortical portion, sometimes they are also deep in the substance of the organ. They look like nodules or partial elevations, pale in color, and the kidney is considerably enlarged. They undergo the changes which we have already men- tioned for the contents of the gumma, while the edges become hard and fibrous. At times the gumma may be in the form of a diffused infiltration, which causes the tissues to fall into a necrotic condition. The symptoms of a gummatous nephritis are different according to the stage of the gumma, and the albuminuria and the presence of casts is not constant. It may be that if the gumma affects only one kidney, its function is entirely impaired, while the other kidney con- tinues to segregate normal urine. A localized tenderness in one of the kidneys may suggest the idea of the presence of a unilateral gummatous nephritis, especially if this is accompanied by a variable quantity of albumen and different casts. Syphilitic affections of the kidneys in the form of acute nephritis in the beginning- of the constitutional syphilis, runs, as a rule, a favorable course. In severe cases also, when the diagnosis has been 84 THE MEDICAL ASPECTS established early and an antisyphilitic treatment has been started, a favorable change may be expected. Even in the gummata of the kidney a favorable prognosis may be advanced, for the reason that, in these cases, a large part of the parenchyma of the kidney is left untouched, and this part continues to perform its function. If the affection is limited to one of the kidneys, the outcome is still more favorable, because the healthy one will compensate the loss of function in the other. Syphilis has been pointed out by v. Frerichs as one of the principal causes producing diabetes, very likely on account of the luetic alterations occurring in the brain, meninges and medulla ob- longata. Other clinicians, however, reject this opinion and maintain the view that if diabetes has been found in a syphilitic, it has only been a mere coincidence. Another cause capable of inducing glyco- suria and polyuria is the use of mercurials, some of which have a decided diuretic action, increasing the quantity of the urine. SYPHILIS OF THE MALE GENITO-URINARY ORGANS In our brief examination of the urinary organs affected by syphilis, we find the urethra also deserves special consideration. The occurrence of the initial lesion in the urethra has been already mentioned. It usually affects the meatus, and the fossa navicularis, but in the deeper portions of the urethra it is a rarity. In the secondary period Lang relates that he found through endoscopic examinations, red patches in the mucous membrane of the urethra, somewhat swollen, at times. with erosion, coincident with a papular eruption of the whole body. Later forms of syphilis are more frequently found. In our practice we have found an ulcer in the urethra, extending from the meatus down to the pars pendula, with a thick infiltration, which had been treated with every kind of remedy except the antisyphilitic. This yielded very easily to the general and local specific treatment. Proksch described ulcerations of the bladder, and Virchow found an ulcer in the bladder of an old syphilitic woman. Syphilitic gummata of the urethra have often been found and in our hospital practice, especially amongst colored people, we have seen gumma of the fossa navicularis, which has broken down and produced urethral fistula in that region. As a con- sequence of gumma of the corpora cavernosa, deformities of the penis have resulted. In a case resulting from an ulcerated gumma of the urethra the patient suffered a heavy hemorrhage, for which he was taken to the hospital. In the article concerning the modes of infection we have alreadv spoken of the frequency with which the initial lesion affects the penis in its different parts. In the same way we have pointed out the CONSTITUTIONAL SYPHILIS 85 different roseolar and papular eruptions showing in the penis as on the other parts of the body. Mucous patches often make their ap- pearance between the sulco balano preputiale in all their different forms. Late syphilitic lesions in the form of gummata are quite frequently met with on the penis. Small indolent gummata from the size of a lentil to that of a bean are found in the glans and also in the corpora cavernosa. We have quite frequently seen small gummata on the glans, which had broken down and produced an ulcer, giving to the patient the idea of a new chancre. Gummata of the corpora cavernosa are more rarely found ; sometimes they may undergo reabsorption and disappear, leaving a hard callosity at its place, but it can also break down, cause ulceration and perforate the urethra. We have not infrequently found g-angrene of the penis as the result of an infiltrated gumma. In one case it produced the spon- taneous amputation of the glans, leaving the urethra sticking out. In the hospital service we have had occasion to see several cases of gangrene coming at once without any traumatic cause, with acute pain in the whole penis, redness, swelling and edema extending to the pubis, together with phimosis. When we have opened the prepuce we have found the glans black and affected with humid gangrene. The death of the affected tissues stopped towards the sulcus balano preputiale, sloughed out in a week or so and then the process of reparation began. All our patients had suffered syphilis at a late stage, and the gangrene of the penis was the result of a gangrenous gumma. It is scarcely necessary to mention that the penis has re- mained mutilated, and deformities have been the result. Syphilis, especially at a late period, frequently affects the testicle. The syphilitic affection may be limited to the epididymus, to the testicle, to the vaginalis, or may affect the whole apparatus in the form of a simple inflammatory process. It is also found to invade the testicle in a gummatous form. Drou 21 of Lyons called attention to the presence of epididymitis in secondary syphilis, which was after a while confirmed by Tanturri and Fournier. The affection makes its appearance at the secondary stage in the form of an indurated point at the head of the epididymus, of the size of a bean or a hazelnut ; in some cases it is indolent, though usually it is accompanied by acute pain and tenderness. The inflammation spreads to the neighboring structures of the testicle and cord, which are involved together with the epididymus. The tunica vaginalis is also involved, and Jullien 22 referred to a case where there was an 21 Drou. Arch, de Med., 6 ser, tome II, 1863. 22 Tullien. " Malad. veneriennes." Paris, 1886. 86 THE MEDICAL ASPECTS abundant hydrocele. Keyes has found six and Fuller 23 two cases, in which an extensive induration of the epididymus and of the testis was accompanied by considerable hydrocele. Oelsnitz 24 and Ozenne 25 have published articles on syphilitic pachyvaginalitis and from the fact that in the serum there has been found some blood, Ozenne has called it hemorrhagic pachyvaginal- itis of syphilitic origin. In our practice not rarely have we met with cases of this kind. We remember a young man who had suffered a rather severe case of syphilis for over two years, who began to com- plain of a swollen testicle, which had gradually reached an enormous size. It was uneven, the epididymus could not be distinguished from the testis. It was a uniform mass, elongated in the shape of a sausage, extending to the spermatic cord. On account of the undulating sen- sation produced by the serum, it was tapped, but only a small quantity of brownish bloody serum came out. Under a regular mixed treat- ment the enlargement of the testis gradually diminished and returned to its normal limits. In simple orchitis, a chronic indurating infiltration arises from the albuginea, sometimes from the septa and from the connective tissues which surround the seminal ducts. It affects larger or smaller por- tions of the testicle ; causing at first an enlargement, and later a con- traction of the organ. When the process is equally diffused, the surface of the testicle is smooth, but it usually is limited to different parts forming nodules, which later are converted into depressions. According to the seat of the infiltration, either in the albuginea or in the interior of the testis, we speak of orchitis or periorchitis. The tunica vaginalis is also thickened and contains exudation. Gum- matous products are also combined with orchitis, and in the con- necting tissues infiltrating nodules are found, which may undergo reabsorption, or are found calcified or in cheesy degeneration. Clinically the syphilitic orchitis, especially if it comes a few months after the infection, may be bilateral ; it is accompanied by little pain and the swelling is diffused over the testicles together with the epididymus. Usually syphilitic orchitis is a late manifestation of syphilis ; the enlargement of the testicle takes place slowly, being accompanied by a slight pain and a sense of weight in the scrotum. The surface of the testicle is uneven, for the reason that the affection results from nodules disseminated in the substance of the gland. Sometimes, when the vaginalis propria is involved, there is some 23 " A System of Genito-Urin. Diseases." Edited bv Prince A. Morrow, 1893. 24 0elnitz, A. "These de Paris." 1886. 25 Ozenne. Gas. Hcbdom. dc Med. 1882, 2 ser. xxv. CONSTITUTIONAL SYPHILIS 87 effusion, and when the affection is near the epididymus, this also is involved in the process. , Gumma of the testicle but rarely suppurates ; it is usually reab- sorbed, producing sclerosis and contraction of the affected tissues. In consequence, the segregating part of the gland rarely escapes de- struction, causing diminution of the spermatic secretion, or even total aspermia, with a lack of desire for sexual relation or total impotence. After many months the testicle gradually diminishes in size, its shape is usually preserved, remaining sometimes smooth, at other times uneven with depressions. In some cases it is reduced to a shapeless rudiment of the testicle. The general condition of the patient is not involved with the affection of the testicle, on account of its indolent course, but it usually produces a great depression of mind when it is known that the organ of generation has been attacked. We have seen patients affected with syphilitic orchitis who complained of obstinate insomnia, caused by the gloomy thought of remaining impotent. In rare cases the gummatous infiltration of the testicle forms a tumor involving all the coverings of the testicle, comprehending the skin, which softens and will perforate. In this case the gumma grows exuberantly in the form of a granular mass, which has been named fungus testiculi syphiliticus. It is usually accompanied, in the begin- ning, by a pain, which gradually subsides. It takes on the appear- ance of a fleshy tumor sticking out of the skin, narrowed at its base, red and cyanotic, exuding pus and covered with necrotic detritus. The fungus of the testicle lasts for some time, gradually becoming smaller, partly by absorption, mostly by sloughing of the necrotic parts. This process takes a long time. The prolonged suppuration and resulting fever greatly weaken the patient, and the cicatrization follows accord- ing to the treatment. Syphilitic affections of the testicle, when making their appearance at a late period of syphilis, are usually accompanied by gummatous lesions in other parts of the body. In our practice we have, at present, a patient affected with syphilitic orchitis of the left side, who has at the same time a periosteal gumma of the internal malleolar region. In other cases deep syphilitic lesions have already healed up and the presence of the scars will be a valuable help for establishing the diagnosis of syphilitic orchitis. There are, however, cases of syphilitic orchitis which make their appearance without deep lesions having taken place, and when the enlargement of the glands had somewhat subsided. In these cases some doubt may arise as to the nature of the affection. No difficulty may be found in diagnosticating between a gonor- 88 THE MEDICAL ASPECTS rheal affection and a syphilitic orchitis. In the first the symptoms are of an acute inflammatory nature, affecting mainly the epididymis, with swelling accompanied by an excessive pain and with some exudation in the vaginalis. The spermatic cord is also involved, and the scrotum on the affected side appears red, tender and swollen. There will be found some discharge from the urethra, or the patient will admit that it was present for a time and that it ceased at the time of the inflam- matory attack. In syphilitic orchitis the affection makes its appearance without pain, being indicated only by the swelling of the testicle, pro- ducing only a sense of weight. The epididymus cannot be distinguished from the testicle, as it forms a mass which is uneven to the touch on account of the nodules which are formed on the testicle. There may be some difficulty in cases of tuberculosis, which often affects the epididymus. It affects this organ in several foci of infiltra- tion, independently of each other, from the size of a split-pea to that of a walnut, firm to the touch, but becoming soft in a few weeks. The skin is bluish red in color, forming small prominences which break down and give issue to a quantity of pus. It leaves a fistula, which leads through a tortuous path to the place of infiltration. From the fistula a thin pus exudes, which may sometimes contain tubercle bacilli. It heals up now and then and in a short time opens again, discharging the accumulated pus. The process is accompanied by fever, especially in the evening, and the patient becomes weak on account of the continuous suppuration. The tubercular foci affect the testicle also and in this case the condition of the patient is still worse. The individual foci on the testicle are not easily found, unless the skin has been ulcerated, and the perforation taken place. The skin of the scrotum is tense over an enlarged testicle and studded with ulcers covered with necrotic shreds of tissues or showing red, " proud," granulations. In the testicle can be found soft points corresponding with the suppurating foci. Tuberculosis of the testicle is usually accompanied by other symptoms of tuberculosis, especially of the lungs. There will be no difficulty in differentiating a syphilitic orchitis from a tubercular testis when we take under consideration the seat of the affection, which is the epididymis in tuberculosis, the purulent disintegration of the infiltrated foci, and the possible presence of the tubercle bacilli. Syphilitic affections "of the vas deferens have been reported by Zeissl in the form of a suppurating infiltration of the organ, and by Bert in the form of nodules. Very few observations have been made in reference to the seminal vesicles and to the prostatic gland. There is no doubt that the semen is affected by syphilitic virus, and the fact of the transmission of syphilis to the offspring is a valid CONSTITUTIONAL SYPHILIS 89 proof that the poisonous germs are carried in the semen. It seems that the syphilitic germ directly affects the spermatozoa, which entering into the ovum, infect it at the time of fecundation. This is the paternal heredity, which appears clearly in the cases where a mother free from syphilis gives birth to a syphilitic child, and receives the infection from her syphilitic babe. The infectious qualities of syphilis are preserved in the semen much longer than in the other fluids of the organism, so that, when syphilis has ceased to be transmittible by the ordinary ways, the semen still maintains the property of infecting the offspring, and through it, of communicating the disease to the mother. The testicles are often the seat of syphilitic affections. Severe forms are, however, found only at a late period. Impairment of their functions and destruction of the organs occur, with resulting impotence, at the late stage of lues. SYPHILIS OF THE FEMALE GENITO-URINARY ORGANS From their anatomical structure it can be seen how easily they can be inoculated with syphilitic virus, and present the initial lesion in almost any part from the labia majora to the cervix of the womb. If local infection from the semen be admitted, then we should assume the possibility of an initial lesion in the cavity of the uterus and in the tubes. The external genitals of the woman are favorite places for the eruption of mucous patches, which appear on the labia majora and minora, on the ostium vaginae, and are the most dangerous lesions for the transmission of syphilis. Papules in the vagina are of rare occur- rence and are more often found on the cervix. Virchow spoke of a papular endometritis which he observed in the post-mortem of corpses of individuals who had suffered with severe syphilis. Gummata on the external genitals of the woman are frequently found, usually in an ulcerated condition, but rarely on the organs of generation. In fact, we have so far no report of gummata of the body of the uterus. Bouchard and Lepine have each reported a case of three gummatous nodules of the size of a hazel-nut, in the tubes of a woman who had gummata of the brain and of the liver. The ovaries are subject to syphilitic affections in the form of diffused or gummatous oophoritis. Diffused oophoritis has been recog- nized in the bodies of women who had not yet reached the menopause, and was recognized by the shrunken condition of these organs, which had become fibrous, showing cicatricial points, without the follicles of Graaf. 90 THE MEDICAL ASPECTS It is not necessary to state that syphilitic affections of the uterus, tubes and ovaries have a great influence upon the development of the fetus, which usually dies in utero. In the same way cicatricial points in the substance of the uterus may at the time of delivery produce some difficulties during labor. SYPHILITIC AFFECTIONS OF THE BONES AND JOINTS The bones are especially subject to syphilitic lesions of a gum- matous nature ; in fact, gummata were first recognized and studied in the bones and in the periosteum. The alterations of the bones conse- quent to the syphilitic affections are of a deep character, and they usually remain through life, to witness the existence of syphilis. Furthermore, syphilis produces anemia and induces a lymphoid change in the marrow of the bone. The prolonged suppuration of the bone seems to be one of the most effective causes in syphilis, as well as in tuberculosis, in produc- ing amyloid degeneration of important organs. In the course of syphilis, affections of the periosteum occur quite frequently in the form of a simple irritative periostitis, and later on they may be associated with gummatous infiltration. Simple periostitis is the result of an hyperemia with increased vascularity, which, lasting some time, causes alterations of nutrition in the connective tissue fibers, revealed by swelling and tenderness. The periosteum is thickened sometimes in circumscribed areas, at other times on a diffused surface. An infiltration is formed between the bone and the periosteum, which, loose at first, remains later on inti- mately attached, and after undergoing involution is ossified, molding itself exactly on the bone, and so there remains that peculiar roughness of the bones, especially of the tibia, which will last all the life long to witness to the existence of an old syphilis. In other cases the accumulated infiltration is much circumscribed and forms a growth of osteophytic formation, which has been described by Fallopius under the name of tophi. Under an appropriate treat- ment they may disappear if the absorption begins before the ossifica- tion of the periosteal product. In some cases when the individual is badly nourished or affected with tuberculosis, the infiltration may undergo disintegration and end in suppuration, which may cause caries and necrosis of the superficial layer of the bone. We find this affection in the form of an elastic, soft periosteal swelling, arising from the inner surface of the periosteum, involving at the same time the bone. It causes a depression on the bone corre- sponding to the gummatous swelling, but at the base and the periphery of the gumma it shows a certain degree of hyperostosis. CONSTITUTIONAL SYPHILIS 91 When the gumma undergoes fatty degeneration it is reabsorbed, leaving* a limited depression on the bone, the result of the loss of sub- stance. The edges, however, will remain hard and prominent on account of the new bony formation. The periosteal gumma may be- come liquefied and cause caries and necrosis of the bone. In this case the contents find their way under the skin, which is inflamed, forms an abscess, and breaking down, gives issue to purulent and cheesy matter, sometimes leaving sinuses in connection with the dis- eased bone. In the same way as we have done for the periosteum we must distinguish for the bone a simple .irritative osteitis and osteomyelitis, and a gummatous osteitis and osteomyelitis, where we find the infiltrat- ing character of the gummatous process. Specific osteitis is not different from a non-specific ; it shows at first as a rarefying osteitis, and then when the reabsorption takes place it becomes a formative osteitis. The disease begins in the soft tissues around the blood vessels, causing an enlargement of the Haversian canals, and consequently the erosion of the superficial layer of the bone ending in partial necrosis. The cells contained in the Haversian canals in the diseased bone take on a certain degree of development, as in the embryonal stage, and as a result of their pressure on the tissue of the bone produce absorption of the osseous tissue. The lamellae of the bone are eroded and the bone corpuscles open and the cells con- tained therein are set free, and, in this way, they may join the em- bryonary cells in the medullary spaces. It seems that from the en- largement of the bone corpuscles, a solution of area of the osseous substance is produced, with the final result of their fatty degeneration and absorption. This process of rarefying osteitis is usually limited, but sometimes may affect the whole surface of a flat bone. So long as the irritation continues, there is no attempt to repair, the tissues are more and more eroded, and the detritus is carried away in the purulent secretion, or remains as a dead product in the form of a sequestrum surrounded by granulation tissue. In consequence of treatment, when the discharge is free and the irritation has ceased, the bone begins to repair through a formative osteitis. In this process a new bone is produced either beneath the periosteum, or in the substance of the bone, or in the medullary canal. The deposits of new bone on the surface are called osteophytes when small, or nodes and exostoses when larger, and when affecting the whole length of the bone, hyperostosis. When the new bone is found in the medullary canal it is termed enostosis. The new bone is dis- tinguished from the old bv the different direction of their blood vessels 92 THE MEDICAL ASPECTS and of their trabecular, which run perpendicular to the surface. This is due to the fact that the osteoperiosteal vessels in the new bone have origin from the Haversian canals on the surface of the bone, and around these the new lamellae are formed, which produce the ossifica- tion from the elements of the embryonal tissue. The new trabecular are the production of the embryonal cells, which we saw were the result of the rarefying osteitis. They are usually disposed around the edges, where the process of reparation takes place, forming new bone around the existing depressions. This causes irregularities on the surface of the bone. When cavities have been produced in the bone near the medullary canal, new bone may be produced in a similar manner as on its surface. When a sequestrum has been formed it remains imbedded in the new bone ; it may cause repeated attacks of osteitis until it is removed. Formative osteitis, when involving the substance of the bone, leads to its sclerosis or hardening, a process which is known as eburna- tion or condensing osteitis. In this case the new bone is very dense and has a consistency like that of ivory. When it occurs under the periosteum, the condensing osteitis may affect the bone in parts or its whole extension. When in the medullary canal, proliferation of the bone tissue may take place to such an extent as to obliterate it entirely. In some rare cases eburnation of the bones takes place on their sur- face, while the interior is eroded by the rarefying osteitis. The con- densed bone forms the support of the shaft, which would otherwise easily break. A rarefying and formative osteitis often changes the shape of the bone, especially towards the joints. In children, on account of this peculiar process of inflammation, there may be a detachment of the epiphysis from the diaphysis, leading to a pseudo-paralysis. W Tien the condensing osteitis is active, premature ossification of the bones of the skull may occur with resulting cranial asymmetry and malformation. The new bone may produce a pressure on the Haversian canals so as to cut off the blood supply from other parts of the bone, causing them to fall into necrosis. It is soon surrounded by numerous granu- lations, the result of the rarefying osteitis, which is an effort of nature to get rid of the necrotised part called sequestrum. If this is seated on the surface of the bone, it is soon separated and carried away with the purulent discharge. But when it is deeply seated in the substance of the bone, it acts as a foreign body, maintains a constant irritation causing abscesses and sinuses, until it is entirely removed. Gummatous infiltrations occupying the bony tissue are capable of causing necrosis by cutting off the nutrition from the bone. The sequestrum has an appearance as if it were worm-eaten, being traversed CONSTITUTIONAL SYPHILIS 93 by small channels and holes, while the sequestrum from other causes appears smooth and equal. The gummatous deposits penetrate into the substance of the bone, leaving marks of their destruction. After the sequestrum has been removed the loss of substance is imperfectly repaired, leaving inequalities on the surface of the bone. In some cases caries and necrosis of the bone may be the result of ulceration of the skin or of the mucous membrane. The dis- integration of the soft parts reaches the bone, which is denuded and is affected with superficial necrosis. We have already considered the destruction of the bones of the nose and of the palate, in consequence of gummata affecting the mucous membrane of these parts, which, breaking down, involve the bone in the process of disintegration, pro- ducing perforations and destruction. There has been attributed to syphilis another condition of the whole osseous tissue, whereby the bones become of such a fragil- ity that any forcible effort may break them. It has been called osteopsathyrosis, fragilitas ossiiim, which is especially found in the long bones. According to Charay the resistance of the bones must be diminished at least fifty per cent., and the resulting fragility must be caused by a marked decrease of fluoride of calcium. The whole affec- tion must be the result of the syphilitic cachexia, from the lowered nutrition of the general system, which also extends to the bones. An irritative form of periostitis is revealed by diffuse swelling of the periosteum, accompanied by dull pains, which are usually more intense at night. The patient's general nutrition is usually well main- tained and, in spite of his pains, he is still able to go about. We find this condition quite often in the tibiae and in the bones of the skull. Under an appropriate treatment the inflammation subsides, the exuda- tion is easily reabsorbed, and the pains gradually cease. But when the swelling remains there is reason for believing the possibility of the ossification of the periosteal products. In cases where periostitis ends in suppuration the pain is still more severe. The inflammatory swelling is painful and tender to the touch. The skin covering the area becomes red, edematous, and gradually assumes a bluish color, and at the highest point of its con- vexity is greatly reduced in thickness. The pressure of the pus per- forates the periosteum, and consequently the skin, giving issue to a thick, dark yellowish pus. The pains then diminish and also cease entirely when there is a good drainage opened. On introducing a probe we find that the bone is detached from the periosteum and with- out any roughness. If no complications arise, the periosteum may again be attached to the bone by means of granulations, and leave very few traces of the process. In the places where the periosteum has 94 THE MEDICAL ASPECTS been ulcerated the granulation coming from the bone may form a cicatrix involving all the tissues, leaving the skin adherent to the deep tissues. In cases of gummatous periostitis the infiltration is more circum- scribed, and the accompanying pains are much more intense. The gumma is felt as a firm nodule in the beginning, but becomes soft later on, and when liquefaction takes place, may cause a sensation of fluctuation. The skin is somewhat raised by the gumma, and only when the disease is advanced does it take on a brown red color, which lasts for a long time if the gumma undergoes absorption. In case the gumma is liquefied and a necrotic process takes place, the skin is then involved ; it is swollen, has a deep bluish red color, and at the point of pressure is gradually perforated. The result is an ulcer with a deep bottom covered with a large quantity of necrotized tissue, and with thick and deeply infiltrated edges. The process of disintegration of the gummatous infiltration is a slow one, and begins in the center and extends to the periphery. For this reason, while the center of the periosteal gumma is broken down, the edges are still thick, infiltrated and swollen. The ulcer begins to heal up only when the peripheral portion of the gumma is destroyed, then the swelling goes down, the surface is covered with healthy granulation and heals up in a short time. In the periosteal gumma, the bone is also involved, and in both cases, whether the gumma undergoes reabsorption or disintegra- tion, the bone is damaged by the process, and will have a depression in the place where the gumma has been. This depression left by the periosteal gumma is made more perceptible by the morbid ossification of the infiltration along the edges, which makes the surface of the bone rough and irregular. If it is easy to make the diagnosis of periostitis, it is not so easy to establish the diagnosis of osteitis and osteomyelitis. The process begins with dull pains in the deeper parts which are subject to exacer- bations towards evening. Mild fever may be present, but this is not usually the case. The bone does not show any objective symptoms, and its changes are not shown until very late. The diagnosis will, therefore, rest on the continuous and even increasing pains, and the absence of perceptible alterations of the bone. In case of sclerosis of the bone as a consequence of osteitis, the patient will complain of a peculiar heavy feeling of the limb, which may interfere with its functions. Osteitis is subject to the reabsorption, and only very rarely may end in an abscess. Gummatous osteitis and osteomyelitis run their course in an obscure way. Osteocopic pains are present in some cases, but in others CONSTITUTIONAL SYPHILIS 95 they are absent. By means of palpation or by gentle percussion, we find limited tender spots in the tibiae or in the skull, which makes us suspect the presence of osteitic affection. A gummatous osteitis, however, is usually accompanied by localized pain, increasing after some exertion, and more intense at night. In some cases the peri- osteum and the surrounding tissues are involved, and then the affected place is shown by marked swelling and tenderness. In other cases the gummatous process dilates and distends the osseous tissue, causing an increase in the size and a change of the shape of the bone, which in the phalanx was called spina reutosa. The bone is light and porous, in some cases it is reduced to a shell (osteoporosis), and in this condi- tion may easily be fractured. The gummatous infiltration, as a rule, undergoes absorption under proper treatment, while the swelling and the other symptoms gradually disappear. The rarefied bone is compensated by the formative ostetitis and in this way there are found areas of greater density surrounding the affected places. When the rarefaction in the bone has been of a certain extension, it may, after the healing of the gumma, remain somewhat fragile and liable to suffer spontaneous fracture. In some cases the loss of bone after the reabsorption of the gumma can be seen in the phalanges, which remain shortened and half mutilated. The gummatous process undergoes disintegration, producing necrosis of the bone accompanied by suppuration. When the pus is retained in the sinuses under the periosteum it causes pain, and it may bring about an attack of erysipelas, lymphangitis, etc. When the pus has free drainage, the pain is very slight. The pus is of foul odor, mixed with the necrotized particles of the bone, and suppuration con- tinues until the dead bone has been removed. The bones can be attacked at any time during the evolution of syphilis, and in some cases we find symptoms in the osseous system at the early period of constitutional syphilis. Every bone of the body is liable to be affected by this disease, and Dittrich referred to a case of caries and necrosis of the hyoid bone in a female day laborer, thirty- one years of age, who had also other symptoms of syphilis. In the line of frequency we find that the bones of the skull are frequently attacked by syphilis, the frontal and the parietal bones much oftener than the occipital and the temporal bones. The nasal bones and those forming the hard palate are often perforated and damaged by syphilitic affections. The long bones are also affected, especially the tibia and the fibula, the radius and the ulna ; while the humerus and the femur are only rarely involved. The clavicles are often found affected with periostitis and osteitis, and their sternal extremity remains thickened 96 THE MEDICAL ASPECTS and tender, this alone giving good ground for the diagnosis of syphilis, The ribs are also affected by syphilis, while the vertebrae are usually spared. When the epiphysis of the bones is affected with gumma the process may spread to the joint. The bones most frequently attacked are those which are most superficial, and, in consequence, most exposed to external injuries. In fact, the patients often speak of an injury causing the affection, and it is not entirely out of the range of possibility that the syphilitic virus affects the places where an irritation has already been produced. Although syphilis apparently does not interfere with the healing of wounds, yet observations indicate that it may retard the formation of the callus in a fracture of the bones. The failure of the fractured bones to reunite must be due in all probability to a gummatous deposit at the point of fracture. Lang refers to cases of imperfect reunion of fractured bones in syphilitics which became perfect after a good constitutional treatment had been given. It is well known that the affections of the bones have been con- sidered by the antimercurialists as produced by mercury. It was the popular belief that mercury would accumulate in the bones and, by its expansion, caused by the rising of the temperature, produce the osteocopic pains. It is not necessary to say that this is a simple prejudice without any foundation. We have found affections of the bones in syphilitic individuals who had received no mercurial treatment whatever, and we see in our ordinary practice that mercury alone cures the affections of the osseous system. In our practice we meet every day with cases of osteitis and periostitis in individuals who have had no mercurial treatment at all, or at least an insufficient one. The affections of the bones have an exceedingly slow course. It takes months and even years to see the end of these syphilitic attacks. In some cases gummatous foci are successively repeated, thus pro- longing the existence of the disease. Syphilitic osteitis and periostitis are not always painful, and with the exception of some paleness and decreased nutrition they do not cause grave functional disturbances. The pain seems to be the result of acute swelling of the periosteum and of subperiosteal exudation. In some cases of osteitis, without marked swelling, there has been found extreme tenderness in the bones. The pain accompanying syphilitic affections of the bones has been described as boring, beating or sawing, or as tearing, dragging, or representing any other heavy, torturing sensation. The pains are more intense at night than in the daytime, so much so that they prevent the patient from sleeping. It seems that the heat of the bed, the hori- zontal position, and probably the attention of the patient drawn con- CONSTITUTIONAL SYPHILIS 97 stantly to the locality of the pain, make the pains appear much more intense at night. It has been observed in cases where the patient, on account of his occupation, was working at night and sleeping in the daytime, that he did not notice pains while working, and the pains prevented him from sleeping' as soon as he lay down in bed in the morning. When the bones of the skull are affected, if the process is limited to the periosteum, the affection remains local and without serious con- sequences ; but if the process has its seat in the internal surface of the bone, it may, by compressing the brain, become the origin of serious nervous disorders. Gummatous osteitis producing necrosis is one of the gravest occurrences. On the skull it may run a latent course, but the soft parts are usually involved to a certain extent, and the necrotized bone appears as a blackened mass. If the process has involved the whole bone, then the sequestrum may be detached and a hole is made in the skull, -leaving the brain covered only by the meninges. Even such grave destructions are repaired by nature; a strong and heavy cicatri- cial tissue is capable of covering the destruction and leaving a thick cicatricial depression, where the pulsation of the brain can still be perceived. Cases of osteitis with necrosis of the bones of the skull must be treated with local and general treatment, but as far as surgical inter- ference is concerned, it is better to leave it to nature, which is capable of throwing off a sequestrum without assistance, and of limiting the process to the least destruction. It is not so in those cases compli- cated with severe cerebral symptoms, when syphilitic bony produc- tions cause a pressure on the brain. There are cases on record where, by the timely removal of a portion of sequestrum, the patient's life has been saved by the removing of the pressure on the brain produced by the necrotized bone and by an accumulation of pus. Cases of this kind, however, are very rare, because the syphilitic process fortunately limits itself to the superficial surface of the bones, which can be reached with therapeutic means. We can only refer to one case of periostitis of the orbital bones, which ended with an abscess in the inferior segment of the orbit. The individual had contracted syphilis some eight years before the affection of the orbital region developed, and for some months he complained of neuralgia of that region. The eye protruded somewhat, and was pushed upwards, fixed, and entirely immovable. A large swelling was made out underneath the eye-ball, which revealed the presence of pus. The abscess was opened, the pus evacuated, the cavity was packed was iodoform gauze, and recovery was the final result. 98 THE MEDICAL ASPECTS Cases of the same kind have been reported, one by Ferdinand Schott and Soloweitschick, the patient dying with meningitis; another by R. Campana, where the abscess opened externally and the case ended in recovery. The bones forming the base of the cranium can be affected by the diseased condition of the nasal or pharyngeal cavity. Fortunately the occurrence is a very rare one. In the same way affections of the temporal bones by syphilis have been very seldom met with. The bones of the face are also affected by the syphilitic process, and we have already spoken of the frequency of these attacks on the nasal bones of the septum of the turbinates, etc. ; but the maxillary superior, the zygomatic arch have sometimes been affected with peri- ostitis and osteitis. Syphilitic affections of the spinal column have been referred to by John Hunter. The cervical region of the spinal column is more frequently attacked. Lang reported a case of periosteal enlargement developed on the anterior surface of the cervical spine, in a man after nearly one year from the infection. He also reported another case of syphilitic caries of the cervical vertebrae resulting from gummatous osteitis, which could be demonstrated through a sinus opened in the posterior wall of the pharynx in a man eight years after the infection. Observations of syphilitic affections of the dorsal and lumbar spinal column are very rare. Affections of the fingers from syphilis are quite frequently found, and they are so characteristic that A. Lucke applied to them the name of syphilitic dactylitis. It affects the fingers and the toes in the form of a gummatous infiltration, but it is oftener the former than the latter which are attacked. It is found in cases of acquired as well as in cases of hereditary syphilis, but is more frequently a lesion of hereditary syphilitic taint. Two varieties of this disease have been described : one where the affection involves at first the fibrous structures of the joint; another, where the periosteum and the bone are at first affected and the joint is attacked only secondarily. When the bones of the phalanges are affected, soon the periosteum and the soft parts of the fingers are involved. The phalanges are swollen to twice the normal size, puffed up in the middle in a round shape, covered by a shining, smooth bluish white skin, which is not movable over the tissues underneath. The bone is greatly increased in thickness, and its enlargement is due to a periostitis or to an osteitis, which causes the swelling of the cortex of the bone. Usually the gummatous infiltration is reabsorbed and the swelling gradually diminishes, and everything returns to a normal condition, leaving the skin somewhat pigmented. CONSTITUTIONAL SYPHILIS 99 In some cases, however, the skin is pierced and through the opening which is formed are felt pieces of necrotic bones. The necrotized phalanx is gradually destroyed by suppuration and cast off. The swelling diminishes and healing takes place, but the finger remains shortened on account of the loss of bone. When the joint is involved in the process, an anchylosis may result on account of adhesions and contractions of the fibrous tissues. These affections of the phalanges are only a very late manifesta* tion in acquired syphilis, but in cases of hereditary lues they show up early, in the first year of life. They are not limited to the phalanges, but the bones of the metacarpus and metatarsus are also affected. The process is slow and tardy as we have noticed in all syphilitic affections of the bones. In establishing the diagnosis of syphilis of the bones, we must not forget that other affections may produce disease of the bony tissue. In workingmen employed in match factories, where they are exposed to phosphorous vapors, a necrosis of the jaw may occur and is known as phosphorous necrosis. The seat of the necrosis and the occupation of the patient will place us in a position to eliminate syphilis. In consequence of gangrenous mercurial stomatitis the bone may become denuded and suffer necrosis. It has, however, different char- acteristics from the syphilitic affections, where formative osteitis is the predominating feature. In syphilis several bones are affected at the same time, and this will exclude a traumatic affection. Tuberculosis affects the bones, usually leading to caries. The bones which are affected by syphilis are usually spared by tuberculosis. We have seen that the frontal and temporal bones are frequently affected by syphilis, but very rarely by tuberculosis. Vice versa, the temporal bone, which is only rarely attacked by syphilis, is often the seat of caries from tuberculosis. Syphilis prefers to attack the diaphyses and the long bones, while scrofula oftener affects the short bones of the spongious kind. The presence of the tubercle bacilli in the purulent exudation will be the absolute proof of the tubercular origin of the affection of the bones. But it must not be forgotten that scrofula may be asso- ciated with syphilis in the same individual. The syphilitic affections of the bones are, as a rule, found in an advanced stage of the evolution of syphilis, and therefore belong to late symptoms ; consequently the individual has already had other syphilitic troubles on the skin or on the mucous membranes, of which there must remain some traces. By an accurate examination of the body we will find signs of an old syphilis and this will give us a clue for a differential diagnosis. 100 THE MEDICAL ASPECTS There may be also taken into consideration the character " a javantibus " and " lcedentibus/ J which is to give antisyphilitic treat- ment and from the obtained results trace the syphilitic origin of the disease. This, however, must be considered as a poor and deceitful argument for a diagnosis. In many cases of rheumatism, we find syphilis to be the cause. Like any other infectious disease, syphilis affects the joints with such persistency that it has been one of the symptoms which mostly at- tracted the attention of the observers. Babington, Ricord and Richet have looked upon some forms of artropathies rather as complications of syphilis ; but Lancereaux firmly established the existence of arthritis from a syphilitic origin, by finding gummous infiltration in a knee joint. Oedmansson pointed out a form of synovitis with erosions of the cartilages of the joints, as of syphilitic origin. This was after a while confirmed by Schuller, Falkson, Finger, and others in a series of well-studied cases. No joint escapes the attacks of syphilis, but the most frequently affected are the knees and the elbows. The first symptoms which begin to trouble the patient at the time of the syphilitic invasion are pains in the joints. These pains usually make their appearance a few days before the roseolar eruption, or they may come at the same time, or a short time after the roseolar eruption. Several joints are affected at the same time, and at this period the trouble is of an irritative character, because there are usually no objective symptoms present. The pains are similar to those in rheu- matism ; they increase at night and are often accompanied by syphilitic fever. They often recur, as we have had occasion to observe in some cases where every eruption was accompanied by articular pains. Monoarthritis with a marked swelling of the joint we have always looked upon as a symptom of late syphilis, or otherwise of hereditary syphilis. The cases which have come under our observation were at least one year or two after the infection. Syphilitic arthritis begins with pains, accompanying an attempt to move the joint to its full ex- tension or flexion, and the joint is found to be somewhat swollen and the skin is red. By palpation some points can be found in the joint where the pain is more accentuated. In some cases fever accompanies the affection, and is remittent in type. In the ordinary cases the synovitis undergoes involution, and after two or three weeks the joint gradually returns to a normal condition. In some cases synovitis may take a chronic course ; there is a very mild pain, but the swelling is greater, due to a large effusion of serum in the joint, which is called hydrarthrosis. Under proper treatment the serum is reabsorbed, the swelling diminishes and the condition is CONSTITUTIONAL SYPHILIS IOI improved ; but in some cases relapses are seen quite frequently, while in other cases permanent recovery may be obtained. In cases of old syphilis the monoarthritis is somewhat more serious, for the reason that a thickening of the capsule may take place, with some impairment of the functions. It is a villous hyperplasia of the synovial membrane which is at times accompanied by condritis and leaves defects in the cartilage. This condition only causes slight pains, but from the damaged joint, anchylosis may be the result. In some cases the swell- ing of the joint may appear in limited, circumscribed points of the capsule or of the ligaments as a gummatous infiltration of the joint. The pain is not so severe and the effusion in the joint not so abundant. The gumma may be reabsorbed or break down and cause an abscess in the joint with external perforation. In cases where the joint is attacked secondarily as a consequence of osteitis or periostitis the affection is much more severe, and the pathological alterations produced on the capsule and on the cartilages are usually of such a nature as to cause great damage to the joint. We may find some difficulty in establishing the diagnosis of syphilitic affections of the joints, in view of possible ordinary or gonorrheal rheumatism. In the case of acute polyarthritis the roseolar or the papular eruption will soon reveal the syphilitic nature of the rheumatism. When it appears later after the infection, the presence of periostitis of the tibiae will easily reveal the nature of the arthritis. Some difficulty may be found in determining in a case of mono- arthritis, whether syphilis or gonorrhea is the cause of the affection when both causes have been present. We think, however, that gonor- rheal arthritis will soon be found out when we prove the presence of an acute or subacute gonorrheal urethritis. The inflammatory symptoms of the joint in gonorrheal arthritis are much more violent and the pain and swelling are of a much more acute character than in a syphilitic arthritis. In cases of doubt, we must take under consideration the result of the remedies. Salicylic acid will promptly benefit a case of ordinary rheumatism, and also a case of gonorrheal rheumatism, but potassium iodide will be the best remedy for syphilitic affections of the joints. SYPHILIS OF THE MUSCLES AND BURSJE The muscles are affected by syphilis in the secondary period, in the form of an irritative myositis, and at a late period as a chronic interstitial inflammation. The vague pains, which are complained of by the syphilitic patients at the time of the constitutional invasion, which they usually refer to by saying that they are all broken up, may be due to an irritative 102 THE MEDICAL ASPECTS myositis. Indeed, the dolorcs rhcumatodes are quite often referred to the joints or to the bones, and yet when we try to locate the pain it is found that the muscles are tender, and the bones and joints under pressure do not cause any distinct pain. The tenderness is sometimes found in the body of the muscle, at other times is limited to the tendon. The muscles are found firm, thickened and contracted, and when one tries to overcome the contraction, pain is produced. Gummatous infiltration also affects the muscles. It presents itself in the form of hard and firm knots which follow the movements of the muscle, and when pressed produce localized pain. The gumma is usually located near the tendons and grows very slowly, gradually be- coming softer, while the muscle remains rigid and also contracted. In favorable conditions absorption takes place, the muscular fibers which have been compressed and destroyed by the gumma are replaced by connective tissue. In some cases the gummatous infiltration may progress and affects the covering fasciae, proceeding to the subcutan- eous tissue and assuming the proportions of a large tumor. It bulges out and is very little movable. The skin gradually becomes adherent to the whole mass, and is of a bluish red color. The gummatous in- filtration, while undergoing disintegration, softens towards the sur- face, and forms a large, deep gummatous ulcer. A large quantity of the necrotic mass which belongs to the tendons and fasciae is sloughed off. It requires many weeks and months before the healing process takes place. After the ulcer has healed there remains an iregular deep scar, involving tendon and muscle, which remain adherent to the skin, with the resulting distortion or permanent contraction. In some cases when the gummatous infiltration from the muscle has spread to the periosteum or to the bone, a cicatrix may result which adheres to these parts and causes great impairment of movement. The muscles are also affected by an interstitial infiltration, which, starting from the affected blood vessels, causes a compression of the muscular fibers. The blood vessels affected in their tunics cannot nourish the muscular fibers, and in consequence they undergo degenera- tion, and the muscle is converted into a fibrous tissue. The nuclei of the sarcolemma which stand together in groups, on account of the pressure of the infiltrating cells and of the proliferation of the con- nective tissue elements, are cut off from their nutrition, and the con- tractile substance is atrophied and a thick connective tissue takes its place. This form of myositis begins with pain and swelling of the muscle, as an ordinary muscular rheumatism, and by the degeneration of the muscular fibers in connective tissues, leads to permanent contrac- tion of the muscles. In some cases of torticollis syphilis is the cause of the contraction of the sterno-cleido mastoid muscle. CONSTITUTIONAL SYPHILIS 103 Affections of the muscles are always found in grave cases of syphilis, and at a late period ; the diagnosis will therefore be helped by the presence of periostitis, of scars of healed up gummata. Usually several muscles are affected at the same time. In cases of a single gumma of the muscles some doubt may arise in the differential diagnosis between gumma and sarcoma or other new growths. In these cases we believe a great deal in the argument of a juvantibus, and a few weeks of a well-directed specific treatment will solve the problem. The tendons have been reported affected in syphilis in the form of tendo-synovitis, by Herman Holder, 1851, revealed by swelling of the sheaths of the tendons. Yerneuil found, at an early stage of syphilis, acute painful hygroma in the sheaths of the tendons of the fingers. Alfred Fournier considers the occurrence rather common and refers to cases of hygromata in the extensor of the toes, the tendo-Achillis, biceps brachii, biceps femoris, supinator longus, and peronei. Observa- tions of the kind have also been reported by Baumler and Chouet. The tendons are affected in the form of an acute, irritative tendo- synovitis, which is an inflammatory process of the sheath of the tendon, accompanied by pain and some exudation. Motion is painful, and a kind of crepitation is produced on account of the exudation in the sheath. It may end in resolution or in hydrops of the sheath. The tendo-synovitis may be chronic, and is either the result of the acute form, or begins as such, with little pain and a great quantity of exudation. It remains stationary for a long time, causing hyperplasia of the tendon sheath and hygroma. Gummatous tendo-synovitis shows a round spindle-shaped swelling around the affected tendon. It grows slowly ; little or no pain is present. It remains for some time as a gummatous swelling, and finally is either rebasorbed or, undergoing degeneration, breaks down, affecting the surrounding tissues and ulcerating the skin. Swelling of the bursas is quite frequently found in syphilitic patients. We often have occasion to see bursitis of the bursa prepatel- laris, which attains large proportions in the form of a defined fluctuating tumor in front of the rotula. Lang refers to cases of bursitis of the olecranon at an early period of syphilis, which have resolved and dis- appeared under antisyphilitic treatment. Fournier also reported cases of hygroma prepatellaris, and Verneuil found a fluctuating tumor of the bursa olecrani in a man affected with syphilitic roseola. Cases of gummatous infiltration of the bursse have been reported by Lang and by E. L. Keyes, which ended in sinuses and fistula?. In our experience we have met quite frequently with hygroma of the bursa olecrani, and of the bursa prepatellaris. In all cases syphilis 104 THE MEDICAL ASPECTS had been inoculated several years before, and antisyphilitic treat- ment produced the complete reabsorption of the fluid forming the hygroma. Syphilis also affects the aponeuroses and the ligaments ; in ordinary cases in the form of diffused infiltration, which is revealed as small nodules scattered on the surface of the fasciae, with some tenderness. This specific inflammatory form has been found at different stages of the evolution of syphilis. Gummata of the fasciae have also been described, but on account of their thin structure will soon affect the neighboring tissues, and it would be difficult to establish the place of origin of the gumma. VI SYPHILIS OF THE NERVOUS SYSTEM That the nervous system is exposed to the ravages of syphilis was supposed when syphilis first began to be studied with some attention. The first idea, however, was that expressed by Botal and Fallopius, that the symptoms of the nervous system were the consequence of the syphilitic affection of the bones in the form of necrosis, tophi or gum- mata, which damaged the nervous substance. A gummatous process affecting the brain had, however, been already recognized. Progress on the subject was stopped by the misleading statement of Hunter claiming that he had never observed syphilitic affections of the internal organs or of the brain. The every day observation, which clearly showed cases of peculiar affections of the nervous system in individuals who had suffered severely from syphilis, revived the old ideas expressed by Fallopius and Botal, that syphilitic deposits in the bones were accountable for the grave symptoms of the brain. THE BRAIN" The careful study of the nervous affections, which was begun in earnest towards the middle of the last century, revealed that cerebral symptoms are the direct result of syphilitic attacks on the nervous cells, and that only rarely are they due to the presence of exostoses. We have already spoken of some neurotic condition affecting deli- cate patients in the form of headache, vertigo, irritability, on the first invasion of constitutional syphilis. It seems that this condition may be ascribed to a certain degree of hyperemia or even of slight effusion into the meninges or the brain. This irritative condition of the meninges may represent in some way the irritative eruption affecting the skin at the time of the appearance of the secondary symptoms. This was the opinion of Prof. Sigmund, who referred to an irritative disturbance of the meninges, the loss of sleep, the peculiar lassitude, and the irritability shown by some patients at the time of the invasion of the secondary symptoms. Alrik Ljunggren maintains as an established fact during the first stage the occurrence of a temporary hyperemia of the cerebral meninges or of the interstitial matter, which he compares to the hyperemic forms of the secondary syphilitic eruptions. He insists that cases of menin- 105 106 THE MEDICAL ASPECTS geal irritation at the period of invasion of syphilis have not to be counted a rare affection. In meningeal irritation the headache is sometimes marked on the frontal region, some other times on the occiput, while in some cases the whole cranium is affected. It makes its appearance as a neuralgia, which is sometimes accompanied by vertigo and by mental irritabilty. In some cases there has been found some irregularity in the size of the pupils, probably from paralysis of the sphincters, and others have called attention to a slow pulse. The affection has been considered as one of short duration, which easily yields to the mercurial treatment. We have seen this affection in a patient affected with papular syphilide, who from the intensity of the pain could not sleep during the whole night, in spite of opiates and hypnotics administered. The syphilitic cephalalgia finally yielded to a protracted mixed treatment, but was rather stubborn. Lang is also of the opinion that this affection is the result of a meningeal irritation with a probable infiltration, on account of the exist- ence of similar irritative changes, which in many cases can be demonstrated in the fundus of the eye. He had examined ophthalmo- scopically a large number of patients in the early stage of syphilis. Of forty patients, only nineteen showed the normal color of the fundus of the eye ; of the twenty-one, in fourteen there was found choroidal irritation in different degrees, and in seven Lang was able to dem- onstrate an inflammatory process of the choroid or of the retina. These changes in the fundus of the eye, which he found repeatedly in the early stage of the constitutional syphilitic affections, have fre- quently attained such a high degree as was found in retinitis with as grave consequence on the visual function, and yet the vision was not at all or only slightly impaired. Syphilitic meningitis is quite difficult to demonstrate during life. It has also been found in the form of gummatous meningitis, ending in connective tissue callosities. A circumscribed spot of constant pain in the head, sometimes increased by percussion, may be a good character- istic for a pachymeningitis affection, but will not exclude the possibility of the presence of a gummatous osteitis of the bones of the skull. Gummatous products have been found in the membranes of the brain. In the dura mater the gummatous infiltration is developed be- tween its layers, assuming sometimes the size of a walnut, and made up of fibrillary tissue containing a large quantity of cells, with some signs of fatty degeneration. A gumma of the dura mater always causes a certain pressure on the lamina vitrea of the bone of the skull, producing a kind of erosion. This does not occur in the case of a gumma of the pia mater, which leads to adhesions between the pia and the dura, and §YPHILIS OF THE NERVOUS SYSTEM 107 between the pia and the cortex of the brain. It appears like a deposit of reddish, jelly-like pulp, which infiltrates the meninges in circum- scribed points. In some cases of gummata of the pia the infiltration does not remain limited to the membranes, but affects the cortex and also the white substance, with disastrous consequences to the life of the surrounding brain substance. One of the most frequent forms of syphilitic affections of the meninges is that of a diffused meningitis gummosa basilaris. It is often found in the neighborhood of the chiasm involving the oculo- motor, the optic and other cerebral nerves. In the autopsy x of a girl eighteen years of age, who had been affected with progressive idio- pathic atrophy of the skin, there was found a gummatous infiltration in the form of a gelatinous mass on the upper part of the right optic tract, which pressed on the right middle cerebral artery, and another mass of infiltration was found on the right surface at the junction of the pons and medulla. To the first was to be attributed the impairment of the vision, and to the latter the atrophic degeneration of the skin. It seems that the gumma of the brain has its origin in the pia, and from that affects the cortex and also the white substance of the brain. Only a few gummata have been found in the substance of the brain, which is the consequence of the obliterating process of one of the arteries, and the result is the softening of the brain around the gumma. Syphilis, when it affects the brain or its membranes, producing alterations of organs of the greatest delicacy and of vital interest, must produce changes in the most important functions of life ; in the mental, in the sensory, in the motor, also in the trophic sphere. It will be re- vealed in the beginning by an increased irritability of the patient, or a lowering of the intelligence, a diminished power of attention, and later on by psychoses of different kinds. Headache is a constant symptom, which precedes and accompanies syphilitic affections of the brain. At times it attacks the whole head : at times the pain is limited to one part of the head. Headache from a syphilitic affection of the meninges or of the brain is likely to increase at certain hours of the day, becoming excruciating at night, and rarely presents a total intermission. When the headache is constantly limited to one point for a long time it can be considered as a symptom of a localized process. Vomiting sometimes accompanies the headache. At the same time that patients are suffering with the headache they are troubled with insomnia, with the flashing of lights before their eyes, are extremely irritable, and they sometimes suffer with vertigo. The patient gradually loses his memory and is not able to concentrate 1 Ravogli, A. " A Case of Progressive Idiopathic Atrophy of the Skin." The Journal A. M. A., Jan. 10, 1903. 108 THE MEDICAL ASPECTS his thoughts. In some cases the patients are affected with epileptic convulsions. In our practice a young man affected with cerebral syphilis could not walk straight without leaning against the walls of the houses, and when without support he always fell on his left side. The pulse is usually retarded, but in some cases accelerated or even irregular. In syphilis of the brain there has also been observed poly- uria and polydipsia as frequent accompanying symptoms. Optic neuritis is often found in syphilitic affections of the brain with little or with great disturbances of the visual power. In syphilitic ependymitis a constant violent headache with exacerbations is one of the symptoms. This is so intense that when the patient tries to raise his head he is taken with nausea and vomiting. The psychical func- tions are somewhat weakened. The pupils are usually dilated, the visual power diminished, and the fundus of the eye is passively congested. When parts of the brain are involved in the syphilitic process symptoms arise which lead us to the diagnosis and to the determina- tion of the affected locality. Recent physiological and pathological researches have shown positively the functions of the different tracts of the brain, so that from the disturbed function we can establish to a certainty the tract of the brain affected by the infiltration or by the effusion. It is clear that the motor tracts which take their origin from the central convolutions pass through the corona radiata, the internal capsule, reaching the cerebral peduncles, the pons to the crossing of the pyramids, if an effusion, a hemorrhage, or a gumma is found in one of these spaces where the fibers run together, complete hemiplegia will be the result. On the contrary, if this alteration takes place on the cortex it will cause only a circumscribed paralysis, a monoplegia. These isolated forms of paralysis are frequently met with in the leg, arm and face. Monoplegia facialis is quite often associated with monoplegia of the arms, while paralysis of the arm and leg together is less common. A cortical lesion can be assumed with some degree of certainty, when partial jactitations are confined to single muscular areas at the beginning of a cerebral hemorrhage or when a tumor is developing. According to Nothnagel the diagnosis can be made with certainty when clonic contractions appear at a later period in the paralyzed parts. The convulsions may affect circumscribed regions, or several regions together, as arms and face; or they can attack one-half of the body in the form of cortical epilepsy, which is known as Jacksonian epilepsy. The motor cortical area is situated in the anterior and posterior central convolutions, and in the medianly situated lobulus paracen- tralis ; motor areas are found also in the contiguous portion of the superior parietal lobe, and probably also in the gyrus frontalis superior. SYPHILIS OF THE NERVOUS SYSTEM 109 In general, we find that the upper portion of the central convolu- tions, preferentially the lobulus paracentralis, are the center for the movements of the leg. The middle portions, anterior of the central convolutions, preside over the movements of the arms, while those below control the movements of the face and tongue. The tactile cortical area is entirely associated with the motor areas, so much so that Wernicke and Munk call the motor region the tactile region. This, however, is found not exactly corresponding to the clinical observa- tions, and Nothnagel has found that the surface of the brain lesions causing motor paralysis is not exactly the same that produces disturb- ance of muscular sensation, although both are situated so near to each other. Cases of syphilitic affection of the cortex have been reported where marked monoplegia was present ; but the sensation of the skin was maintained. In other cases where monoplegia and spasms were present the sense of touch was entirely abolished. Clinical observations show that these nervous centers are quite often affected by syphilis, and cortical epilepsy, without a traumatic cause, is more frequently the result of syphilitic affections. Partial epilepsy or the hemiplegic form is usually preceded by an increase of headache, which is of a unilateral character, or radiates from a single point of the face and throat. Convulsions in the form of rhythmic mus- cular contractions appear in one extremity and soon affect the other of the same side, involving also the muscles of the face and head. The mind is somewhat obscured and the patient falls. The attack may last one hour or even more, and as a result of the attack there may temporarily remain a difficulty of speech, weakness of memory, or of the affected limb. The attacks usually recur after weeks or months. It is only very rarely that they appear daily, at the same hour. The convulsions, according to Charcot, in partial epilepsy caused by syphilis, maintain a certain rule in the order of jactitations. When the convulsions affect the upper extremity the face will be next attacked, and then the lower extremities. If the face is first attacked, the convulsive movements will affect the upper extremities first and then the lower, finally when convulsions begin in the lower extremity they attack first the upper limb and then the corresponding half of the face. In partial epilepsy the consciousness is clouded only when the convulsions affect the face. In cases when consciousness is retained the convulsive form of the disease may occasionally simulate chorea. These affections have always been found to correspond to altera- tions of the cortex caused by exostoses or a gummatous process. H. Oppenheim found in a post-mortem a hyperostosis of the left cranial vault, and a diffuse gummatous infiltration of the dura, near the HO THE MEDICAL ASPECTS frontal lobe affecting the central convolutions, and part of the left parietal lobe. The man, who was thirty-nine years old when he died, had complained during life of a tenderness of the left side of the skull, paresis of the right extremities, disturbance of the sense of position in the right foot, clonic spasms, paresthesias, which extended from the right foot to the right half of the body, and after a while he was affected with aphasia and hemiparesis of the right side. In one case of epileptic attacks from syphilitic affection of the brain, referred to by Byron Bromwell, there were found no peculiar alterations of the central convolutions. The patient was a man thirty- four years of age, who had been infected seven years previously, and for some time had epileptic attacks, which occurred without any disturbance of consciousness, and hemiplegia of the left side, which had improved under a mixed treatment. He died after a convulsion which lasted three days. The post-mortem showed adhesions of the dura to the brain in the posterior portion of the second right cerebral convolution, and the posterior portion of the middle and upper frontal convolutions were infiltrated throughout the whole extent by a firm gumma, while the central convolutions and the rest of the brain were normal. Cases of aphasia have been observed in consequence of cerebral syphilis. Lang observed a case of motor aphasia in a patient ten years after infection. He had suffered severe secondary symptoms, asso- ciated with persistent neuralgia. The patient died afterwards with severe cerebral disturbances. Other cases of permanent aphasia as a result of cerebral syphilis have been referred to by C. Wunderlich, and by C. Wernicke. Some cases of aphasia were accompanied by alexia, although the vision was maintained intact, and agraphia, although the motility was not disturbed. In some cases alexia alone has been found, which has gradually disappeared under specific treatment. The base of the brain is often subject to syphilis, in the form of diffused or circumscribed syphilitic infiltration. In this case the cere- bral nerves are involved, together with the neighboring portions of the brain. The resulting symptoms are partly produced by the affected nerves and partly by the involved cerebral areas. In consequence of the alterations of the blood vessels, it is not rare to find a basilar meningitis, hemorrhages, and softening of the brain substance. This affection is sometimes confined to single nerves or to their branches, at other times as a larger area of the base is affected, several of the cerebral nerves are involved in the process. During the evolu- tion of cerebral syphilis we not infrequently meet with cases of optic neuritis, choked disc, and atrophy of the optic nerve. But sometimes SYPHILIS OF THE NERVOUS SYSTEM m the affection extends forwards to the olfactory nerve, or backwards to the trochlears, trigeminus, abducens and also to the facial and auditory nerves. When the gummatous process remains localized in the pos- terior meningeal portion, then the hypoglossus, the vagus, etc., may be affected. The neighborhood of the chiasm is quite often involved in basilar meningitis, and this explains the^ frequent affections of the optic nerves and of the ocular muscles. H. Oppenheim considers as a characteristic symptom of syphilitic affections of the base, oscillating hemianopsia bit emp oralis. The appearance and disappearance of the hemianopsia is explained by the great quantity of blood vessels, which according to the quantity of blood, produce temporary swelling of the tissues. When basilar meningitis attacks the posterior portion, then the symptoms will reveal affections of the pedunculi cerebri, the pons, the cerebellum, the medulla oblongata, etc. In the affections of the cerebral peduncles, symptoms of crossed paralyses are obvious, in which the cranial nerve, especially the oculo- motor of the side where the syphilitic lesion is, and the extremities of the opposite side are involved. This was called by Leyden hemiplegia alternans superior. When we find paralysis of the facialis on one side and paralysis of the extremities on the other, it is a symptom of hemi- plegia alternans inferior of Gubler. Paralysis of the cerebral nerves occurs on the same side of the affection of the peduncles, while the body is affected on the opposite side, because the motor fibers from the cortex going to the spinal cord cross lower down in the pyramids. When the pons is affected, the facial nerve is more often impli- cated, and there are also present disturbances in the power of speech and of deglutition. In the case of involvement of the corpora quadri- gemina there is bilateral lesion of the branches of the oculo-motor, together with disturbances of the equilibrium and of co-ordination, as in the affections of the cerebellum. Indeed, when the cerebellum is involved there are some peculiar changes in the gait and disturbed equilibrium. In walking, the patient is unsteady, and goes like a drunken man. Gummatous syphilitic infiltrations have been found in the medulla oblongata, which had caused different and peculiar symptoms during life. In the case of progressive idiopathic atrophy of the skin in a young woman, already referred to, a gummatous infiltration was found on the right surface at the junction of the pons and medulla, which is considered the center of the vasomotor nerves of the skin. The affec- tion of the skin was accompanied by several areas of anesthesia. Syphilis may be the cause of affections of the brain substance in the interior of the organ. These affections are more frequently found 112 THE MEDICAL ASPECTS in the corona radiata, and in the central ganglia, and also in the sub- stance of the cord. In these parts syphilitic gummatous infiltrations or limited gummata are very rare, but hemorrhages, and softening foci, on account of the altered condition of the blood vessels, are fre- quently found. In the affections of the corona radiata, and of the internal capsule, paralysis is much more extensive and complete, without any signs of irritation. Indeed, the fibers from the cortex run through the corona radiata and the internal capsule, which is between the large basal ganglia. Any effusion or softening foci involving one organ must directly or indirectly affect the other. The symptoms will depend exactly upon the size and extension of the focus. It is not possible to determine whether the affection is the result of gummatous infiltration or whether it is the result of the affected blood vessels. Symptoms are of a somewhat common order, usually revealed by headache, vertigo, insomnia, mental irritability, loss of memory, accompanied by a general mental deterioration. Hemiplegias and hemipareses are liable to occur suddenly without loss of consciousness ; in some cases they are preceded by an apoplectiform attack. In some cases paralysis gradually subsides, in others it may quickly disappear. Hemianesthesia, aphasia and hemianopsia, due to central lesion, are found with the other symptoms. In the affections of the blood vessels from lues, the oscillating character of the symptoms is one of the best signs, being due to the changes of the blood supply. In a large number of observations, there only appeared general cerebral symptoms, and local symptoms were only added later, and sometimes, never appeared. In several of our cases epileptic attacks have followed the various general symptoms, which have been relieved or discontinued by the antisyphilitic treatment. Cerebral syphilis, as we will see in the following chapter, is quite frequent in our times. It is possible that the increased mental work, the mental strain, and the worriment in the struggle of life have multiplied the possibilities for its occurrence. It has a chronic course, and although greatly influenced by the antisyphilitic treatment, it im- plies a dark prognosis for the future of the patient. THE SPINAL CORD Although it has been asserted that syphilitic affections of the spinal cord are of rare occurrence, yet from the studies of Rumpf, Oppenheim, Sachs, Siemerling, and especially from the investigations of Erb, we find that the medulla spinalis is not infrequently affected during the course of syphilis. SYPHILIS OF THE NERVOUS SYSTEM 113 It is not improbable that some irritative symptoms, which are observed at the time of the invasion of syphilis, such as vague pains, paresthesia of the legs, a feeling of debility, may have some reason for their existence in an irritation, direct or reflex, of the spinal cord. In fact, when a roseolar or papular eruption affects the skin and the mucous membranes, it is not impossible that the presence of an hyper- emia or slight infiltration on the meninges of the cord causes the above referred to symptoms. Jarisch and Finger have reported cases of increased reflexes of the skin and tendons in recent syphilis, before, or at the time of the appearance of the eruption. In some cases the in- crease of the reflex was followed by a decrease in the reflex irritability, which gradually, after some treatment returned to the normal. It is possible that on account of syphilitic periostitis of the verte- brae the process may reach the meninges, and so produce a spinal meningitis. But this is only a very rare occurrence, as the intervening fatty tissues protect the dura. The process more often starts from the pia, which leads to the adhesion of all the meninges together, con- sequently involving the roots of the spinal nerves. Spinal meningitis, like cerebral meningitis, shows as results of its alterations, gelatinous masses covering the cord, or dense fibrous vegetations made up of connective tissues, and packed with mono- nuclear leucocytes. Gummatous foci are also scattered through the mass. Spinal meningitis is more frequently found in a diffuse form than in a circumscribed one, and the dorsal section is more often affected. The cord is not equally affected by the infiltration, but some regions are more thickened than others, and the posterior sulci are more intensely affected. The lesions from the pia extend to the external surface of the cord, and from there affect the interior parts. The blood vessels affected with the luetic affections either fail to nourish the nervous cells and cause softening, or break and produce hemorrhages. Isolated gumma in the spinal cord have only rarely been found. It is more usual to find diffuse gummatous infiltrations, which form between the meninges and the cord jelly-like or dry, cheesy masses, which are found scattered over a large surface. The nerve roots when involved by the infiltrating process cause interruption of the conducting tracts with disturbances either of the motor and of the sensory sphere or of the trophic functions. The symptoms of syphilis of the spinal cord vary a great deal according to the tracts and to the extension of the affection. As general disturbances, it causes a certain degree of stiffness of the spinal column, and a sense of heavy weight of the extremities ; to this 114 THE MEDICAL ASPECTS are to be added various neuralgic pains around the chest, and pares- thesia. When the process has attacked the conducting tracts then pareses of the sense or of the motor sphere begin to appear. In case the gray substance of the anterior horns of the spinal cord is involved the muscles depending on the affected tracts will suffer, either falling into paralysis and then into an atrophic condition, or remaining in a spastic form. Paresis of the bladder and of the rectum follows, and the tendon reflex is usually greatly lowered. These symptoms take some time before they show up in their full develop- ment, and after a well-directed treatment, they may gradually dis- appear, or they may inexorably continue in their progress. Then, according to the tracts of the spinal column affected, we see hemi- paresis, or paraparesis in correspondence with the cross sections. It is clear that when the dorsal or lumbar region of the cord is affected by a gummatous infiltration the abdominal and intercostal muscles will suffer, and paraplegia of the lower extremities will follow with paralysis of the sphincters. The skin, on account of the diminished vitality in the place where the patient lies, is readily excoriated, falls into necrosis, and decubitus follows as a complication. In the same way the patients suffer with cystitis in consequence of the paralysis. When the cervical portion of the spinal cord is the seat of the syphilitic alterations, then stiffness and paresthesia of the neck and arms will be the first symptom. In consequence of paralysis of the diaphragm the patient may undergo attacks of dyspnea or asphyxia. The affection may show only a unilateral or bilateral tendency, it may spread gradually from the upper to the lower extremities, or, vice versa, from the lower extremities the paralysis may ascend to the upper regions of the body. As we have seen that paralysis of the lower limbs leads to severe and dangerous complications of decubitus and cystitis, so paralysis of the respiratory muscles may cause inflammation and gangrene of the lungs, and on account of the paralysis of the phrenic nerve, the diaphragm is impaired in its function, and asphyxia ends the life of the patient. The spinal affections from syphilis appear gradually, and some- times they accompany the same affection of the brain, showing a descending course, in the form of cerebro-spinal syphilis, as noted by Jurgens, Oppenheim, and Sachs. In spinal syphilis we always have hopes that the symptoms will recede, and especially after a well-directed antisyphilitic treatment, the condition improves, the muscles regain their power ; but some irrepar- able changes in the delicate structure of the nervous system remain with permanent results. SYPHILIS OF THE NERVOUS SYSTEM 115 In the cases where the posterior roots of the spinal cord are affected the symptoms have a great resemblance to those caused by tabes, so much so that Oppenheim called it pseudo-tabes syphilitica. In fact, we find that the patellar reflex is absent, the patient complains of lancinating pains, shows an ataxic gait, immobility of the pupils, inability to retain or void urine : all symptoms which we find in tabes. Erb has claimed to have found a special type of symptoms coming from a diseased spinal cord, which he considers invariably due to syphilis. The symptoms are spastic paraplegia, with a peculiar gait, exaggerated reflexes, muscular contractions slight in comparison with the increased reflexes, involvement of the bladder, disturbance of sen- sation, gradual onset of the disease, finally a tendency to improvement. This type of spinal syphilis, however, does not include all severe cases of this disease. It comprehends cases of syphilitic spinal men- ingitis, with some infiltration of the lateral columns, but not those with deep gummatous infiltration or true syphilitic myelitis, where improve- ment, if at all, is only temporary, and ends with irreparable paralysis. In cases of gummata of the spinal cord, the affection, although very rare, is usually limited to the anterior horns. The muscles, par- tially paralyzed, show an inclination to atrophy; they do not react to the irritation of the faradic current, but show some irritability with the galvanic current. The affected locality will be easily determined when together with the above mentioned symptoms we find no disturbances of the bladder and of the rectum, or troubles of the sensory sphere. Many nervous affections have been referred in some instances to syphilis, such as progressive muscular atrophy, especially that of the type known as Aran-Duchenne, where the paralysis and the atrophy are principally marked in the hand, in the thenar and hypothenar eminences, the interossei and the abductor indicis. The Erb spastic paralysis has also been referred to a syphilitic infection by Leyden, Minkowski and Naunyn. This is characterized by a spastic paralytic condition of the muscles, without any disturbance of the bladder, rec- tum, or of the sensory sphere. From a gummatous meningitis a multiple syphilitic root neuritis may result. It is the production of a small cell infiltration on the epineurium of the pia, which pressing on the roots of the nerves, causes atrophic condition of the nerve fibers. When in a case of syphilis of the brain, already manifested by paralysis of the cranial nerves, such as the facial, or those of the ocular muscles, a gradually progressive paralysis of the spinal nerves takes place, we can, in such a case, assume the existence of a syphilitic neuritis of the roots. The affection is then usually accompanied by various neuralgias of the spinal nerves, with hyperesthesias of the skin. Il6 THE MEDICAL ASPECTS girdle pains, and if it affects the anterior roots, spasms and motor palsies will be present. In these cases the administration of anti- syphilitic remedies has failed to bring any benefit, and for this reason have been regarded with some doubt as true syphilitic affections. Fournier has comprehended all those affections, which are rather con- sequent to degenerative processes of syphilis than the direct result of the disease, in one group, which he has called parasyphilitic affections of the nervous system, which we shall consider in the next chapter. GENERAL SYPHILITIC AFFECTIONS OF THE NERVOUS SYSTEM There is no doubt that syphilis, of late years, on account of a more judicious treatment and of the facilities for its application, has lost some of its virulence and malignancy. Indeed, we but rarely find at present cases of malignant syphilis, which we have seen in the preced- ing chapter, to be mostly due to the lack of resistance of the infected organism. But although its manifestations are milder and easily yield to treatment, yet its pathological domain has greatly enlarged by the knowledge of the complexity and character of its morbid processes. Formerly the study of the cutaneous manifestations of syphilis formed the most important subject of its symptomatology; but to-day the visceral affections, cerebral, spinal, vascular, ocular, articular, pul- monary, hepatic and renal attacks are of the greatest significance. As a consequence, the infection of syphilis to-day, although mild, and better treated, has a much more profound and permanent character than we have at first believed, when we think that it affects every con- stituent element of the body, and may produce systemic complications of a serious nature, which often have a fatal termination. The idea that syphilis has assumed a milder appearance, that its manifestations are much less severe, that its apparent cure is much more easily effected, that cases of death from syphilis are extremely rare, is all very true, but we cannot deny, as Morrow 2 very wisely main- tains, that a great number of deaths from apoplexy, paralysis, consump- tion, hepatitis, Bright's disease, etc., etc., recognize as their remote factor this protean morbid affection, syphilis. Mucous membranes and the skin are the organs preferred by syphilis in its manifestations, the brain and the spinal cord coming next in frequency. In fact, Fournier, from his personal statistics, gathered in a period of thirty-nine years and embracing 4000 cases of tertiary syphilis, shows that next to the skin, the brain and the cord are the organs most frequently affected. Cutaneous tertiary manifestations 2 Morrow. " The Prophylaxis of Venereal Diseases." Philadelphia Medical Journal, 1901. SYPHILIS OF THE NERVOUS SYSTEM 117 number 1145, affections of the brain 758, and those of the spinal cord 1098, giving a total of 1856 cases in which the brain and the spinal cord had been affected. It is worth while to follow these statistics, and we find that 354 of these cases of cerebral syphilis have reached a known termination ; yy were cured, 68 died, while 209 survived, but with various infirmities of a grave character irremediable in every case. In our experience we have had several important cases of syphilitic patients, which have ended with cerebral and spinal complications. It is quite easy to find a case of syphilis of- the nervous system, but the interesting case is the one in which the disease can be followed from the beginning to the end. It is for this reason that we refer to the fol- lowing cases : In 1883 we were consulted by a young man of German extraction, strong and healthy, a butcher by trade, who had recently contracted syphilis, and who showed a papular eruption which spread all over his body. He was married and had several children, all born before he became infected. His wife had already been infected. He and his wife were treated with intramuscular injections of a one per cent, solution of corrosive sublimate. After sixteen injections he considered himself cured and refused any further treatment. His wife came after a few years to consult about sores on her legs, which were ulcerated gummata. She subjected herself to the mixed teatment of inunctions and iodide of potassium, and has never again had any syphilitic manifestation. Her husband never had any more symptoms of any kind. He was addicted to the use of alcoholics, and had changed his occupation, opening a restaurant and saloon. In 1898 we were called to see him. He had acute mania, he was threatening everybody in the house, and it was necessary to have him taken to the sanitarium, where he died without regaining consciousness. An Italian fruit dealer, with syphilis in a florid stage, consulted us in 1884. He took some treatment, and seeing that he was getting well, stopped it and without asking for consent, married a young woman. Several years afterwards we were called into his family for the reason that his wife had had four miscarriages. He was reminded of the dis- ease which he had contracted and the insufficient treatment he had undergone. He and his wife were subjected to a mixed treatment of mercurial ointment inunctions and large doses of iodide of potassium. Since that time his wife has borne five children, who are all enjoying good health. They are not the highest type of strength, but with the exception of the diseases of infancy, they have never shown syphilitic symptoms. The man, however, in 1899, was affected with ptosis of the right eyelid, for which he again began treatment. In 1900 he was Il8 THE MEDICAL ASPECTS affected with a stroke of paralysis affecting the right facial nerve and the arm and leg of the left side. He is now taking large doses of potassium iodide, his face has nearly returned to the normal condition, his left leg is slightly weak, but he can walk with the aid of a cane. The arm and the hand are still powerless. So much syphilis has been found as the cause of nervous diseases thai: Berkeley 3 has attributed to this disease all cases of hemiplegia or monoplegia and mental disturbance in people under forty years of age, where no cardiac or renal affections could be found. In the same way he considers syphilis responsible for all cases of dementia with obscure symptoms in patients between twenty-five and forty years of age. Moebius 4 considers paresis as a syphilitic toxin disease, and only patients who have previously had syphilis are affected by general pa- ralysis. According to Fournier, hereditary syphilis plays an important part in the development of psychoses, especially in adolescence, and Hurd 5 has thought that syphilis may cause any simple psychosis, paresis and pseudoparesis. J. H. McBride 6 claimed that syphilitic insanity may mimic every known form of mental derangement. He has also tried to give a differential diagnosis between mental derangements when caused by syphilis, and when the result of other causes. In mania and in melancholia, an earlier appearance of confusion and weakness, stupor and dementia will point towards a syphilitic origin. It is agreed to by the generality of the neurologists that the anterior portions of the brain, frontal and central, are more open to syphilitic infection, which ex- plains, according to R. Dewey, 7 the frequent dullness and stupor found in nervous affections of syphilitic production. A certain relation has been found between senility and syphilitic insanity, without giving any particular diagnostic points. Spitzka, 8 calculating on the figures of Snell, claimed that 75 per cent, of cases of paretic dementia were due to syphilis. According to the figures of Erb, a similar proportion existed for tabes. He, in his practice among the insane paupers of New York, found that thirty-three per cent, of the cases of insanity was referred to a syphilitic history. But an energetic antisyphilitic treatment did not give any result, and in several cases intervals of spontaneous improvement occurred independently of treatment. Syphilis produces alterations in the nerve fibers at the very begin- 3 H. J. Berkeley. "Mental Disease." 4 Quoted by Bannister. " General Paralysis a Toxin Disease." Am. Journ. Insanity, vol. i. 5 " Psychosis in Cerebral Syphilis." Journ. A. M. A. October, 1901. 6 " Paresis and Cerebral Syphilis." Buffalo Med. Journal, 1901. 7 " Mental Symptoms of Cerebral Syphilis." Journal A. M. A. Feb. 2d, 1901. 8 Spitzka. " Manual of Insanity." SYPHILIS OF THE NERVOUS SYSTEM 119 ning in the localized initial lesion. Berkley 9 found interstitial and parenchymatous neuritis, due to the compression of the infiltrating cells, and to the endarteritis interfering with nutrition as a result of the local action of the syphilitic virus. The alterations, however, were limited to the nerve fibers imbedded in the exudation. In the course of syphilis it is not uncommon to meet with cases of root neuritis, cranial and spinal, and also peripheral mono-neuritis as secondary lesions. A case of syphilitic multiple neuritis was reported by Fry 10 as occurring one year after the initial lesion, and others by Cestan. 11 ' It is, however, not frequent that one sees neurotic affections as a consequence of syphilis in the secondary stage, while in late syphilis the occurrence is much more frequent. In the first, especially in women, syphilitic in- vasion at the time of the feverish reaction and on the first appearance of the erythematous eruption, may be the cause of hemicrania, of hys- terical convulsions, and even of temporary delirium. F. W. Langdon 12 would attribute the production of the syphilitic fever to the invasion of the nervous system by syphilitic toxins or its germs. The changes which take place in the constituents of the blood clearly explain the production of the fever and also of the neurotic affections. Syphilitic toxins invade the blood and produce such marked alterations in its composition that it must surely cause some morbid influence upon the cerebro-spinal system, revealed as neuroses of a simple irritative nature. Most of the nervous affections are found in late syphilis, of a permanent and destructive nature. They consist in a chronic specific inflammatory process, with a hypertrophic and hyperplastic nature, gummatous production, gummatous infiltration, gumma. This, how- ever, is not a primary affection of the nervous tissues, but must be con- sidered as an affection of the vessels, either blood or lymph vessels. It is in the nature of a peri- and of an endo-arteritis, as we find infiltra- tion in the connective tissues forming the tunics of the vessels, and an enlargement of the endothelial cells, with a thickening of the lumen of the vessels. The lymphatic vessels accompanying the blood vessels are the channels through which the syphilitic spirochaetse find their way to the blood vessels, as it is not very credible that the infection of the vessels comes from the main blood stream. In this point of view we agree with the opinion of Langdon, 13 who considers the source of in- fection in the walls of the blood vessels from the lymphatic vessels in 9 H. J. Berkeley. " Mental Disease." 10 Journal Mental and Nervous Diseases, 1898. 11 Quoted by Gould's Year Book, 1901. 12 Langdon. "Syphilis of the Nervous System," A. M. A., 1901. 13 L. c. 120 THE MEDICAL ASPECTS their tunics. Indeed, we know that syphilitic infection in the blood is only temporary and due probably only to the toxins, as the blood easily finds the way to get rid of them, while the infectious germs of syphilis, as Virchow 14 said, remain in the lymphatics, which offer the best cul- ture medium for their development. It is only the capillary plexuses of the vasa vasorum and in the intramural lymph spaces where a syphilitic germ finds the conditions favorable to its development. In accordance with these views, syphilis of the central nervous system is originated by a lymphangitis, phlebitis, or arteritis, from which an exudation of small infiltrating cells arises, small leucocytes of a delicate structure without any phagocytic power. They cannot oppose any resistance to the invading germ, and on the contrary they constitute the natural bouillon where the germ proliferates. These cells are collected in masses forming a gummatous tumor, or are spread out in the connec- tive tissues in thin layers causing fibrous organization, as in gummatous meningitis, diffuse arteritis. These infiltrating cells, however, have no right to remain in those tissues and on account of the pressure on the blood vessels they remain without nutrition and in consequence die. It may also occur that the blood vessels are capable of reabsorbing the small infiltrating cells, and take them again into the general circulation. In both cases, however, the irritation produced on the connective tissue fibers has already caused an hypertrophy and a proliferation of their corpuscles, and in consequence they must undergo the natural changes due to this process ending in cicatrix or rather in sclerosis. It is according to the period of the evolution of the pathological process that the manifestations on the nervous system will be of dif- ferent order. In case of an endoarteritis or of a thrombosis, which prevents the circulation in the blood vessels, the nutrition of the infiltrat- ing cells, and also of the tissues of the region must fall into a necrotic condition, and areas of softening are the result. Secondary degenera- tion of the neuron may occur in consequence of mechanical compres- sion of the infiltrating elements. As a result of stasis of the lymph in the lymph channels, toxic conditions may arise from different bac- teria, which cause local toxic conditions. Indirectly, syphilis may be responsible for chronic nervous affec- tions resulting from arteriosclerosis, such as paresis and ataxia. Syphilis in the late period, either acquired or of hereditary origin, constantly produces an infiltration and hypertrophy, which in the form of gummatous arteritis or of meningitis affects the nervous system. Many cases of infantile hemiplegias, and also of spastic paraplegias, recognize this source. Syphilis in children, moreover, is responsible 14 Virchow, R. " Ueber die Natur der constitutionelle syphilitischen Affec- tionen." Virchow's Archiv. 15 B. SYPHILIS OF THE NERVOUS SYSTEM 121 for defects of a developmental nature, and cases of idiocy and of im- becility find their cause in a degeneration of the vascular system. In the same way, in adults, syphilitic infection affecting the last plexuses of the capillary blood vessels in the cortex, is capable of attack- ing the various association tracts in the form of minute multiple foci of encephalitis, producing syphilitic epilepsy and other psychoses. This shows that the action of syphilis on the nervous system is quite an extensive one, at times, in the form of thrombosis, causing softening with resulting hemiplegia, at other times, in the form of meningoencephalitis and meningo-myelitis, causing various psychoses, and chief of all in the form of massive gumma with its train of con- sequences. Syphilis has been considered as one of the most powerful factors in the production of multiple neuritis. Dubois 15 has described an in- flammation of the sciatic nerve of syphilitic origin. The nerves may undoubtedly be invaded by minute gummata, but they may also be the seat of irritation or inflammation due to the syphilitic poison. There may also be a virulent subacute neuritis analogous to that caused by various other infections. In some cases the neuralgic pains may be the result of the compression of exostoses and other gross specific lesions. In the syphilitic neuritis it seems that the affection is not widespread to many nerves, but it is limited to the sciatic nerve, and may sometimes be only a reflex pain from spinal meningitis of syphilitic origin. LOCOMOTOR ATAXIA Locomotor ataxia and paresis are clue rather to degenerative changes. In many cases they are attributed to syphilis. But there are a few cases where syphilis was not found. In consequence the opinion of Strumpell that these alterations are the result of a post-syphilitic toxin, which, circulating in the blood, poisons the neuron, cannot be consistently accepted. But a much more plausible explanation is that of Berkely, 16 namely, that an extensive hyalin degeneration affects the arteries and prevents the nutrition of the neuron, causing it to undergo a molecular death. In some cases there have been found specific vas- cular alterations without gumma, which were the cause of the degen- eration of the nervous fibers. It seems that the infiltration takes place in the adventitia and in the intima of the arteries with hyaline fibrous material which narrows, and in some places nearly occludes their caliber. This condition is the direct cause of degenerative nervous processes in all its forms. 15 Quoted by James H. Lloyd, Twentieth Century Practice, Vol. XI. p. v }So. 16 " Specific Degeneration of the Cortical Arteries." Johns Hopkins Hospital Reports, IX, p. 236. 122 THE MEDICAL ASPECTS There is a close relationship between syphilis and insanity, and a great interval of time has been found to elapse between the syphilitic infection and the onset of insanity. In a series of cases of insanity following syphilitic infection, Dewey 17 found : in one, insanity follow- ing the infection wdthin two years ; in two, within three years ; in four, within seven years ; in three, within eight years ; in two. within nine years ; in one, within ten years ; in one, within twelve years ; in four, within fifteen years ; and in one, within sixteen years. In one case insanity occurred after nineteen years. Dr. Clouston 18 narrates a strik- ing case of syphilitic insanity from vascular alterations, in one man, twenty-five years after he had been infected. He became subject to regularly recurring convulsive seizures, and after a few years he was affected with general weakness, partial paralysis of the left side and thickness of speech. With enfeeblement and loss of memory, he passed into stupor and died. The autopsy revealed the calvaria condensed, the dura thickened and adherent to the bone and pia. and the latter to the convolutions. A great part of the center of the anterior lobe of the right hemisphere and many of its convolutions were atrophied. There were found hypertrophy of all the arterial walls and every form of irregular local arteritis. In some cases, in consequence of syphilitic arteritis, the whole of the white substance in the inside of the anterior and middle lobes, lying between the outside convolutions and the central ganglia, had gradually and entirely disappeared, leaving the gray, matter intact. This is due to the different way in which the gray and the white matter are supplied with blood, and the much larger quantity which the gray receives. Syphilomata produce brain and mental symptoms of a different nature, but they may sometimes be affected by treatment and the patient may recover. The mental symptoms may be those of an ordinary insanity, mania or melancholia, with or without delusions. We must call attention to the fact that in some cases of melancholia the patients claim to have been syphilitic, and may call the attention of the physician to any little pimple, believing it to be the result of syphilis. They have never had syphilis, and the idea of being syphilitic is nothing but a delusion, a gloomy idea due to melancholia and not to syphilis. In some very sensitive individuals the idea of having contracted syphilis remains with them, and they cannot think themselves free from the disease. They are neurasthenic, a kind of neurasthenia induced by syphilis, not of a material order, but only of a mere psychic origin. They are continuously hunting for symptoms, and any little indisposi- 17 Journ. A. M. A., p. mo. 18 Quoted by Fielding Blandford. " Insanity," Twentieth Century Practice, 1897. SYPHILIS OF THE NERVOUS SYSTEM 123 tion is by them referred to syphilis. This condition belongs to the class of nosophobias, and is called syphilophobia, which in some cases has caused a true melancholia. Mobius 19 calls tabes and paresis metasyphilis, and believes that they both become more frequent in just the degree syphilis extends. He finds both diseases to be essentially one metasyphilis of the nervous system, with a difference in the location : when the brain is affected, it is general paralysis ; when the centripetal nerve fibers are involved, it is tabes. But it is necessary to consider that in the largest number of syphilitic patients no general paralysis follows, and also that in many cases alcohol and syphilis may produce alcoholic and syphilitic insanity without general paralysis. In this regard there is a great division of opinion among the authors. Some are of the opinion that patients affected with insanity have been already predisposed to insanity, and that syphilis has very little influence or none at all in the production of the disease. Bevan Lewis excludes syphilis entirely from the category of the causes. He thinks that many cases of insanity occur in in- dividuals who have had syphilis, and some of them have been affected with pseudo-general paralysis, which closely represents the true kind. In these cases an antisyphilitic treatment may be beneficial in arresting the late syphilitic process, and has led to the belief that with anti- syphilitic treatment a case of general paralysis has been cured. As a rule, the antisyphilitic treatment in general paralysis is of no benefit, and it is strongly condemned by Fielding Blandford 20 as very harmful. But, indeed, we do not see what the treatment is capable of doing in a degenerative affection, where the gray and the white cerebral substance has been invaded and starved by the pressure of the increased connective tissues. It is the end of a process which affects the meninges and the brain in its totality without sparing any organ. In consequence, the criterion from the result of therapeutic measures is invalid, and of no interest. It is true that congenital syphilis is not a cause of insanity, but is a cause of idiocy, juvenile dementia and of different neuroses. GENERAL PARALYSIS General paralysis in rural districts is found very rarely, but, in large cities is quite a common disease. In England it is rare among the women of the upper classes, but appears much more frequently in those of the lower classes. In fact, among the latter we must consider the effects of alcohol and syphilis. 19 Mobius. "Tabes Dorsalis. Diseases of the Nervous System." Twentieth Century Practice, vol. xi, p. 806. 20 L. c. 124 THE MEDICAL ASPECTS Alcoholism is not entirely uncommon among ladies, and its results have been observed in the form of paralysis and dementia, but not as general paralysis. Syphilis is rather common among women of the lower class, and Blandford 21 says it is so common that if it were a frequent cause of general paralysis, the number of female general paralytics ought to be larger than it really is. The wonder is that this disease in syphilitic women is not more frequent, and for this reason he claims that syphilis is but one factor in the causation of this disease. In reference to the two diseases, general paralysis and tabes, Idelson 22 points to syphilis as a factor of etiologic importance, from the frequency with- which they occur in husband and wife. He believes this to be an argument in favor of the syphilitic origin of these diseases. He has collected 45 cases from the literature, and 5 cases of his own. In 47 per cent, of these both husband and wife were paralyzed ; in 20 per cent, the husband was paralyzed and the wife had tabes; in 13 per cent, the wife was paralyzed and the husband had tabes, and in 20 per cent, both had tabes. At times the diseases occurred simultaneously in both husband and wife ; in other cases at long intervals. In most in- stances the husband suffered first, the wife succumbing to the disease shortly before the death of the husband. Syphilis was confessed but thirty-six times in these cases. Since Duchenne pointed out the relationship existing between syphilis and tabes, the argument of the inefficiency of the antisyphilitic treatment was brought forward to deny this etiological connection. It was only in 1876, when Fournier, basing his deductions on his statistics, expressed the opinion that locomotor ataxia was most frequently caused by syphilis. Erb supported his views with a series of 44 cases, of which 2"j had a clear syphilitic history. This doctrine was opposed by the most distinguished neurologists, such as Westphal, Remak, Bernhard, Leyden, and also in France it found Julliard and Charcot as opponents. Their strongest argument was that syphilis of the spinal cord has a different appearance from that of locomotor ataxia. Gradu- ally the study of subsequent cases gave the interesting statistics of L. Meyer of Berlin, who found 19 tabetic women, all with previous syphilis. Moreover, in 1881 Gowers found 70 per cent, of cases of tabes to be syphilitic. In 1882 Fournier was able to produce a series of 117 cases of tabes, of which 91.45 per cent, had suffered with syphilis. In that number of patients he was able to show that tabes occurs only in the tertiary stage of syphilis, and in 85 cases out of 89, it had begun after the third year from the infection, and the course of the evolution of syphilis had been of a mild type. In 10 cases syphilis had 21 " Insanity." Twentieth Century Practice, 1897. "Idelson. St. Petersburger med. Wochenschrift. 1901, N. 43. SYPHILIS OF THE NERVOUS SYSTEM 125 shown symptoms of some severity, in 61 syphilis had been of a so-called benignant type. Of the 200 cases reported lately by Erb only 9 were without history of syphilitic infection. Of the 100 cases of tabes re- ported by Oppenheim, 59 had no history of infection, and in the last statistics of Bernhardt 83 per cent, of cases of tabes were found to have suffered with syphilis. From the result of these statistic data it is a consequent conclusion that syphilis and tabes are related. The objection that tabes is not tertiary syphilis does not disprove that tabes is a sequel of syphilitic pathological lesions on the nerve fibers of the spina. Mdbius 23 gave a detailed exposition of the history of the syphilitic etiology of tabes, concluding that in the great majority of cases of tabes it is possible to demonstrate the previous existence of syphilis, and tabetic patients where syphilitic infection is improbable are very rare. It is quite peculiar that in some cases of cutaneous syphilid, where we see with our own eyes the lesion to be a late syphilitic one, where we see the antisyphilitic treatment make the eruption disappear, yet the patient denies any possibility of infection. We are satisfied that the affection is due to a late syphilis, and yet we must resort to the term of ignored syphilis. We can apply the same reasoning to the few cases of tabes where a history of syphilis cannot be found. Tabes begins between the thirtieth and the fortieth years, rarely before the twenty-fifth, and rarely after the fiftieth year. Yet a few cases of tabes begun before the fifteenth year have been referred to by Fournier, Gowers, Remak and Strumpell, in all of which hereditary syphilis was demonstrated. One case of a tabetic patient at the age of seventy-four was reported by Berger, and he had been infected with syphilis when seventy years old. Tabes is found with more frequency among men than among women, in the ratio of 1 to 8, or at least of 1 to 4.4. This has been used as an argument against the syphilitic origin of tabes. But accord- ing to Mobius, in 50 tabetic women he found syphilis in the great majority, and not in a single case was it improbable. In the same way, of 32 tabetic female patients of Erb, 14 were certainly syphilitic. 12 were probably infected, and in only two cases there were no signs of infection. Tabes is found oftener in private practice than among the poor. The greatest number of cases collected by Erb was in private practice. He found in 550 of his cases that 324 were merchants and manufac- turers, 50 officers, 34 lawyers, 24 professors and teachers, and 1 clergy- man. The rarity of tabes among clergymen is quite remarkable, as noted by Mobius, and also by Bouchard among the French ecclesiastics. 23 Neurologische Beitragc, Heft iii. 126 THE MEDICAL ASPECTS That syphilis is related to general paralysis and to tabes is clearly shown by the above referred considerations. The age when tabes begins is in perfect relation with the time when syphilitic infection occurs. A man usually acquires syphilis in early life, just when the sexual instinct is most developed and legitimate gratification not possible. The infection is spread from prostitutes who, unrestrained, infect a number of young men. Men of higher social position marry comparatively late in life, and when they have contracted syphilis, they take the precaution of postponing their marriage for some years. In the larger cities the laxity of morals and the number of prostitutes are greater than in country towns, and consequently opportunities to con- tract syphilis are more frequent, which is in relation with more fre- quent cases of tabes furnished by the larger cities. In the same way the classes of men who, in general, must be virtuous are relatively spared, while the classes of men who claim to be men of the world, are more frequently the victims of this dreaded disease. A long interval occurs between syphilis and the appearance of tabes. The restoration to health after svohilitic infection is, in general, only apparently perfect ; modifications persist which are too slight to be perceived, but which nevertheless follow their progressive evolution. The syphilitic germ remains dormant, inactive in the lymphatic system for a long period of time, and through any peculiar irritation regains its activity and shows up in the form of multiple gumma or of a diffused inflammatory infiltration, around the blood or the lymphatic vessels, and in many cases the preferred tissues are the most delicate of all, the nervous center. It is a chronic affection, which will gradually bring about its effect. Organic affections are sometimes simple cicatrices, which, disengaged from the primitive cause, become autonomous and develop on their own account. Thus tabes is a chronic disease, which follows syphilis with the interval of many years. The time between syphilitic infection and the appearance of tabes may vary from two to twenty years. On an average it can be stated that the time which intervenes is from five to fifteen years. The same observations can be applied to general paralysis. Tabes is a parenchymatous atrophy of the posterior cords, and it is not a syphilitic neoplastic infiltration, but the atrophy and sclerosis is a consequence of the neoplasy, or a necessary end of the evolution. The parts of the nervous system which are attacked are not capable of regeneration, the changes there- fore are permanent and not susceptible of a cure. It has been stated that tabetic patients have had cases of very mild syphilis, and Fournier thinks the causation of tabes to be the insufficient treatment undergone by these patients. In our experience we have found cases of severe tertiary symptoms follow very mild SYPHILIS OF THE NERVOUS SYSTEM 127 cases of secondary syphilis. It is in the cases of benign syphilis that the patient, although intelligent and well educated, thinks that the continuation of treatment is superfluous as he finds himself in excel- lent health. But Fournier himself admits that even patients who have had a long and thorough treatment have been later affected with tabes. The question arises, how is it that of a great number of syphilitic patients fortunately only a few are affected with tabes? The answer to this question is easily found in the way that syphilis attacks the different organs in the different patients. We find that one patient will skow the most persistent manifestations in the skin, another in the throat; one will have iritis, another will be affected with syphilitic orchitis. It seems that syphilis attacks an organ according to the continuous stimulus which is applied to it. A man who smokes tobacco will show mucous patches on the lips and tonsils ; a man who has had gonorrheal epididymitis will in all probability show a syphilitic orchitis. In the same way on account of some accessory cause the nervous centre may be the point of attack of the syphilitic germs or of its toxins. In a neurotic, if he becomes syphilitic, it is possible that tabes develops on account of his nervous system being the pars minoris resistentice. SYPHILIS OF THE ORGANS OF SPECIAL SENSES As stated in the beginning of this work, our principal object is to treat syphilis from a general point of view ; so we cannot dwell long on the syphilitic affections of each one of these org-ans : even to give a short description would take us beyond our limits of space. However, as the affections of the organs of sense are of the greatest interest in reference to the infected, so we will very briefly summarize the prin- cipal syphilitic troubles occurring in these organs. Sight. This is the organ which in preference to all others is the favorite localization of lues. It has already been mentioned that the eyelids and the eyebrows are often the seat of papular and papulo- pustular syphilides, and in a late period gummatous foci are often found in these regions. Initial lesions of the eyebrows have been but rarely observed. One case was found by Ricord, and Lang refers to a case recorded by Morel-Lavallee, where an initial lesion developed on the left eyebrow, caused by a bite during a scuffle. We have observed an initial lesion exactly covering the glabella in a woman who fell and accidentally struck her face on a elass. Initial sclerosis of the lids have been 128 THE MEDICAL ASPECTS quite frequently found on the edge of the lid, on the inner conjunctival surface and on the outer skin. The manner in which the virus has been carried to the lids is different in the reported cases. The initial lesion of the eyelid has been observed after a kiss on the eye; in other cases it has been caused by rubbing the eyelid with a dirty finger. Lang refers to a case of Tepliaschin, where a syphilitic female " healer " was in the habit of licking the eyes of persons suffering with ophthalmia, who had in this way infected the lids of seven persons. One case of chancre of the left eyelid came under our own observation in a Russian Jewish girl, who had her eye licked by another person for the purpose of removing a small piece of cinder from under the eyelid. An interesting case is referred to by Desmarres, where a physician contracted an initial lesion of the eyelid from the saliva splashed into his face by a syphilitic patient in a paroxysm of cough, while the doctor was touching his ulcerated throat. In the case of the initial lesion of the eyelids, the trouble is, that it is not recognized till late, when it has fully developed and ulcerated, and only then does it receive an appropriate treatment. For this reason the surrounding skin of the lid is greatly swollen and edema- tous, the conjunctiva is red and greatly swollen, to the degree of chemosis. From the initial lesion of the eyelids, the lymph glands which begin to be infected are the preauricular and the submaxillary, which are at first either involved separately or together. In the evolution of secondary syphilis the eyelids are often the seat of papules and pustules, which are found also scattered over the surrounding skin of the forehead, nose and cheeks. Papules affecting the free edge of the lid, and especially at their angle, soon become abraded and ulcerated in the form of mucous patches. The eyelashes are often likely to fall off either from the ulcerated condi- tion of the edges of the lids or from the general alopecia. Gummata affecting the eyelids may remain limited to the skin or to the edge of the lids in the form of chalazion. When a gumma affects the skin of the eyelid it shows a nodular infiltration, surrounded by a dark red or bluish red color, the whole lid is painful and gradually becomes swollen, and when the upper lid is affected the eye is closed. The process may be acute or chronic, but usually lasts for several weeks, ending with ulceration. It heals up, leaving a cicatrix, which will usually lead to some degree of disfigurement, on account of the contraction of the skin. When the gummatous infiltration affects the free edge of the eyelids, then we have that rare syphilitic affection of the lids, which SYPHILIS OF THE NERVOUS SYSTEM 129 was called by Michel and Magawly tarsitis syphilitica. It is in a form of chronic indolent infiltration of the tarsus, which does not involve the external skin. This, however, is somewhat swollen and edematous, and the conjunctiva is also somewhat red and swollen. It looks like a hard and resistant tumor, consisting of a homogeneous infiltration starting from the tarsus, involving the mucous membrane of the inside of the lid, with some complication on the side of the bulbar con- junctiva. Under an appropriate treatment, the infiltration gradually subsides, and then the eyelid can be turned, showing patches of yel- lowish infiltration on the thickened conjunctiva. It is often followed by a deformity of the tarsus, the consequence of the pressure and destruction of the cartilaginous tissue. The conjunctiva is more rarely affected by syphilitic lesions. Only a few cases of initial lesions of the conjunctiva are on record, and nearly all have been found in physicians, who got into their eyes the saliva thrown off by the patients whose throats they were treating. In these cases when a hard chancre is developing in the conjunctival sac, conjunctivitis and photophobia will follow, and after healing only a superficial cicatrix is left. The preauricular and the submaxillary glands are enlarged, swollen and indolent. Gumma may show up on the conjunctiva, involving the sclerotica and also a limbus corneae, in the form of a hard, flat infiltration. It may undergo a process of involution and be reabsorbed. In case of its ulceration and breaking down, a thick cicatrix in the form of a pterigium will deform the conjunctiva. It is necessary to state that many of these affections have often been mistaken for malignant growths, or for lupous ulcerations, and the study not only of the lesion but of the whole body will reveal the presence of lues, and throw some light on its nature. We will only mention that the carunculse, although very rarely, have been found affected by the primary lesion or by gummatous infiltration. The tear ducts have been found involved in the syphilitic ulcerative products of the neighboring skin. The lachrymal sac and ducts have been equally affected in consequence of periostitis or ostitis of the bony lachrymal canal. Very few observations have so far been recorded relating to syphilitic affections of the lachrymal gland. Hutchinson called the attention of the practitioners to peculiar lesions of the cornea, which appear at a late period of the constitutional symptoms, and yields only to an energetic antisyphilitic treatment. Corneal affections have been found by Alexander to form 5.48 per cent, of all syphilitic diseases of the eye which came under his ob- servation. 130 THE MEDICAL ASPECTS It may come in the form of diffuse parenchymatous, or intersti- tial keratitis, which is more frequently found as a consequence of hereditary syphilis than of acquired lues. In this case it begins as an opacity in the center of the cornea extending towards the periphery, or more rarely from the periphery towards the center. The opacity has its place in the deeper layers of the cornea, and it is not homo- geneous, but is made up of small gray or yellowish-gray spots, more visible by oblique illumination. It lasts for a long time, the opacity gradually being reabsorbed, without leaving permanent alterations. The other form of luetic keratitis was described by Mauthner as keratitis punctata, and it affects the cornea in the form of a small gray spot the size of a pin-head imbedded in the corneal parenchyma. These spots suddenly come, and easily disappear, without producing any ulceration. Cases of gummata of the cornea have been reported, and most of them had begun upon the conjunctiva extending towards the cornea. The sclerotic is also affected by syphilis, unaccompanied by iritis or cyclitis. Mooren, and afterwards Galezowski and Higgens de- scribed an episcleritis, and Bull 24 divided the processes of the sclerotic into episcleritis, or superficial scleritis, scleritis parenchymatosa, and scleritis gummosa. They show as infiltrated patches of the connective tissues of the sclerotic, causing the elevation of the conjunctiva. On account of a marked vascular injection they are deep red in color and formed by the minute congested blood vessels. These patches are more frequently found in the vicinity of the ciliary region. Some- times an iritis may also be present. The affection is chronic, lasting for months. The patches are usually reabsorbed and in the true superficial form will not leave any permanent discoloration of the sclerotic. When, however, the process has affected the deeper layers of the sclerotic, the alterations of swelling and of congestion will be much more intense. The parenchymatous scleritis does not end in suppura- tion or ulceration, but by reabsorption causes an atrophy of the sclerotic, which appears as a bluish dark discoloration, making visible the pigmented ciliary bodies and the choroid. In the gummous scleritis the infiltration is localized, in the form of a flat projection, from the size of a lentil to that of a split pea. Thev are more often found on the external segment of the eye, and on the course of the straight muscle, giving rise to the idea of its originating from the sheath of the tendon. They are hard nodules, sensitive to the touch, surrounded by congested blood vessels. They 24 Bull, Ch. S. " A System of Gen. Urin.," etc., " Syphilology," 1893, p. 352. SYPHILIS OF THE NERVOUS SYSTEM I.3I cause pain, some degree of photophobia, and the eye is much impaired in its movement. Syphilitic iritis is a common affection, which is found at any stage of the evolution of the disease. It has been stated that over one-half of all inflammatory affections of the iris are of luetic origin. Usually only one eye is at first attacked, although the other eye may suffer later on. It comes, as a rule, at the time of the papular eruption as an early lesion of constitutional syphilis, and it is found again with the late symptoms of tertiary syphilis. Iritis has been divided into plastic, serous, and gummatous forms. The first two forms of iritis have very little to distinguish them from one another, but the gummatous iritis or gumma of the iris is characteristic of syphilis. In some cases of syphilitic iritis, yellowish red points of the size of pin-heads can be seen on the edge of the cilia or the pupil, which are true papules, and this was called by E. Fuchs iritis papulosa. Iritis gummosa is characterized by a small distinct nodular elevation on the iris, yellowish in color, affecting the pupillary margin. It is the true gumma of the iris, which usually occurs solitary, lasts for some time, and usually disappears by fatty degeneration. After reab- sorption has taken place there remains a scar on account of the atrophy of the iris. It is a lesion of late syphilis. Any form of iritis is a grave affection because it may produce injury to the function of the eye by the formation of posterior synechias or by the occlusion of the pupil. The specific inflammatory process may spread from the iris to the choroid, and although rarely, may lead to the formation of secondary glaucoma. Syphilitic choroid- itis of an exudative type may also appear independently of iritis, and it may come as choroiditis centralis. In this case the macula is covered by exudation, and later on is changed into a grayish mass of connective tissue. Affections of the retina are considered also as not rare occurrences in syphilis. The optic nerve is, as already stated in the previous chapters, usually affected, in case of gumma of the base of the brain or of its meninges, in the form of syphilitic optic neuritis, or neuroretinitis. For this reason cases of amblyopia and amaurosis from brain syphilis are of not infrequent occurrence. Hearing. The ear comes next in importance. At the Interna- tional Congress of Otology, in 1887, we made syphilis of the ears 25 the subject of an article, which was afterwards quoted and misquoted in nearly every book. Our observations were made in the clinic of 25 Revue Medicale Franqaise et Rtrangere, Sept. 25. 1880, p. 427. I 3 2 THE MEDICAL ASPECTS Rome, then directed by Professor C. Manassei. The cases of syphilis were in all 144, of which 94 were men, 50 females. Of the 94 men, 60 were affected with secondary syphilis, and 34 had late tertiary symptoms; of the females, 35 had secondary lues, and 15 were in the tertiary period. In 144 syphilitic patients, we have found 16 with affections of the ears, while in the same number of patients 5 suffered with syphilis of the eye, and 4 with that of the larynx. Of the 16 affections of the ears, 15 were in the form of catarrh of the middle ear with an acute or chronic course, the sixteenth was in the form of syphilis tuberculo ulcerosa affecting the auricula. Affections of the ear have been more frequent in the secondary period than in the tertiary, in the proportion of 11 to 5. Patients with well developed roseola or papular syphilide have never shown signs of otitis externa, or alterations on the membrana tympani ; but they were affected w T ith catarrh of the middle ear. In 6 cases an acute catarrh of the tube and of the middle ear appeared at the beginning of the secondary period, and was accompanied by erythema faucium, swelling and occlusion of the Eustachian tube. Five cases of catarrh of the middle ear developed in a more advanced stage of syphilis, accompanying an eruption of mucous patches of the tonsils and of the posterior nasal cavity in the vicinity of the Eustachian tube. In these cases the catarrh of the middle ear was not so acute as in the first cases, but was more persistent. In four cases of tertiary syphilis, patients affected with deep gummata suffered with catarrh of the middle ear, independently of the condition of the pharynx and of the nasal cavity. In these cases there was found abundant exudation in the tympanic cavity. Only one case of tuber- culo-ulcerative syphilide had affected the auricula and the duct of the ear, extending its lesions to the promontorium, with perforation of the membrana tympani. From these observations conclusions were summarized as follows : 1st. Syphilis affects the ear more frequently than other organs, in the form of acute or chronic catarrh of the middle ear ; 2d. This inflammatory process in the earlier stage of the secon- dary period is mostly due to the inflammation of the pharynx and of the nasal cavity; 3d. In late syphilis a form of idiopathic catarrh of the middle ear is produced with peculiar characteristics ; 4th. In late or hereditary syphilis an ulcerative form of syphilis affecting the external ear may find its way to the mucous membrane of the tympanic cavity ; 5th. Syphilitic forms of ear affections, together with a general specific medication, require a special localized treatment. SYPHILIS OF THE NERVOUS SYSTEM 133 In regard to the initial lesion of syphilis on the external ear, it is so rare that it seems only two cases are on record. Lues was inocu- lated several years ago by a physician in Paris, through the catheter- ization of the Eustachian tube in five or six persons. Papular eruption when spread all over the body shows also on the auricula, and papules in the form of mucous patches not infre- quently appear on the concha or at the entrance of the auditory canal. Lang referred to the presence of a syphilitic papula on the right mem- brana tympani, in a factory girl suffering from syphilis. Zaufal, Knapp and Politzer have reported cases of otitis media from the con- dition of the Eustachian tube in the course of syphilis. But they do not find marked symptoms to distinguish a syphilitic otitis from otitis produced by other causes. Gruber has pointed out the syphilitic af- fection of the labyrinth, which suddenly and permanently impairs the hearing power. It usually affects both sides, though to different degrees. In cases of cerebral syphilis, especially of basilar meningitis, dis- turbance of the hearing may be present. Lane has referred to one case of deafness occurring after the appearance of the constitutional symptoms, accompanied by weak memory and diabetes insipidus. Cases of hallucinations of the hearing are the result of cerebral syphilis, as reported by Ayer. In one of our cases the patient com- plained of an unbearable noise in his head, which diminished after he was affected with hemiplegia. The seat of the ear affection has to be carefully determined for diagnostic, prognostic and therapeutic purposes. Smell. While describing the alterations of the syphilitic affections of the nose, especially of the syphilitic ozena, we had occasion to mention the bad odor produced, called cacosmia. We haVe also men- tioned the results of the destruction of the filaments of the olfactory nerves by a syphilitic ulcerative process which causes impairment of the sense of smell, anosmia. Cases of cerebral syphilis have been referred to where the sense of smell had nearly disappeared. Hal- lucinations of the sense of smell have, sometimes preceded attacks of convulsions, which as a premonitory symptom gave to the patient the illusion of the presence of a pungent and disagreeable odor. In cases of basilar meningitis the olfactory nerves have been found involved. with diminution or abolition of the sense of smell. Taste. Taste may suffer on account of syphilitic lesions of the tongue and palate, and as a consequence the obtusion of the sense 134 THE MEDICAL ASPECTS and inability for fine gustatory distinctions follow. As for the sense of smell, syphilitic infiltrations may effect compression on the fibers of the glossopharyngeal nerve, or of the chorda producing diminution of the gustatory sense. Lang referred to the case of Piogey, who found loss of taste in a man, who was suffering from neuralgia of the third branch of the' trigeminus, who had been infected with syphilis twenty years previously. Under the use of iodide of potassium the affection improved considerably. Touch. The skin is attacked by syphilis in preference to any other organ, and in the previous chapters we have briefly described the numerous cutaneous eruptions and lesions produced by syphilis. As a rule roseola and papular eruptions are ushered in without any sensation, but we have had occasion to see patients complaining of an unbearable itching sensation on the first appearance of an acute eruption of papular syphilide. Pain seldom accompanies syphilitic eruptions of the skin, and only in some ulcerated gummata accompanied by marked inflammatory symptoms does the patient complain of pain. In consequence of a syphilitic affection of the nervous centers, as gummatous infiltrations, or from altered condition of the blood vessels, the sensitive nerves of the skin may show alterations in their sensitive functions, in the form of paresthesia or anesthesia. Pares- thesia as a state of perverted sensibility, is revealed by burning, sting- ing and itching sensations, which closely resemble pain. Paresthetic phenomena depend more upon mild forms of irritation of the peripheral sensory neurons, and are found in cases of neuritis. In these cases syphilis acts more as a toxic agent, irritating the sensitive fibers of the roots of the nerves. In consequence of more severe affections in the cerebral and spinal regions we have seen the skin deprived of its tactile sense and become anesthetic. The patient himself does not usually know that he has lost in some areas the tactile sense, because there remains a subjective sense of numbness. In several cases of paralysis from cerebral syphilis where the tactile sense had been abolished, we found that the sensation was restored much sooner than the motion. In anesthesia not only the sense of contact and the sense of pres- sure is lost, but also the sense of temperature and that of pain is abolished. In some cases, however, the sensations are dissociated, so that we may find abolition of the sense of temperature without tactile anesthesia. This dissociation of the tactile sense is not found in peripheral lesions, but in deep affections of the gray matter of the SYPHILIS OF THE NERVOUS SYSTEM 135 spinal cord. The pain sense is associated with the temperature sense, and their abolition shows that the terminal sensitive nerves are en- tirely cut off from the neuron. In a case of progressive idiopathic atrophy of the skin from hereditary cerebral syphilis, which we reported one year ago, the atrophic patches of skin retained some dull sensation of pressure, but the sense of temperature and the sense of pain were greatly benumbed. VII THE NATURE OF SYPHILIS AS INFLUENCED BY OTHER PATHOLOGICAL CONDITIONS In medical practice it often occurs that cases of syphilis are observed so different in their clinical appearance and in their results that they can scarcely be recognized as belonging to the same disease. In some cases a patient after having exhibited an initial lesion will later show systemic symptoms so mild that at times it seems doubtful if he ever had syphilis. While in other cases the symptoms are so angry, so severe and so persistent as to produce alterations of the different organs with impairment of their functions. THE CAUSES OF MALIGNANCY In the previous chapter we mentioned that the evolution of syphilis has been divided by Ricord into three stages, primary, secondary and tertiary. The primary stage comprehends the period from the ap- pearance of the chancre to the general adenopathy. The secondary period is calculated from the first breaking out of the erythematous eruption, roseola spots on the external integument, or on the mucous membrane of the palate and tonsils, to the appearance of the superficial cutaneous gummata. In consequence this period includes the series of symptoms arising from a superficial, irritative process with a ten- dency to reabsorption without leaving permanent resulting alterations. The secretions from the syphilitic lesions at this stage are highly con- tagious. The tertiary period is marked by the tendency to hyperplasia, deeply involving the tissues and the organs of the body. The super- ficial gummata of the skin, which was also called syphilis tuberculo- ulcerosa, would be the line of demarkation between the secondary and the tertiary period. At this time syphilis is not so easily communicated from the secretion of the broken-down infiltrated lesions. The distinction of the evolution of syphilis in three periods has been readily accepted by all practitioners, and although an artificial one and objectionable in many features, yet we find it of great use- fulness. The study of disease cannot be based on exceptions, but on a general rule. If in some exceptions we may see tertiary symptoms occur at the time when the secondary ought to occupy the phenome- nological scene, this is only an exception, which deviates from the 136 NATURE OF SYPHILIS 137 general rule. If in many cases of syphilis we are fortunate enough to see only a mild roseolar eruption, a few papules, and then no other symptom whatever probably during the whole life of the patient, yet this fortunate occurrence will not forbid us to call a tertiary mani- festation a gumma, which may come after several years. In order to avoid the nomenclature of primary, secondary and tertiary symptoms, it has been proposed to make a distinction, in precocious . and tardy, or in early and late manifestations. In the same way the resolutive or irritative symptoms have been called the secondary, and the ulcerative or hyperplastic the tertiary. It is a matter of great importance to draw a line between the two orders of manifestations. It is true that it is hard to find the place at which to draw this line, but remembering the assertion, in natura non datur saltus, we will be perfectly satisfied to distinguish the two orders of symptoms. In some patients syphilis will have a complete evolution in the lightest form, the whole phenomena may consist in a chancre, a mild general adenopathy, a scarcely perceptible roseola, and that is all, the patient remaining in doubt whether he has had syphilis or not. In another patient we find that the syphilitic symptoms follow each other with some regularity and with some persistency ; an erythem- atous eruption is followed by a papular one, and papules on the tongue, or on the lips or on the palate and tonsils are persistently relapsing, then after several months the symptoms gradually disappear and no further relapse is seen. Both cases may be considered as cases of benignant syphilis, the first exceedingly mild, the second somewhat more severe. In neither have there been any symptoms showing any of the malignancy of the disease ; there have been no ulcers, no result- ing scars, no impairment of any organ or tissues. In some cases the general health of the patient suffers very deeply from the ravages of the syphilitic virus. The patient becomes very pale and anaemic, his face is of a sallow yellowish hue, he suffers pains, and instead of an ordinary papular syphilide, his body is covered with a papulo pustular syphilide. He has that kind of an eruption which has been called syphilis varicellaformis, or his body is covered with large pustules in the form of ecthyma or rupia, with large thick crusts. When syphilis produces these very deep and severe mani- festations, we call those cases malignant syphilis. This malignancy of syphilis, however, is not so bad and so dread- ful as that which we fortunately see in but a few unfortunate cases. where after a few eruptions syphilis manifests itself in deep forms with profound lesions, ending in destructive results. In consequence we find ourselves in the presence of two kinds of malignant syphilis, which must be considered separately. 138 THE MEDICAL ASPECTS MIXED INFECTION In the first case there is a double infection present, and syphilis changes its course and symptoms on account of the simultaneous en- trance of the pyogenic elements. In fact, Campana 1 considers the suppuration in the syphiloderma as the result of a new septic infection, which joins the chronic granulomatous one, as a result of syphilis. Tarnowski at the third International Congress of Dermatology main- tained that syphilis modifies its course and shows peculiar and severe symptoms as the result of the mixed infection of syphilitic virus and pus germs. This condition can be revealed at the time of the appear- ance of the initial sclerosis, as well as at the secondary and tertiary period of the disease. In this case after a short incubation the patient is affected with an initial lesion which promptly becomes ulcerated. The ulcer discharges abundant pus and detritus, the bottom takes on a gray yellowish appearance, the edges are somewhat detached, and an edematous condition of the. surrounding parts masks the characteristic induration. In these cases the lymphatic glands are soon swollen, in- flamed and break down with suppuration. The second incubation is a very short one, an intense syphilitic fever soon appears, followed by a polymorphous pustular syphilide. In some cases the lesions begin in the form of large isolated papules, on which the overlying epidermis is soon raised by a purulent secretion, which is readily converted into a dark crust. In other cases nodules of the size of split peas are formed in the depth of the derma, showing an inflammatory tendency. They soon break down, and the pus drying up in masses forms thick brown crusts, which cover an ulcerated surface. The ulcers on healing leave scars which remain through life. From these papules and nodules are originated the different pustular forms which we designate as syphilitic ecthyma, impetigo and rupia. On acount of the severe symptoms which appear at once, together with the general denutrition of the whole system, we consider these Cases as of malignant syphilis. Some of these cases with a well-di- rected mercurial treatment, together with tonics and reconstituents, are soon modified, and the disease takes the aspect of an ordinary case of syphilis in the condylomatous period, and is followed by recovery. In some other cases, however, the general debility is maintained and syphilis from the pustular form soon reaches the gummatous period. It is necessary to understand that cases of grave malignant syphilis do not originate from others of the same type. On the contrary, in cases where both parties could be seen, it has been found that the case of malignant syphilis had taken the infection from a case showing 1 " De morbi sifiliticiee venerei." Genova, 1894, p. 64. NATURE OF SYPHILIS 139 small ordinary mucous patches. In some cases, however, there was a purulent discharge from the vagina which could have produced the pyogenic infection together with the syphilitic virus. As already re- ferred to in this case the initial lesion takes a phagedenic aspect from the beginning, accompanied in short time by suppurating bubo. In many other cases we find that syphilis has a tendency to malignancy during its evolution, although it has begun like any other ordinary case. This condition is liable to arise at any time in con- sequence of other morbid causes debilitating the general system. The development of the microbes of the skin is favored, and they tend to penetrate into the integuments on account of malnutrition. We will never forget some cases of malignant syphilis developed after the injection of Coley's serum obtained from cultures of strep- tococcus erysipelas and bacillus prodigiosus. The injections were made by a distinguished colleague for experimental purposes. In one case a pustular syphilide developed covering the whole body, and after getting over this attack, the patient had several relapses in the form of rupia. In another case where the same injections had been made the patient showed acute pulmonary symptoms, which resulted in an abscess of the lung. In this regard Dr. DuCastel of Paris 2 had the same experience in the case of a man who had been affected with syphilis, but for several years had shown no manifestation whatever. He was affected with erysipelas, and was treated with injections of the antistreptococcic serum of Marmoreck. When convalescing from the erysipelas he showed an eruption of superficial cutaneous gum- mata spread in many places on the body, with ulcerations, which still persisted after two years. These few instances referred to show beyond a doubt that syphilis takes a malignant character, not on account of the greater or less virulence of its toxic elements, but from circumstances inherent in the general condition and the general nutrition of the system. In fact, syphilis reproduces morbid manifestations in those organs or tissues which were already liable to be affected before the infection ; in a word, attacks the pars minoris resistentia?. It is thus that we see nervous people affected with syphilis of the nervous system, others easily suffering with catarrhal conditions of the throat are annoyed with per- sistent patches in that region. It seems that syphilis takes the oppor- tunity of all hereditary or acquired predispositions to show its ravages in the predisposed organs or tissues. In this way we find that the causes of malignant syphilis are somehow connected with the systemic condition of the patient : some. 2 Comptes rendus, iv. Congres International de Derm, ct Syph., par G. Thibierge. i 4 THE MEDICAL ASPECTS however, are the result of his way of living, of his habits, which we will briefly consider. We have already pointed out that neither the origin of the virus nor the locality of the initial lesion has anything to do with the produc- tion of malignant syphilis. It is, therefore, due to a predisposition of the organism to the pyogenic elements which is the principal factor. It is readily understood that all causes disturbing the state of health, mechanical, physical, chemical or animate agents ; bad nourishment, fasting, overwork, excesses, all these conditions capable of weakening the organism are favorable to the development of the infectious germs, rendering their evolution more serious. TUBERCULOSIS Tarnowski refers to cases of malignant syphilis, one in a man addicted to alcoholics, another in a patient affected with diabetes, a third had been very ill with an attack of typhus, a fourth had been affected with malignant syphilis following a case of gastroenteritis, a fifth had been exposed to hard labor under a severe moral strain. In our experience tuberculosis has a great influence on the course and on the malignancy of syphilis. It seems that the tubercle bacillus, in consequence of the new syphilitic infection, takes on an extraor- dinary activity and in this way syphilis assumes malignant forms. Vice versa, tuberculosis, which was latent under the appearance of good health, in consequence of the syphilitic infection shows itself with quick and destructive results. It is incredible how the two infections have so direct an influence on one another, so that when syphilis runs a severe course, tuberculosis usually supervenes and ends the life of the patient. In some malignant forms of syphilitic phagedenic ulcers, it is quite difficult to say whether they are due entirely to syphilis or to syphilis and tuberculosis together. These stubborn and destructive forms are a hybrid mixture of both infections, limited and localized to one part or organ, showing the malignancy and the destructive character of the two viruses. The tissues in a debilitated organism have no power to resist the ravages of the infectious germs, and in consequence undergo the work of destruction without a tendency to any reaction. ALCOHOL In Hospital service, where we have had occasion to see most of the cases of malignant syphilis, the most of the individuals are ad- dicted to the use of alcoholics. Indeed, in our private practice only rarely do we have occasion to see cases of this kind. In the public venereal wards of the hospital many of the patients coming from the NATURE OF SYPHILIS 141 lower class are addicted to the use of strong alcoholics, and, when infected, syphilis shows a malignant tendency. Chronic alcoholism is a powerful agent in producing ulcerative lesions of the skin and mucous membranes, and its disastrous effects are also frequently shown on the nervous system. Alcoholism hastens the evolution of syphilis so much that after a few months the lesions begin to have the characteristics of tertiarism. In one of our patients, a heavy drinker, one year after the infection gummata appeared on his face, head and nose, which ulcerated and left permanent scars. At the same time a gumma of the hard and soft palate destroyed that organ, leaving him in the most dreadful condition. Alcoholism tends to the localization of syphilis in the viscera, liver, kidneys and lungs, which, however, without the irritant action of the alcohol, under ordinary circumstances, are usually spared by the syphilitic virus. In the same way, patients affected with syphilis, continuing the use of intoxicants, are subject to cerebral syphilis in all its severe and distressing forms. Alcoholism and syphilis are each most effective causes of arte- riosclerosis. When, however, they are combined their result is abso- lutely disastrous to the system. For this reason, when a man is affected with syphilis, he must absolutely abstain from the use of intoxicants. TOBACCO Next to alcohol comes the use of tobacco, although it does not produce so dangerous results. At any rate, starting from the principle that syphilitic virus shows its lesions there where an irritation is applied, or better in any place or pars minoris resistentia, which is already liable to the action of morbid causes, it must be clear that the local irritant action of the tobacco will cause syphilitic lesions in the mouth, throat and nose, of a persistent and severe type. Syphilitic patients continuing the use of tobacco frequently show ulcerated mucous patches of the lips, tongue, tonsils and palate. The tongue is often affected in the form of extended glossitis with a tendency to ulcerative or hypertrophic process. Tobacco is often the cause of irritation of the stomach, producing catarrh and dyspepsia, and on account of this the patient suffering in nutrition is made much more liable to the ravages of syphilis. Further- more, a dyspeptic stomach will refuse the remedies, and we will find this condition also to be a drawback to treatment. We have- already called attention to the production of deep syphilitic ulcers in the pharynx of patients addicted to the chewing of tobacco. In tobacco has to be considered also a general action upon the whole system, in consequence a man affected with syphilis, having his system weakened by its toxins, is made more liable to feel the effects 142 THE MEDICAL ASPECTS of the tobacco on the general organism. In consequence tobacco will show its action upon the heart and the patient will suffer with a rapid heart and become neurasthenic. The injurious effects of tobacco, which are not seen in a man in his ordinary state of health, begin to be shown in the same man when he is affected with syphilis. Several patients have shown symptoms of tobaccoism ; they could not sleep, their appetite was lacking, their nutrition was run down greatly, and the total abstinence from tobacco helped their treatment considerably. Tobacco has also injurious effects upon the eye as well as syphilis, in consequence the patient must refrain from the use of the weed out of regard of the organ of vision. The bad effects of tobacco on the heart and nervous system are counteracted from the use of alcoholics, in consequence, in the ordinary circumstances, excessive smokers are also addicted to the use of intoxicants, and for this reason, if for no other, the abstinence from tobacco has to be enforced with the patient during the treatment of syphilis. OTHER DISEASE CAUSES In general every cause and every condition tending to weaken the organism is capable of rendering the character of syphilis severe and malignant. Individuals affected with malaria, if infected with syphilis may show a case of malignant syphilis, and vice versa a patient already infected with syphilis on becoming affected with malarial fever is liable to the severe manifestations of malignant syphilis. If a man affected with albuminuria, or with diabetes, unfor- tunately becomes syphilitic, he is liable to have a severe case of syphilis, on account of his previous debilitated condition, and also on account of the difficulty of the tolerance of treatment. A great deal has been said and written in regard to old age as one of the causes of malignant syphilis. It is quite natural to foresee severe manifestations of syphilis in old persons as the result of the prevalent arteriosclerosis and of the natural debility. Boy-Teissier 3 considers syphilis in the aged always grave, terminating speedily in death. All its manifestations from the initial sclerosis to the secondary forms are of unusual severity, and numerous infiltrations soon appear. The already existing arterio- sclerosis, increased by the syphilitic action upon the vascular system, soon becomes the cause of deep lesions of the blood vessels and of the "heart, so- that death will soon result. Robert W. Taylor 4 in this regard says, " A review of my clinical experience has convinced me that in rnanv elderly persons of vigorous physique and good habits syphilis runs a comparatively mild course, in less vigorous persons it is more 3 " Old Age." Twentieth Century Practice, New York, 1897. 4 " A Practical Treatise on Genito-Urinary," etc. New York, 1897. NATURE OF SYPHILIS 143 severe ; and in poorly nourished, weakly and underweight individuals, in the nervous, excitable, neuropathic and overstudious, it is often severe and even disastrous." In our experience we have seen several cases of syphilis taken in old age from sixty to seventy-two, and during the time the patients were under observation we did not observe any more severe manifestations than in younger persons affected with the same disease. We will only mention one case of a man at seventy-two who contracted a chancre on the glans penis, with all the characteristics of the initial sclerosis. It soon showed a gangrenous appearance, and the gangrene affected nearly the whole penis. The patient died with septic infection. Other cases of syphilis acquired in old age had rather severe symptoms during the evolution of the disease, and three cases in our practice were affected after the second year with a stroke of paralysis. From the foregoing considerations we must see that the virulence of syphilis is not clue to the virus itself, but to the condition of the infected organism. These may be found sometimes in hereditary dis- positions, sometimes in dyscrasia of the general system, either inherited or acquired, and finally in the way of living and in the habits of the patient. The first may be corrected by the physician with a well-directed adjuvant tonic treatment, and with well-directed hygienic rules, together with the antisyphilitic remedies. The second must be care taken by the patient himself to avoid the use of alcoholics, and the use of tobacco, and all the debilitating causes which are of great influence in the malignancy of syphilis. In consequence, when we find a case of malignant syphilis, and we do not find the patient under another dyscrasia which has a tendency to make syphilis of a malignant char- acter, we must inquire into his manner of living. In many cases we will find that poverty and lack of nutritious food are the principal cause of the weakening of the system. In many other cases we will find that the patient is continuing the use of strong stimulants, is often drunk and exposed to the cold air, and has continued in venereal excesses. The malignancy of syphilis is a punishment to his reproach- able conduct. INDIVIDUAL DANGERS FROM SYPHILIS On account of a prejudice, which in the olden times arose amongst the people against the acquiring of the so-called loathsome disease, the practitioners felt some aversion towards this line of practice, fearing it would bring discredit upon them. As a consequence, good con- scientious physicians neglected this branch of medicine, and quacks and charlatans got hold of the patients suffering from syphilis, imposing 144 THE MEDICAL ASPECTS on their ignorance, and taking from them all the money they could. Their first task was to fill those unfortunate patients with fear and despondency, exaggerating the seriousness of their condition and the future results. To-day, on account of the development of the auxiliary medical sciences, bacteriology and histopathology have thrown light on this branch of medicine, the venereal disease was changed into venereal diseases, assigning to each one their right nosological groups ; and their producing causes have been demonstrated. Therapeutics have shown what the remedies can do and what results are obtained. Men of integrity, science and ability have worked and are now working on the subject; they have brought the study of syphilis and the venereal dis- eases to the level of any other branch of medicine, and by showing the importance of a rational treatment, they have restored the confidence of our patients. We can state as a fact that syphilis at the present time is no longer so serious and so terrible a disease as it has been in days gone by. The judicious and appropriate treatment applied at the right time, to- gether with respect to due hygienic rules, has been a great help in diminishing the severity of the disease, and also in checking its spread. In this regard we will peruse testimonials of great competence, brought by Sir Herbert Spencer in his study of Sociology, vol. i, page 84. The chairman of the late Government Commission for inquiring into the treatment and prevention of syphilis, Mr. Skey, consulting surgeon to St. Bartholomew Hospital, gave evidence before a House of Lords committee. " Referring to an article expressing the views of the Association for promoting the extension of the contagious dis- eases acts," he said, " it was largely overcharged, and colored too highly. The disease is by no means so common or universal, I may say, as it is represented in that article, and I have had opportunity since I had the summons to appear here to-day of communicating with several leading members in the profession at the College of Surgeons, and we are all of the same opinion, that the evil is not so large by any means as it is represented by the Association." Mr. John Simon, F. R. S., for thirty-five years a hospital surgeon and now medical officer to the Privy Council, writes in his official capacity : " I have not the least disposition to deny that venereal affections constitute a real and great evil for the community ; though T suspect that very exaggerated opinions are current as to their diffu- sion and malignity." By the late Professor Syme it was asserted that : " It is now fully ascertained that the poison of the present day (true syphilis) NATURE OF SYPHILIS 145 does not give rise to the dreadful consequences which have been men- tioned, when treated with mercury. . . . None of the serious effects that used to be so much dreaded ever appear, and even the trivial ones just noticed comparatively seldom present themselves." We must, therefore, conclude, either that the virulence of the poison is worn out, or that the effects formerly attributed to it depend on treatment. The British and Foreign Medico-Chirurgical Review says : " The majority of those who have undergone the disease, thus far, including secondary manifestations, live as long as they could otherwise have expected to live, and die of diseases with which syphilis has no more to do than the man in the moon." It is stated by Mr. Byrne, surgeon to the Dublin Lock Hospital, that " there is not nearly so much syphilis as there used to be," and after describing some of the serious results that were once common, he adds, " you will not see such a case for years." Mr. Surgeon-Major Wyatt of the Coldstream Guards, when examined by the Lords Committee, stated that he quite concurred with Mr. Skey, and he said : " The class of syphilitic diseases which we see are of a very mild character, and in fact none of the ravages which used formerly to be committed on the appearance and aspect of the men are now to be seen. . . . It is an undoubted fact that in this country and in France the character of the disease is much diminished in intensity." Dr. Druitt, President of the Association of the Medical Officers of Health for London, affirmed at one of its meetings, that speaking from thirty-nine years' experience, he was in a position to say that cases of syphilis in London were rare among the middle and better classes, and soon recovered. One of the most important testimonies is that of Mr. Jonathan Hutchinson, who is recognized as the highest authority on inherited syphilis, and to whose discoveries the identification of syphilitic taint are mainly due. While under a natural bias rather to overestimate than underestimate the amount of inherited syphilis, Mr. Hutchinson, while editor of the British Medical Journal, wrote : " Although there is an impression to the contrary, yet recent dis- coveries and more accurate investigations, so far from extending the domain of syphilis as a cause of chronic disease, have decidedly tended to limit it. . . . Although we have admitted as positively syphilitic cer- tain maladies of a definite kind not formerly recognized, we have ex- cluded a far larger number which were once under suspicion. . . . We can identify now the subject of severe hereditary taint by his teeth and physiognomy, but those who believe most firmly in the value of 146 THE MEDICAL ASPECTS these signs, believe also that they are not displayed by one in five thousand of our population." In the United States we find James N. Hyde, of Chicago, who, al- though imbued with pessimistic ideas in regard to syphilis, wrote, " But all said and done, the representative of advance in social science should clearly recognize the fact that syphilis is not, as has been claimed by a class of hysterical writers in many lands, a scourge threatening above all other maladies the devastation of the human family. Tuber- culosis annually destroys many more victims. . . . The proportion of syphilitic to other diseases in no part of the world exceeds a variation of between 2 and 5 per cent, when both sexes are estimated in the statistical returns." 5 The statistics of the United States Marine Hospital Service, for the decade 1881 to 1890, inclusive, in a number of patients varying from thirty-two to fifty thousand a year, show that the number of cases of primary syphilis varies from 3 to 5.1 per 100; secondary syphilis varies from 12. 1 to 15 per 100. The percentage of deaths due to syphilis to the total mortality varies from 1 to 2.3 per 100. Sam Treat Armstrong, 6 after considering the statistics of hospital and of dispensary patients for ten years, writes : " In other words, among a number of thousands of patients coming from a class of society sup- posed to be particularly susceptible to venereal diseases, less than 10 per cent, of the total number of patients treated were suffering from the various forms of syphilis. These percentages show no tendency to an increase or to a decrease of the disease during successive years, and their range of variation is so moderate that the mean and prob- able error of each year is about 1 per 100. Another factor that is to be considered is, that there is absolutely no more restriction imposed upon these men than there is upon the members of the community at large." The mortality rate, taking the deaths from syphilis in comparison with the total number of deaths from all diseases, for the said decade, has been of 1.84 per 100. This means that in 10,000 deaths resulting from all kinds of diseases, 184 were due to syphilis. Dr. Joseph Schorr (Intern, klinisch. Rundschau Wien. 1888), in an interesting paper on syphilis as it occurs in the armies, stated that in the large number of 250,589 patients treated in 592 hospitals in Austria, 9.68 per 100 were suffering from syphilis. This calculation is very near to that shown from the statistics of the United States Marine Hospital service. 5 Hyde and Montgomery. " A Manual of Syphilis and the Venereal Dis- eases." Philadelphia. 6 " Syphilis in Relation to Public Health," in " A System of Genito-urinary Diseases — Syphil. and Dermat." Edit, by Prince A. Morrow, New York, 1893. NATURE OF SYPHILIS 147 We find it to be interesting to give the statistics of the City Hos- pital of Cincinnati for nineteen years, from 1888 to 1907, and which we have collected with the help of our clerk, P. A. Marchand. In the large number of 100,713 for the 19 years, the total number of cases of syphilis was 7824, which means 13 per hundred, so far entirely in accordance with the statistics already given. The death rate is also clearly illustrated in the small table; among 100,713 pa- tients, there were 9705 deaths, of which 168 were caused by syphilis, giving 17 deaths for syphilis in 1000 deaths from other causes. We must also remark that in the City Hospital we have two wards pur- CINCINNATI HOSPITAL. Total number of patients for the year Total deaths from all causes Total number of cases of syphilis Deaths from syphilis YEAR M F Total M F Total M F Total M F Total 1888 1889 j 1890 1891 1892 1893 1894 1895 1896 1897 1898..... 1899 1900 1901 1902 1903 1904 1905 1906 4174 2363 2559 2901 2672 3128 3423 ; 3600 3579 ' 3261 ! 2930 1 3051 ! 2750 ! 3257 1 3882 ! 4289 5217 5243 4979 1411 1291 1359 1284 1 143 1307 1523 1621 1675 1557 1492 1658 165 1 2126 2190 2127 2155 2780 2105 5585 3654 39i8 4185 3815 4435 4946 5221 5254 4818 4422 4709 4401 5383 6072 6416 8372 8023 7084 249 220 265 303 302 306 310 399 158 307 213 280 37o 436 5i8 513 583 624 619 126 194 104 in 108 126 149 123 119 120 128 129 147 161 171 180 242 209 257 375 335 369 414 410 432 459 522 442 378 435 342 427 53i 607 693 825 833 876 "3 72 94 72 83 161 214 177 148 99 75 229 275 169 217 270 34o 237 234 93 5i 108 33 67 76 160 100 97 67 120 173 222 525 313 452 955 655 224 206 123 202 105 150 240 374 277 245 168 195 402 497 694 53o 722 1294 932 467 10 5 1 5 2 6 8 8 7 3 1 1 2 2 5 9 5 I 12 10 3 1 1 6 5 7 3 4 2 3 1 2 5 2 5 11 1 4 13 6 2 11 2 11 15 11 11 5 4 2 4 7 7 14 16 13 14 Total.... 67, 258 33> 455 100, 713 6,880 2,825 9>7o5 3,288 4,536 7,824 102 66 168 posely for the venereal diseases for males and females, and no venereal disease is refused admittance to the institution. In reference to mortality in the United States we find very few cases of death reported as due to syphilis, and our figures are perfectly in accordance with those of the U. S. Marine Hospital service and of other hospitals in Europe. In the statistics of mortality reports, we see that most of the cases of death from syphilis occur in infants affected with congenital syphilis. It must also be taken under con- sideration that in some cases of death, syphilis has been the predispos- ing cause, and the disease causing death is accounted for as one from 148 THE MEDICAL ASPECTS other natural causes. This has a tendency to diminish the number of deaths from this disease; however, we cannot place a predisposing cause, which sometimes is only suspected, as the disease causing death. In conclusion, victims of syphilis are scarce, and we can state that they are no more than 2 per iooo, syphilis thus killing less than any other disease. This proves our statement that syphilis is at present no longer so virulent as in former times, that in ordinary circumstances it has no bad influence on the longevity of man, and all the dreaded consequences are no longer as common as we have found in the past generations. There is no doubt that this great change which has occurred in the nature of syphilis in the last century, is due mostly to the treatment and to the facilities with which it can be applied. The heresy that syphilis will disappear by itself without treatment has been entirely dispelled. The idea that mercurial treatment is the cause of so many sufferings, is gradually losing ground to such a degree that intelligent patients already know the medicine to be taken and have no fear of the alleged dangers. Indeed, we no more find a patient who speaks with fear of mercury, and they subject themselves willingly and cheerfully to any method of treatment we choose. We can state as a fact that the evolution of syphilis depends entirely on the treatment. When syphilis is left to itself with no treatment although in the beginning it shows very mild symptoms, it will surely lead later to more serious troubles, until finally it will reach the time when it will be accompanied by conditions of a very grave nature, at times even fatal. We cannot declare as a fact that every case of syphilis left without treatment will show late manifestations of the tertiary period, but we can say that all cases of a tertiary nature with grave symptoms belong to that class of cases called ignored syphilis. It is very difficult to find to-day a patient who, knowing, or suspecting that he has acquired syphilis, does not go to a physician and take some treatment, but cases without treatment come from the mild cases of syphilis which had been totally ignored. Fournier 7 refers to 221 cases of tertiary syphilis in his private practice, with every kind of grave late symptoms, in which no treatment at all had been administered. In our experience, in quite a number of cases of ulcerated gummata, of deep or superficial type, when the diagnosis has been told to the patient, it has been a surprise to him, stating that he did not remember having had syphilis in his life. But making a more careful examination of the past life, one usually finds that in early youth he had seen a small chancre, which the doctor cauterized and assured him to be a small soft chancre. There are many cases of young married women having had syphilis commnni- 7 " Traitement de la syphilis." Paris. NATURE OF SYPHILIS 149 cateci by their husbands, and this running a course with very mild symptoms., it is ignored on account of the unscrupulous fear that the wife may know the truth. It is in this way that we find cases of tertiary destructions of the palate, of the larynx, grave affections of the eye, of the nervous system, in persons where no suspicion of syphilis has ever been expressed. This is the course that syphilis pur- sues when it has been left to itself without treatment. Syphilis remains latent for many years, but finally breaks out in one or another organ, showing its destructive nature at a late period. The idea of the spontaneous epuration of the system from syphilis is entirely wrong, and the consequences show that the germs of syphilis have no tendency to leave the invaded organism. It seems, indeed, as already proposed by Virchow, that the syphilitic virus, taking the lymphatic current, is transported into the lymphatic glands, where instead of finding an obstacle to its progress, it finds a propitious abode and remains there undisturbed. The lymphatic glands, although true defenses of nature against the morbid invading micro-organisms, yet when the virulence of the germs is superior to the phagocytic power of their cells, are sub- ject to undergo the overwhelming power of the morbid agent. In this case, the morbid agent causing a negative chemiotaxis, finds among the young lymphocytes of the cavitary system of the glands a propitious ground for its existence. And so it happens that the germs of syphilis remain latent for years, and when they find an organ or a tissue in a weak condition, as pars minoris resistentice, or when the whole system is lacking in its reactive power, they awake from their latency and attack that organ with their virulent action. Returning to the power of the treatment, which consists principally in the administration of mercury in any shape or form, in any com- bination, with due attention to its inconveniences and injurious conse- quences, we find that it is indeed admirable. Any case of severe syphilis, neglected and ignored, as soon as it is subjected to the mer- curial treatment yields as if by charm. The treatment must be con- tinued for a long time, in fact must be chronic, just as the disease is chronic. We see the influence of the treatment so clearly in hospit-^ practice, where a patient comes with a syphilitic eruption, and he receives a few injections of gray oil or of sublimate, or some mer- curial baths or inunctions, and soon the eruption disappears and he feels well. He asks to be discharged, and although we try to impress upon him the necessity of continuing his treatment, in the generality of cases they stop using any medicine, and so in a few weeks or months they come back with a new syphilitic recurrence. In private practice, on the contrary, where the patient places himself entirely in the hands of the nhvsician, continuing in the use of the mercurials, in one form 150 THE MEDICAL ASPECTS or the other, according to his conditions and to the symptoms of the disease, we can say that only rarely do we see relapses. We can assert that in the patients whom we have treated in the beginning of their affection, and in whom we have maintained the treatment from two to three years at different intervals, has been scarcely ever seen a case of tertiary syphilis. The cases of tertiary syphilis which we have had occasion to see have been treated insufficiently, mostly at the different springs, where they receive the promise that with a few weeks' treatment they will have the syphilis cured. Indeed, such a promise is rather dangerous, not only for the future life of the patient, but for his descendants. The treatment must be severe, and continued for several years, in order to see its splendid results. It is indeed, as Fournier says, the antisyphilitic treatment which neutralizes the heredi- tary influence of syphilis. Many and many people who had been once infected with syphilis, after a good treatment, have been married, and now they have healthy and beautiful children. The evil of repeated abortions, of children born dead, or which die a short time after their birth, in a great many cases must be recognized as the result of syphilis insufficiently treated or left entirely without treatment. Fournier 8 refers to a series of 14 syphilitic patients who by their negligence had never been treated. They all married, some communicated syphilis to their wives, some did not. From these unions resulted 45 pregnancies, with the following results : Children living, of whom 6 are syphilitic 8 Abortions 29 •Children dying a short time after birth 8 This frightful statistical table is entirely different from the other coming from those who, having had the misfortune to contract syphilis, have had the good sense and patience to subject themselves to a long and thorough treatment. This is really reassuring, so that according to the same author, 9 of 100 children born of parents who were once syphilitic but had undergone a severe treatment, only three had died from a syphilitic cause. These tables are most eloquent arguments for recommending a severe and continued treatment in the early period of constitutional syphilis. We can say that syphilis is by the power of treatment amenable to recovery. That the treatment stops the progress of the evolution of syphilis in its secondary manifestations, and bv attacking the syphilitic germ directly, prevents the development of the late tertiary symptoms. The diminution of cases of severe tertiary 8 " Traitement de la Syphilis," p. 17. 9 A. Fournier. " L'Heredite Syphilitique," 1891. NATURE OF SYPHILIS 151 symptoms is due to the recent methods of applying the antisyphilitic treatment, and to the confidence restored in the patients. The medical gentlemen mentioned were right in stating that cases of severe tertiary symptoms are not so common to-day as they were several years ago. In the same way deaths from syphilis, with the exception of cases of congenital syphilis, are rare, and we have demonstrated that they do not exceed 2 per 1000. This reassuring report that syphilis by means of the treatment is diminishing in its intensity must not lessen our efforts to try with social hygienic rules to diminish the cases of inoculation, maintaining the old saying, prevention is better than cure. VIII PARASYPHILITIC AFFECTIONS To the series of syphilitic affections directly resulting from the syphilitic spirilli or from their toxins, another class of diseases must be added, what to-day are known as parasyphilitic maladies. Fournier called the attention of clinicians and pathologists to a series of alterations and manifestations occurring in individuals who had been luetic. He recognized syphilis as their principal cause, but the possi- bility of other causes is not excluded. Indeed, in these affections syphilis is no longer the only morbid factor, but they may arise inde- pendently of syphilis from any other cause which is capable of pro- ducing the same pathological alterations. From the therapeutic stand- point they are to be separated from the syphilitic manifestations by the fact that mercury and iodine, which act so well on secondary and tertiary lesions, have no influence on their evolution. Lesser 1 refers these affections to a special order of the syphilitic process, proliferating in character, which does not form gumma, but remains a pure interstitial process. It is really related to the gumma, but with this difference : in gumma the proliferated elements of the connective tissue pass through a stage of regressive metamorphosis before producing a cicatrix, and in this process they are gradually changed into cicatricial sclerotized elements. They are only a modality of the gummatous process, a modality consisting in the regressive metamorphosis of the proliferated cells. Gumma and interstitial in- filtration go hand in hand, and the first is the result of the second, when its elements undergo degeneration. The infiltration of the small cells takes place in the interstice of the cellular elements, but the pro- liferation takes place in the connective bodies, producing alterations of a rather parenchymatous nature. The interstitial infiltration is rather difficult to recognize for the very reason that so far we have no anatomopathological, histological or bacteriological data which will distinguish a syphilitic process from another of a different nature. In the study of the skin manifestations we are greatly assisted by the clinical appearance, but this process affects internal organs, runs a course without pain, is usually localized 1 Lesser, F. " Zur allgemeinen Pathologie der Syphilis und der sogenannten parasyphilitischen Erkrankungen." Derm. Zeitschr. Bd. XI, Heft 9, p. 627. 152 PARASYPHILITIC AFFECTIONS 153 in places where it does not cause objective symptoms, and is therefore obscure and difficult to recognize in its beginning and in its course. Indeed, it is so very difficult to make a differential diagnosis of a syphilitic gumma of the lungs or of the liver from a solitary tubercle of those organs, that in many cases we are compelled to resort to the criterion of the special preference of the affections for these organs, and to the result obtained by the remedies administered. The reasons which prompt us to refer the interstitial infiltration to syphilis are first the history of a past syphilitic infection, second the coincidence of scars or indurations which remain as the result of ex- tinct syphilitic lesions. Besides these general anamnestic characters, Lesser takes into consideration the locality in some organs which are by preference af- fected by syphilis, as the testicle, in the form of orchitis fibrosa, or in the lungs as interstitial pneumonia, when tuberculosis can be excluded. Another character is furnished by the grouping together in one organ of many cicatricial retractions, so as to impart a peculiar aspect, for instance to the liver in interstitial hepatitis as hepar lobatum, or to the tongue in interstitial glossitis as in lingua lobata. In the same way finding the same interstitial process in several organs in the same body as hepatitis, nephritis, myocarditis, etc., points out the luetic origin as the only factor of the alterations. Some light may also be afforded by the anatomical region of the affected organ, for instance, the base of the tongue, which is often affected with a characteristic atrophy, called by Virchow atrophia lsevis basis linguae; the aorta when affected in its arch, as mes- arteritis, producing aneurism, and the tibiae when showing those rough inequalities which we know as hyperostoses. The age of the subject can furnish some diagnostic data, when we consider that syphilitic interstitial process of the organs is found usually at an early age, much more than is the case from the common causes. Indeed, a cirrhosis of the liver at the age of forty will in all probability be the result of lues. It must be stated beforehand that the virulence of the syphilitic infection has a great deal to do with the production of intense inflam- matory irritation in the organic tissues. As a consequence, it will awaken an acute reaction on the part of the organism as an active chemotaxis, with production of infiltrating elements. On the contrary, when the produced irritation is feeble, and the vitality of the system is inefficient, a slight chemotaxis and a mild inflammatory process will be the result. The reaction, therefore, will be inactive and inefficient, the infiltration will be scanty, and it will have rather a tendency to the proliferation of the fixed tissue cells, causing interstitial luetic process. The interstitial syphilitic infiltrations are usually found in the in- 154 THE MEDICAL ASPECTS ternal organs, their progress as in the case of the gummata is unaccom- panied by pain, and does not produce objective symptoms which can be of any help for diagnostic purposes. The remains of this process are usually found in the internal organs at an advanced age in most of the individuals who have been infected with syphilis. Lesser especially would go so far as to say that the latent period of syphilis is only an apparent and a misleading one. In many cases the disease after the secondary manifestations, without showing any gumma, produces the interstitial process. This occurrence, of great scientific importance, places us in a condition to explain many questions concerning syphilis. In fact, we cannot explain in any other way the presence of the prod- uct of this process, unless we maintain that the virus many years after the infection is still alive and active in the system. In the same way it will be interesting to see how efficient the antisyphilitic treatment is in reference to the latent gummata and to the interstitial process. The presence of this latent process in the system of an infected person who, showing no symptoms for years, transmits lues to his children, can be found an important explanation for many problems concerning in- herited syphilis. In this regard we cannot put much trust in the statistics, which in a great many instances are not correct on account of the difficulty of diagnosis. Gummata of the brain on account of the appalling symptoms on the part of the sensory and motor nerves involved, are more easily diagnosed. But gummata of the lungs are quite fre- quently accompanied by tuberculosis, and as such are noted. In reference to the gummata or to gummous infiltrations of the liver, they pass quite often for cirrhosis of the liver. Gumma of the kidney and of the spleen quite frequently remains unobserved. The interstitial syphilitic infiltration is liable not to appear until many years after the infection, usually a long time after the gummatous period. Infiltrations of the kind are found in post-mortem of subjects who for twenty-five or thirty years had been infected with lues. Lesser has found syphilitic infiltration in the form of orchitis fibrosa in 31 cases, and as atrophy laevis basis linguae in 26. In the form of he par lobatum it was found in 12 cases; in 10 cases presenting in the form of hard callosities in different organs. These affections were found accompanied by remains of past syphilitic processes, as destructions of the hard and soft palate, scars on the bones, and characteristic scars on the mucous membranes. Their occurrence is only about 8.6 per cent., but very likely the per- centage may increase when we are able to take in many peculiar mani- festations of the lungs and of the myocardium, which are separated from syphilitic affections, for the only reason that they were not ac- PARASYPHILITIC AFFECTIONS 155 companied by other clearer manifestations. Indeed, we can say that parasyphilitic affections are distinguished with difficulty from other affections, which are capable of producing the same results. An inter- stitial orchitis will be differentiated from an orchitis caused by mumps, only through the existence of old syphilitic lesions, which point out the syphilitic origin of the manifestation. The lack of reaction to the mercurial and iodine preparations, 0:1 the part of the parasyphilitic affections, does not exclude their luetic origin. When we unfortunately have to do with cases of tabes, or of general paralysis, we establish their diagnosis when degenerative symptoms of the nervous substance are present, and as the nervous cells are not capable of regeneration, so from mercurials and iodides no benefit can be expected. In this regard we find many authors who still advise antisyphilitic treatment as the last resort, in tabes and general paralysis, but many others look to this treatment in the mentioned diseases with no con- fidence and rather as dangerous. The idea is expressed by comparison with the fire, which, when extingished, leaves the ashes ; syphilis has been there ; the process, however, is exhausted, and there only remains the degenerated tissues. By the majority of the practitioners tabes is always considered of a syphilitic origin, and it is only one of its final manifestations. The neurologists, however, consider that seventy per cent, of the tabetics re- cognize a syphilitic origin, and the manifestations of tabes arising from lues are favored by a nervous disposition, by alcoholism, and mostly by insufficient antisyphilitic treatment. The degenerative consequences of lues have a tendency to limit themselves to the system of the posterior cords in ataxia, to the pyram- idal system in the lateral hemiatrophic sclerosis. When the degenera- tion extends to the brain, then we have destruction of the nervous cells, hardening of the neuroglia, with the terrible and irremediable lesions of general paralysis. We must not limit ourselves to parasyphilitic affections, which are the result of acquired syphilis, but we must comprehend in this large group of maladies those which recognize as their factor inherited syphilis. In consequence of an arrest of psychical development, chil- dren remain imbeciles and idiots. When physical development is im- paired, we have found as a consequence inferiority and degeneration, lack of vital resistance and liability to be affected with other disease?. In the following chapters we will have occasion to study all the anomalies and malformations which are seen at the time of puberty, as the result of retarded inherited syphilis. The mentioned dystrophies and degenerations constitute marks of 156 THE MEDICAL ASPECTS inferiority for which inherited syphilis is alone responsible. They are types of degenerations, which lead to sterility and to diminution of the population. In reference to the treatment we have already had occasion to state that many authors are still inclined to try the administration of an antisyphilitic treatment, and they have claimed good results in many cases. We have already stated that these affections are not influenced by the mercurial or iodid preparations, but it cannot be admitted in an absolute way for every case. In retarded inherited syphilis the use of mercurials and iodides is attended with a very good action, and when continued with perseverance they may have a beneficial influence in the physical development of the child. Sanz y Bombin 2 referred to three cases of tabes and two of general paralysis where he obtained perceptible improvement and a standstill of the process, by means of intramuscular injections with benzoate of mercury, 5 centigrams every other day, together with the administration of iodide of sodium in large doses, continuing for several months. Syphilis is the modern scourge which causes disasters not only to the infected, but to his family, causing degeneration of the race. So terrible a scourge must be stopped by any means within our power. A perfect knowledge of this disease on the part of the physicians is a necessity, and for this purpose clinics, dispensaries and hospitals must be opened to the medical student in order to render him as far as possible familiar with the different manifestations of the disease. Hos- pitals and clinics must be open to the poor patients so that they may be treated with care and without expense. In this way the poor patients will avoid falling into the hands of quacks, who are the pest of society, and detrimental to the welfare of the infected patients. Syphilitic patients with eruptions dangerous for transmission of the disease ought to be detained in the hospital, and they ought not to be allowed to mingle with healthy companions in factories or in shops. Large numbers of patients are infected with syphilis without any fault at all on their part, and this spreading of the dreaded scourge could have been prevented if the individual infected with dangerous symptoms had been detained in a hospital. Physicians as well as patients must be thoroughly convinced of the necessity of the continuation of treatment. Treatment which we have already recommended must be long and chronic, as the disease is long and chronic. 2 Sans y Bombin, M. " Maladies parasyphilitiques." Cotnpt. Rend., XIV Congres Intern, de Medicine, 1903. PARASYPHILITIC AFFECTIONS 157 Finally, the greatest benefit would be the compulsory medical examination of the young man who applies for a marriage license. If this wise rule would be established, we would save a great many poor girls from being contaminated with syphilis by their husbands. If a man applies to an insurance society for a policy, he must undergo a strict medical examination. In the same way, when he applies for a marriage license he ought to be examined by an expert appointed by the Probate Judge, and when he is found infected with syphilis, license ought to be refused until he has taken sufficient treatment and the dis- ease has become so attenuated that there is no risk on the part of the bride. We are of the opinion that a law of this kind regulating the mar- riage license would contribute a great deal to the stamping out of this modern plague. IX THE INFLUENCE OF SYPHILIS UPON OTHER DISEASES It is quite interesting to consider to what extent syphilis does in- fluence other diseases, and, vice versa, how they influence the evolution of syphilis. This argument was very scientifically approached by Neisser, Bulkley, Ducrey, and Hallopeau, at the Dermatological Con- gress in Paris in 1900. 1 The door of entrance of the syphilitic virus is furnished by ex- coriations, which may sometimes be the result of vesicles of herpes labialis of herpes progenitalis. In some cases the syphilitic virus is mixed with other infectious germs, as in the case of a mixed chancre, where it is associated with the streptobacillus of chancroid, or with the staphylococci of the pustules, and both begin their morbid process in their own way. Clini- cal observation shows that an infectious disease can run its course in a syphilitic individual as an accompanying infection, while in other cases it shows that syphilis produces interesting modifications in the course of the associated infection. Syphilis, or rather syphilitic manifestations, may be associated with infections having a local action, as for instance a chancroidal virus or pyogenic infections, which, however, have no influence on the general evolution of syphilis. Syphilis, on the other hand, may be associated with infectious diseases, which, although they have a local action, are yet capable of producing general infection, as we have seen when it is associated with local tubercular forms or with gonorrheal infection. Finally, we must consider syphilis associated with general infections with an acute course like eruptive fevers, diphtheria, pneumonia, septic fever, etc., or with infectious diseases with a chronic course like tuber- culosis, lepra, malaria, etc. It is generally known that when the virus producing the chancroid is associated with the syphilitic virus, or that when the viruses are inoculated successively, a mixed infection results in which the char- acters of each affection are at their proper time well marked, and con- stitute a difficulty in diagnosis. In some cases it is necessary to resort to the reinoculation of the chancre so as to obtain a datum, but the 1 " IV Congres International de Dermatologie et de Syphilographie." Compt. Rend, par le Dr. Thibierge, 1901. 158 INFLUENCE OF SYPHILIS UPON OTHER DISEASES 159 best criterion is to follow the evolution of the morbid manifestations, local and general, so as to be able to establish the presence of the syph- ilitic infection. According to Ducrey, the clinical study, the experimental and the histo-bacteriological test show that the streptobacillus of the soft chancre does not find in the syphilitic lesion any condition which opposes its propagation and development. In the experimental in- oculations of the virus of chancroid on the initial lesions of syphilis, he has constantly obtained positive results. Furthermore, the histologi- cal and bacteriological study of the virus has shown that the strepto- bacillus. by its distribution in the tissue elements, and by its histo- chemical reaction, does not undergo any change on the syphilitic ground, and its development is just the same as in non-syphilitic tissues. But it has been observed that a syphilitic initial lesion, when compli- cated with chancroid, is very likely to show a necrotic or phagedenic tendency. An early diagnosis of the mixed chancre is of great interest in reference to therapeutics, for the reason that the use of caustics, which have a good action on the course of the chancroid, have usually a beneficial result on the mixed chancre, while the same caustics remain useless on the initial lesion and are very likely rather detrimental. The association of pus-generating elements with syphilitic products is of the greatest importance in every phase of the disease. With the hard initial chancre there may be associated streptococci, staphylococci, gonococci, which are capable of communicating unusual severity to the lesion. The initial syphilitic lesion, which is made up of an infiltration of small cells, on account of maceration of its epidermic cover, has not only a tendency to become eroded, but is, in consequence of pus germs, changed into a true ulcer. Indeed, from the culture of the exudation of ulcerated syphilitic sclerosis, there is obtained a variety of pyogenic cocci, which are more abundant when the ulceration is more pro- nounced. The same variety of pus cocci are found in syphilitic initial lesions of the tonsils, in individuals subject to pyogenic affections of these organs, and in the same way in syphilitic lesions of the rectum, of the prepuce and of the urethra, especially when a gonorrheal process is complicated. Indeed, syphilitic lesions through the presence of these* germs are rendered malignant and have a tendency to an ulcerative or to a destructive process. Their presence is often the cause of lymph- angitis, and the lymph glands becoming secondarily infected are sub- ject to adenitis, ending with abscesses. The adenopathy which is caused by the syphilitic lesion has a chronic course without any tend- ency to an inflammatory process, and when it shows inflammation, this is the result of the pyogenic cocci, or of allied micro-organisms. 160 THE MEDICAL ASPECTS The lesions of the secondary manifestations of syphilis, as we have already seen, are, according to Campana, greatly influenced by the presence of pyogenic elements. To them are due the ulcerative process shown by some papular eruptions, and the destructive characters and the long suppurations shown by some ulcerative processes of the mouth and throat. In the same way there are to be ascribed to the presence of the white or yellow staphylococcus, the pus collections which are found at the top of the syphilitic eruption in the form of the varicelli- formis syphilide. The power of the pyogenic germs is better shown in the long suppurative and ulcerative process affecting tertiary lesions of syphilis. To them are due the extended gummatous ulcers, which we see reach the skin, muscles, bones, etc. We have already seen the opinion of Tarnowski, that malignant syphilis is the result of the association of the syphilitic virus with the pus-producing germs. So far, we do not know the action which these germs are capable of induc- ing in the general system, but surely it is one of infection, which has a great tendency to lower the vitality of the organism. Ducrey speaks of a trichophytic patch of the beard, which had found its way deep into the follicles of the hair on account of syphilitic ulceration, assuming the appearance of trichophytic granuloma. In our practice we have often had occasion to see trichophyton in all its varieties on syphilitic patients, but we have never observed any change in its course on account of a syphilitic eruption. We have had many cases of sycosis in syphilitic individuals, due to syphilis and to the staphylococcus in the hair follicles, but we have never found it to be maintained by trichophyton. In reference to chronic dermatoses, such as eczema, psoriasis, lichen planus, ichthyosis, we are not ready to report many observations. In our experience it has not been a rare thing for us to have occasion to see eczema associated with syphilitic eruptions, and in many cases we believe that these have been the cause of the eczema. In some women who neglect the cleanliness of the body the presence of mucous patches in the crurogenital fold was accompanied with eczema, which had its origin in the irritating qualities of the secretion of the mucous patches. Eczematous eruptions of the same kind we have found ac- company the presence of excoriated or ulcerated mucous patches of the angles of the lips. In all the cases we have seen we can state that if the presence of the patches had produced eczema, the eczema had no influence on their course. The treatment of the patches, together with the eczema, in a short time cleared the surface without diffi- culty. Some syphilitic eruptions in the secondary period, having their location on the scalp, forehead, naso-labial furrows, and chin, are. when INFLUENCE OF SYPHILIS UPON OTHER DISEASES 161 accompanied with seborrhea, considered by Unna 2 rather refractory to treatment. Indeed, this author recommends the association of the specific treatment with a medication capable of treating seborrhoic eczema so as to obtain the healing of the syphilitic lesions. In our experience we have seen several patients affected with psoriasis who had been infected with syphilis, or vice versa, syphilitic patients who began to show psoriasis. During the beginning of the constitutional period of syphilis, when the patient had erythematous and papular eruption, the psoriatic patches had entirely disappeared. When the patients began to improve and were free from syphilitic eruptions, psoriasis gradually began to reappear. We are still treating a psoriatic patient for recurrence of the disease who several years ago had a severe case of syphilis, while he has not shown any more syphilitic manifestations. We have seen cases of lichen planus in individuals who many years previously had suffered with syphilis. They were men above fifty years of age, and they had been infected with syphilis in their young days, so that one affection had no connection with the other. In two patients affected with ichthyosis congenita we have observed the development of syphilis. The two diseases did not show any influence on one another except that at the time of a thick papular eruption, the ichthyotic condition of the skin seemed somewhat im- proved. When the patient began to improve in his luetic condition, ichthyosis returned. That syphilis may coexist with gonorrhea is proven every day in our hospital service. It is undeniable that the irritation caused by the presence of the gonorrheal secretion may predispose to eruptions of mucous patches around the genitals, in the ostium vaginae. Only very rarely have we found syphilitic manifestations in the os uteri, which could have been provoked by the presence of the gonorrheal secretion. Ricord, Jullien, Reclus, and others maintain that gonorrhea in man may predispose him to syphilitic epididymitis, orchitis, etc., which is not supported by our observations. Indeed, we have never, or only very rarely, seen cases of syphilitic epididymitis or syphilitic orchitis starting from a gonorrheal complication. It is true that the old asser- tion of the locus minoris resistentice would be there to explain the in- fluence of one affection on another, but we have failed to see the realization of these cases. In cases, however, in which the gonorrheal process becomes gen- eralized, as it is in gonorrheal arthritis, it seems that it would have a 2 Unna P. G. " Syphilis und Eczema seborrhoicum." Monatsh, f. prakt. Derm., vii, 1887. 162 THE MEDICAL ASPECTS deleterious influence on the syphilitic infection. Some observations have been referred to by Rieu-Villeneuve, and Ducrey believes that gonorrheal rheumatism is more frequently met with in individuals who have been affected with syphilis. In Ward C of our City Hospital we have always on hand cases of gonorrheal and of syphilitic rheumatism. We find that there is a great difference between the two affections, but some deleterious influence is surely produced by one disease on the other. Riehl 8 presented a patient to the Dermatological Society of Vienna, who had suffered with extensive syphilitic ulcerations. He came back to the hospital affected with erythema multiforme and pains in the joints. This was regarded by Riehl as a mere coincidence, because, according to his views, he did not find any relation between syphilis and erythema. Erythema in its multiform or nodose types can affect anyone, and it is also possible that it affects some who have been in- fected with syphilis. On this point Finger could not see a simple coincidence, because syphilis can produce lesions very much resembling the erythema multi- forme. He has observed cases of eruptions of erythema multiforme in syphilitics which were only cured by mercurial treatment. Neumann, too, was of the opinion that syphilis can simulate erythema multiforme, and the differential diagnosis may be helped by the localization of the eruptions. Sachs 4 showed another patient who, together with a papular syphilide of the trunk, had an eruption of erythema nodosum of both legs. The question is whether the coincidence of both affections was an accidental one, or whether between syphilis and erythematous forms may exist some near relation. Finger seems rather inclined to think that some relation exists between them, and he supports this view by the observation of cases of gummatous ulcerations of the legs, together with nodules of erythema multiforme. The erythematous nodules dis- appeared without treatment, while the syphilitic gummata required specific treatment to obtain their recovery. In 1876 Mauriac mentioned an erythema nodosum in conjunction with syphilis. Indeed, the pathology of the erythemata has revealed it to consist in a venous thrombosis, thrombo-phlebitis, which are quite frequent as a consequence of syphilitic angioitis. It is necessary in these cases to be careful not to mistake a scrofu- lous erythema for an erythema nodosum. The last easily disappears in a few days without ever producing ulceration, while the scrofulous 3 Riehl. " Syphilis et Erytheme multiforme." Wiener Dermatolog. Gesellsch. May 4, 1904. Ref. Rev. Pratique des mal. cutan., etc. No. 3, 1905- 4 Sachs. Wiener Dermatalog. Gesellsch., May 4, 1904. INFLUENCE OF SYPHILIS UPON OTHER DISEASES 163 erythema or erythema induratum (Bazin) very often breaks down, ulcerates, and only with difficulty is brought to recovery. The influence of syphilis on the eruptive fevers is also apparent. In orphan asylums the children with syphilitic antecedents, when affected with measles, scarlet fever, variola, show a higher rate of mortality than the others who are healthy. In this case, however, it is necessary to take into consideration the weakness of these children, who are in poor hygienic conditions, nourished only artificially with the bottle. Petrowski 5 and Amiel have referred to observations of cases of lues where smallpox had been of great advantage in causing the dis- appearance of the syphilitic manifestations. Ziffer 6 in the same con- nection reported a case of a woman who, while suffering with second- ary symptoms, was attacked with a severe case of smallpox ; after she got well from variola, the syphilitic manifestations had entirely dis- appeared and had never returned. Her husband, also affected with syphilis, escaped smallpox, but suffered greatly from the ravages of lues. Neumann and others speak of the disappearance of macular or papular eruptions of syphilis during the course of variola. As a con- sequence of these observations, Jourjon and Garrigue have proposed the inoculation of variola in cases of malignant syphilis for a curative purpose. This proposition does not deserve much consideration. Moreover, as referred to by Bulkley, 7 the influence of variola on syphilitic subjects would have proved very deleterious on their general condition. Bamberger, Stohr, Guntz, and others have observed vario- lous lesions to be transformed into sypilitic lesions, and syphilitic ulcers to appear foul and necrotic, covered with thick yellow exudation, variola pustules accumulated on mucous papulae. In spite of all this it seems that syphilis, after an attack of variola, becomes somewhat attenuated, an attenuation probably due to the loss of serum through the variolous eruption. Many observations have been made in reference to the influence of erysipelas on syphilis. Ducrey in his experience has seen cases of erysipelas which developed in syphilitic patients, and in nearly all in- stances when the erysipelas had been rather severe and with hig'h tem- perature, syphilitic manifestations of secondary or tertiary type dis- appeared and had never returned. Mauriac, too, maintained the bene- 5 Petrowski and Amiel, quoted by A. Ducrey. L. c. 6 Ziffer. " Tuberculosis und Syphilis der Lunge nebst Reflexionen iiber Misch-infectionen (coincidence of Syphilis and Variola)." Pest. Med. Chir. Presse, 1888, p. 762. 7 Bulkley, L. D. " Syphilis and Associated Infections." IV Congrcs Intern. pp. 647-651. 1 64 THE MEDICAL ASPECTS ficial influence of the erysipelas in syphilis, and he formulated some conclusions in this regard. He thinks that in cases of syphilis where the morbid manifestations of the skin and of the mucous membranes are of a mild form, the occurrence of the erysipelas with a feverish reaction has to be considered as of beneficial influence. Under the in- fluence of the general febrile affection and of the local inflammation of the erysipelas, the syphilitic lesions are easily involved and rapidly disappear. This beneficial influence is seen not only on the lesions which are comprehended in their inflamed area, but it is observed equally in those manifestations far from the infected area. According to the same author, the organism which has been badly damaged and run down from the deleterious action of syphilis, through the curative action of the erysipelas is greatly changed, and its general condition greatly improved. Consequently the erysipelas would have a beneficial influence not only on the existing syphilitic lesions, but it would prevent further manifestations in the future. Quite often cases of erysipelas in the City Hospital are placed under our service. Some of those so affected were also from our ward for those affected with syphilis, but unfortunately we were unable to see the beneficial influence of the erysipelas on syphilis. We have also referred to the deleterious influence of the Coley serum, which was injected in some syphilitic patients for the purpose of curing them of syphilis. We rather agree with Schuster, 8 who does not admit any cura- tive effect in the erysipelas, but considers the disappearance of symptoms as the result of the high temperature, without any permanent benefit. We must also remember that Lancereaux stated that patients suf- fering with syphilis are more easily attacked with erysipelas, and in them it is rather dangerous. In the maternity service, syphilitic women after their delivery are more frequently affected with erysipelas than the others, and in them it is much more dangerous in its evolution. In our experience we also have observed that in cases of puerperal erysipelas syphilitic women are more frequently subject to the inflam- mation, yet we have not found their mortality very high. In a few cases we had under observation we found that they soon became very weak, the pulse was quick and feeble, and frequent doses of strychnia and whisky were the only remedies to maintain the patients until they could recover from the erysipelatous infection. A beneficial action of erysipelas on syphilitic ulcers is possible. The ulcers have been the door of admission to the streptococci. 8 Schuster. " Das Verhaltniss des Erysipelas zur Syphilis." Deutsch. Med, Wochenschr. Aug. 25, 1887. INFLUENCE OF SYPHILIS UPON OTHER DISEASES 165 In reference to tuberculosis we must consider its influence on syphilis in a localized and in a generalized form. Individuals affected with lupus, if infected with syphilis, although no syphilitic manifesta- tion shows on the lupous patches, are more difficult to cure during the syphilitic constitutional evolution. Deutsch, however, refers to a case of an eighteen year old girl, affected with a lupous patch on her right knee, who contracted syphilitic initial lesion on the right labium, and while syphilis was developing the lupous patch healed up. In our experience we have seen entirely different results, and we have constantly found that the association of cutaneous tuberculosis with syphilis is of a severe nature and renders the lesion rather stub- born to treatment. We have given some illustrations (page 59), of extended destructive ulcers of the vulva, and of the skin of the groins, and of the perineum, in some cases involving the anus, in prostitutes affected with syphilis and tuberculosis. We have already seen that the diagnosis is rather difficult and that the microscope is not of great help, because the histological features of the lesion are alike in both morbid processes. The treatment, either specific or tending to improve the tubercular process, shows no decided effect, as we see on syphilitic ulcerative forms. It is usually admitted, as we have already seen, that general tuber- culosis has a deleterious influence on the course of syphilis. Indeed, tuberculosis, although having no peculiar action on the syphilitic pro- cess, must nevertheless have a grave influence in producing weakening of the organism and a tendency to cachexia. Acute or chronic tuber- culosis accompanied by anemia and digestive disorders, in the form of phthisis, renders the system extremely weak, and when syphilis is mixed with it the individual affected with both infectious diseases is fast running down. It is generally admitted that syphilitic virus has a decided action in wakening the tubercle bacillus, and consequently in provoking the evolution of tuberculosis. Neisser referred to the observations of Hochsinger, who had occasion to follow in heredo-syphilitic children cases of anomalous tubercular affections of a malignant type. He found that the lungs did not show signs of syphilitic gummata in caseous degeneration, but rather true tubercular lesions. This would dispel the opinion that pulmonary lesions are the result of mixed infec- tion. Indeed, the two infections together must act severely on the frail organism, and the system weakened by the syphilitic virus is made a favorable ground for the reception and development of tuber- culosis. We have had in our practice several cases of syphilitic patients, who, affected with pulmonary tuberculosis, have died with a severe 1 66 THE MEDICAL ASPECTS type of this disease. In the few cases which we have had occasion to follow, either in our private practice or in the hospital, we have always been convinced that each one of these infectious diseases has a great influence on the increase of the malignancy of the other. In some patients, when affected with tuberculosis, if infected with syphilis, this has taken on the character of malignant syphilis. In the same way in a patient affected with syphilis, when tuberculosis has mani- fested itself it has been of a severe and galloping type. From our observations we are not ready to agree with the opinion expressed by Portucalis and Abrahams : that syphilis acts favorably on the course of tuberculosis. They believe in a kind of specific antagonism between the products elaborated in the system by the in- fluence of syphilis and those caused by tuberculosis. In the cases where an individual affected with syphilis contracts another infectious disease it may be that there is only an association of the two diseases, and that one affection remains indifferent to the other. In these cases, according to Hallopeau, there is rather a con- comitance of the two diseases. He explains the concomitance with the case of a man who, suffering with secondary symptoms of syphilis, with his mouth full of patches, had his superior lip split open by a blow. His wound was sewed and it healed by first intention without sign of an ulcerative tendency. A simple concomitance can be seen in this case of a trauma, where syphilis had no bad influence on the reunion of the wound. But an indifferent concomitance cannot be seen in the presence of infectious diseases, where some influence must be produced by the association of the two infectious elements. Indeed, we have already seen some influence exercised by the evolution of syphilis on the course of psoriasis, ichthyosis, lichen planus, which, although dematoses not established in their origin, are somewhat affected in their course and manifestations. Syphilis may already be in the system when another infection takes place, or the system may be already affected with an infectious element when syphilis is inoculated. In case of microbic association, this could usually happen in the primary and in the secondary period of syphilis. If we could inoculate syphilis experimentally in lower ani- mals, we could inoculate it together with other viruses of infectious diseases, then we could see the modification of their virulence in the poduction of toxins and in their pathogenic action. We must, however, be content with the clinical observations, and with that which w T e know in reference to the local syphilitic symptoms influenced by the pyogenic bacilli. In general, we can state that a man suffering with syphilis can be affected by other diseases without showing modifications in the INFLUENCE OF SYPHILIS UPON OTHER DISEASES 167 character of syphilis. Indeed, in the exanthematous fevers, the infec- tion is only temporary and cannot produce permanent changes in the evolution of syphilis, and their influence on the course of syphilis is an insignificant one. Mauriac 9 reported a case of a young man who had two initial lesions on the penis, and a painful right inguinal bubo. Twenty days later he was affected with measles. During the course of the measles the chancres healed and the bubo subsided. After the seventh day of the measles, at the time of the desquamation, a thick papular eruption covered the body and limbs. In this case he thought that the measles had hastened the development of syphilis, since it had been much quicker than in the ordinary cases. In fact, a papular erup- tion had appeared on the twenty-seventh day after the appearance of the chancre, while in other cases it takes from fifty to sixty days. In reference to typhoid fever there have quite often been observed cases of syphilitic persons stricken with typhoid. Jullien 10 saw a well- defined syphilitic chancre in a man, who was taken ill with a severe case of typhoid, which was not followed by eruption. He quoted Diday, who referred to a man affected with primary syphilis, who becoming ill with typhoid fever showed the syphilitic eruptions only 120 days after. In the City Hospital a young man in D Ward was ill with a severe case of typhoid fever. After six weeks' convalescing from the typhoid a thick eruption appeared on his body and limbs. We were called; to determine the quality of the eruption, which was beyond any doubt that of a papular syphilide. The man when admitted did not mention the existence of an initial lesion, which soon healed. In this case the infection of the typhoid fever must have retarded the eruption of syphilis. A short course of treatment brought about the disap- pearance of the eruption, and the patient was discharged. The man was seen some eight months later and stated that he had not seen any more syphilitic symptoms. Bulkley quoted Krim, who had also reported a case of secondary syphilis, which disappeared at the onset of typhoid fever. In our case we had the Widal test applied with positive result. We have already had occasion to mention the ravages of syphilis in those affected with malaria. Campana, Pellizari and others have referred to severe cases of ulcerative syphilis in patients already weak from the effects of paludism. Malarial cachexia predisposes to visceral syphilis, when the two diseases are acting together. It seems that, according to Lepers' 1X investigation, there is no association of the 9 Mauriac. " Syphilis primitif et syphilis secondaire." Paris, 1890. P. 350. 10 Jullien. " Traite des maladies veneriennes." Paris, 1899. 11 Lepers. " Syphilis et paludisme." These de Lille, 1889. Ref. Brit. Journ. of Dermat., 1891. 1 68 THE MEDICAL ASPECTS two diseases, because their germs are of a different nature. The Plasmodium of the malaria is an aerobic and the syphilitic germ must be anaerobic, consequently the morbid activity of the syphilitic germ would be greatly increased by the consumption of oxygen by the Plas- modia of malaria. This would explain the malignant character assumed by syphilis in individuals affected with malaria. Leprosy has been found associated with syphilis, both diseases showing their lesions. This occurrence, as Bulkley stated, would en- tirely dispel the idea that leprosy is only a form of hybrid syphilis. So far, positive observations on the lepra bacillus in relation to syphilis are lacking. A few observations of mixed infections of lepra and syphilis have been reported by Leloir and by Hillis. 12 A peculiar hybrid form of syphilitic leprosy has been described by Impey, but his observations are not supported by clear cases, nor can they show what the relations of the two viruses are to each other. It is of vital interest to ascertain whether syphilis has any im- portance, or better any possible causation, in the production of cancer. Syphilitic ulcers are not infrequently a good ground for the develop- ment of carcinoma. Lang 13 referred to a case of carcinoma, which developed on the site of a former syphilitic chancre. Carcinomata originating from gummata have been observed several times, but from a primary syphilitic lesion only two authentic cases are on record. One was in the clinic of Lang. There was an induration on the inner surface of the prepuce, which was also covered with papillomata. A few months after it showed a case of carcinoma, for which he was operated in the clinic of Prof. Billroth. Another case was likewise reported by Dutrelepont in a woman thirty years of age, who had a carcinoma developed on an indurated chancre of the right labium. In our practice we have observed only one case of carcinoma which developed on a syphilitic ulceration. A man of splendid physique came for treatment for a papular syphilide of large type papules. He had at the same time an ulceration with a tendency to vegetations in the mucous membrane of the right cheek. The ulceration of the mouth had nothing to do with the initial lesion, of which he bore traces in the sulco balano preputiale. It was a form of secondary ulcerated papule made worse by the use of chewing tobacco. The proliferation of the ulcer began to be so abundant that it was neces- sary to scrape the ulcer in order to reduce the granulations. The operation gave relief for only a few days, and then the granulations took on extraordinary vegetating power. The microscopic examina- 12 Leloir. " Traite pratique et theorique de la Lepre." Paris, 1886. 13 Lang, E. " Acquired Syphilis." Twentieth Century Practice, Vol. xviii, p. 36. INFLUENCE OF SYPHILIS UPON OTHER DISEASES 169 tion showed the carcinomatous stroma, and as it had its base on the inferior maxillary bone, so another operation was performed removing the affected portion of the maxilla, and the whole mass of the affected tissues. For a while we were looking for a recovery, but later on things changed for the worse and the patient, who was of a very sensitive disposition, was found dead in his bed. He had cut his veins with a pocket knife and bled to death. We have referred to this case while trying to see whether syphilis has any influence in the production of cancer. This question, which has been quite often treated by Audry, was very carefully approached by Etcheverry, 14 who gave a literary report of a number of cases where syphilis was associated with carcinoma. According to the views of Audry, carcinoma can develop on syphilitic leucoplasic patches, or on syphilitic stigmata, or even in individuals who had suffered with syphilis. Cases were referred to of the three different types, but the question whether this combination of syphilis with carcinoma is only an accidental one, or whether there is some relation between the two diseases so that syphilis may prepare the ground for the development of carcinoma, has not been touched. Indeed, we often find syphilitic ulcerations which can easily be mistaken for epitheliomata. So much so that it has become a rule that in cases of doubt of the existence of syphilis, before operating on an epithelioma the patient must first be subjected to an antisyphil- itic treatment. The hybridism of syphilis and cancer is not to be thought of, but cancer can easily develop on a syphilitic ulcerative process or on a scar of a syphilitic ulcer for the sole reason of finding a prepared ground. The tissues have no resistance, lack in reactive property, and as a consequence they have more receptivity for the cancerous germ, which finds an easy ground for its development. The same condition exists when cancer is developed on lupous patches, where we do not see any relation of carcinoma to tuberculosis, except the fact that the tissues are rendered better adapted for the receptivity of other infectious germs. In the microscopic specimens of our cases above referred to, the syphilitic ground clearly appeared from the char- acteristic syphilitic hyperplasia of the blood vessels' tunics. We are, however, not inclined to accept the views of Ozenne, 15 that of a mixed condition of cancer and syphilis forming a well-defined pathologic hybridity. The antisyphilitic treatment may improve the condition of the ulceration for a short time, but later the cancer will 14 Etcheverry. "Syphilis and Cancer." Ann. de Derm, et de Syph., 1904, Nos. 8, 9. Ref. Derm. Zeitschr. Bd. xii, 1905, p. 621. 15 Ozenne, F. H. " Du cancer chez les 'Syphilitiques, et de Thybridite cancero- syphilitique de la cavite buccale en particulier." These de Paris, 1884. 170 THE MEDICAL ASPECTS continue its destructive course. We consider syphilis as a simple co- incident cause, which with its irritating and infiltrating process creates partes minoris resistentice, which later on can become affected with cancer. The two diseases have nothing in common, neither do we find any influence of one on the other ; there is only a possibility that a syphilitic ulceration may be the ground for the development of cancer on account of its long standing and of its slow ulcerating process. Hereditary syphilis may be associated with many infectious pro- cesses ; in children affected with syphilitic pemphigus, it is not rarely that a gangrenous process may develop with the destruction of the skin. We have already seen in other chapters the influence of heredi- tary syphilis in predisposing the system to other infections, especially tuberculosis. It is also true that cases of osteo-arthritis, of osteo- myelitis, in the form of coxalgia or of Pott's disease, are often found in individuals tainted with hereditary lues. In conclusion, we can say that every disease may be concomitant with syphilis. Some of them may have no influence at all, each one continuing in its course. Some may exercise a temporary influence on the evolution of syphilis. Others may give the chance to syphilis to bring about more decided ravages, on account of the deteriorated condition of the general system. Others finally may become associ- ated with syphilis and make up a kind of hybrid form, producing more deleterious and disastrous results on the health of the infected. X t THE TREATMENT OF SYPHILIS It is natural for the reader to think, from the above considerations, that if by means of a good and rational treatment we have obtained diminution in the virulence of syphilis, and if through treatment we have reduced so much the cases of tertiary lesions, with the same treatment reducing and curing the earlier syphilitic lesions which are the carriers of the virus, we will diminish the probabilities of the spreading of the disease. Alfred Fournier x has been the first to establish this important prophylactic rule, which is solely in the hands of physicians and has already given such excellent results. In the following chapters we will consider all the different rules for the suppression of the spreading of the venereal diseases. We will see, however, that even with the best will and with the best intentions, the system of the regulation of prostitution either by the police or by the city authorities is inadequate. The strict rules of the police tend to diminish the number of public houses, but on the other hand tend to increase clandestine prostitution, which is undoubtedly the most dangerous for the spreading of syphilis, and for this reason all the rules come to an illusory result. In fact, when prostitution leaves the public houses, there is an increase in the number of puellse fre- quenting concert halls, back rooms of the saloons, etc., which they use for .assignation purposes. Experience shows that the rules of the city authorities, of the board of health and of the police department to restrain and regulate prostitution are not only inefficient, but in many cases injurious. Syphilis is at present just what it has been in the past, an ulcer on the body of society; but we can say, judging from statistics, that in these last twenty years, if it has not diminished much, it at least has not increased. We agree with Fournier that we find syphilis in every place, in hospitals, clinics, infirmaries, insane asylums ; yet on studying the statistical reports of American cities for the last ten years, the number of syphilitic diseases keeps nearly the same proportions. There is no doubt that the most powerful means to prevent the spread of syphilis is a well-directed treatment of the disease. Through 1 Fournier, A. " La Prophylaxis de la Syphilis par son Traitement." Bulletin de I' Acad., 1899. 171 172 THE MEDICAL ASPECTS treatment we succeed in freeing the infected patient from syphilis and at the same time we protect society from the spreading of the infection. After having recognized the treatment as one of the most effective ways to diminish the possibility of infection, there comes as a conse- quence the necessity of an easy access, especially for the poorer classes, to the benefit of the treatment. For this purpose we have hospitals and clinics. Fournier, and we with him, find the hospital a very good institution for the treatment of syphilis, but this only in the case of severe symptoms, when it is necessary for the patient to rest in bed, have careful diet and special nursing. In the City Hospital of Cincinnati we have two wards, C and O, purposely established for venereal and syphilitic patients. Ward C is the male department, and O is for females. In regard to syphilis, we admit patients affected with the initial chancre, as well as those affected with syphilitic gummata. It is our rule to keep patients affected with syphilis in the hospital just so long as they have no lesions capable of transmitting syphilis. For men we have no coercive rule to keep them in the hospital except persuasion, and with a few kind words we succeed in having them remain until we are ready to dismiss them. On the contrary, for the females, especially when they have been sent from the health department, we have the right to compel them to remain so long that they can be discharged as free from lesions dangerous for the spreading of syphilis. Syphilis, however, is a chronic disease, and at any moment may show up in the form of patches in the mouth, or in any other way dangerous to others, and it takes years of constant treatment before we can consider lues entirely eradicated from the system. It is, there- fore, impossible to keep the hospital patients for so long a time, and moreover they can continue their treatment while pursuing their occu- pations. In this case the patient needs some medical advice, and for them the public clinics, dispensaries of the colleges, etc., prove very useful. Fournier vividly described the clinics for skin diseases and syphilis attached to the Hospital St. Louis in Paris. That big gloomy hall, that large table where is the chief of the clinic and the assistant physicians, the surrounding benches where are students and physicians and visitors, enough to make a bad and depressing impression on the patients. Moreover, on account of the number of patients, they must sometimes wait two or three hours before being admitted. The most of the patients come from the class of the working men, and the long wait means half a day or one day lost. The patient is compelled to disrobe, and half naked make his appearance before the public. When af- fected with syphilis, he must confess his guilt, sometimes before forty THE TREATMENT OF SYPHILIS 173 or fifty people. The physician in charge, after having seen many patients, is tired out, wishes to be through with his work, and limits himself to giving a prescription and telling the patient to come back in one or two weeks. Fournier justly condemns this system of clinics as injurious and dangerous. In many instances the patient has been only once in the clinic, he has heard his sentence of being infected, has received his prescription, and has continued with the pills prescribed for a few weeks, has become somewhat better, has left off treatment and has never been courageous enough to think of going back again to that gloomy room, and losing half a day of his wages. This man will be a source of contagium, will spread syphilis without care, and it has happened that his intended bride has been infected with chancre on her lips through a kiss. When questioned by Fournier how he could kiss his sweetheart when he had this inoculable disease, for which he had been to the clinics, he replied that nobody had ever told him that the disease was contagious through kissing. In another case where the man had inoculated his wife, both syphilitic parents brought to Fournier a miserable looking creature, the offspring contaminated with congenital syphilis. When asked how he could have gotten married while having this disease, the father replied that neither in the clinics nor in the hospital had anybody ever told him that he could not marry. Another case where a syphilitic child of syphilitic parents was given to nurse to a healthy woman, the woman developed a hard chancre of the nipple from suckling the babe. When the father was reproached for his carelessness, he said that nobody had told him anything in reference to the danger of infection. It is, therefore, a duty of the physician to instruct the syphilitic patient on the dangers of communicating the disease to others. It is his duty to place before the eyes of the patient the principal ways of the transmission of syphilis, not only through sexual intercourse, but through kissing, through utensils, pipes, towels, etc. Speak to him of the impossibility of getting married on account of the danger to his wife and then to his children. In this way the work in the clinics will be efficient and will result as a preventive to the spreading of syphilis. This can be done, how- ever, only in small clinics, when the number of patients is limited and the physician can afford to give a few minutes to explain to the patient the nature and the dangers resulting from his affection. Fournier therefore condemns the system of the large clinics and advocates the establishment of small ones. We must say that we entirely share in the opinion of the illustrious- 174 THE MEDICAL ASPECTS teacher, and in the principal cities of the United States we follow exactly his ideas. The clinics are independent of the hospitals, and by law the hospitals in Cincinnati are forbidden to have an out-door clinical department. The clinics are dependent on the medical col- leges and the professors of the different departments are the chiefs of the clinics. These clinics are for the benefit of the students of the college, and as an inducement to the patients, the remedies are dis- pensed free of charge. There are other clinics attached to charitable institutions, where patients are treated free of charge ; but with these we are not familiar. One of the interesting points to be explained by the physician to the syphilitic patient is that the disease, though perfectly curable, takes a long time, and requires a treatment continued not only for months, but for years. That the disease is contagious and through scratches, abrasions, small rhagades, cracks, is inoculated from the infected to the healthy individual. In this regard the syphilitic patient must abstain from any sexual relation with a healthy individual in order to avoid inoculation. When affected with mucous patches, abrasions of the lips, tongue and throat they must not kiss anybody, especially near the mouth, on account of the danger of communicating syphilis. They must exercise care in not allowing anybody to use anything which, soiled with the products of the secretions, may com- municate the disease, such as pipes, forks, spoons, glasses, towels, etc. The patient must be told that syphilis is not only contagious, but is also hereditary, and as a consequence a man who has been infected with syphilis cannot marry unless he has undergone a good, methodical, and often repeated treatment for three or four years, and a few months before he must be visited by his physician and obtain his consent, which will be given when no more signs of the disease can be found. The patient must realize that if married when still under the in- fluence of the disease, although having no lesions which can com- municate the disease to his wife, the fetus will be contaminated and through utero-placentary circulation the wife will be infected. His children when coming into the world infected with syphilis, will be a source of possible infection, and the nurse or anybody else having contact with the child may be easily infected. Another advice to impress upon the mind of a syphilitic patient, and upon which Fournier insists so much, is that the patient must always tell a physician in case of any illness, that he has had syphilis, in order to cast light on the nature of the affection. Fournier is of the opinion that a small printed card with these few instructions distributed in the clinics to the patients affected with syphilis would have a beneficial effect for the public. Azua, who has THE TREATMENT OF SYPHILIS 175 charge of the clinic in the Hospital de S. Juan de Dios in Madrid, has had these few points printed as avisos sanitarios, and they are given to the syphilitic patients coming to the clinic. In our clinic we limit ourselves to explaining to the patient the disease which he has, the danger of its contagiousness for others, and its hereditary tendency for the children. In our clinic of the Medical College of Ohio, a department of the Cincinnati University, the patient is inscribed in the regular book by one of our assistant physicians, who writes the diagnosis, a few points of interest and the treatment. At the same time the patient receives a card, which has a number corresponding with his number in the book. In this way by the number, without writing anything on his card, the assistant reads the diagnosis and treatment given on the last visit. We must say that we do not meet with all the difficulties and troubles complained of by Fournier in the polyclinics. It may be the different nature of the race, it may be the education, but our patients have no objection to being examined before the class and to being the subject of a few remarks on their case. On the contrary, they are so interested that after we have made a little explanation to the students. they ask for more information, showing that they have followed the remarks with attention. The patients in our clinic come before the class as they are dressed, and very likely they would object to disrobing in another room and coming into the clinic room naked. One patient at a time goes to the desk of one of the assistants, who writes down his name and the generalities, and asks also what the trouble is from which he is suffering. Cutaneous diseases and syphilis are treated together, and this makes it more pleasant for the patient who is afflicted with syphilis, since he can say that he comes to be treated for a skin disease In our clinic we have never found a patient who has objected to loosening his clothing and showing the eruption by degrees, first the chest and back, then the thighs and legs, or first the genitals and then the chest and back. In our experience we have always found objection on the part of the patient when directed to come into the clinic room entirely naked, and on the contrary they have never objected to re- moving the clothes or the wrap in the presence of the students. We divide the students into classes of twelve or fifteen for daily attendance at the clinics, changing about in order not to have the room crowded. It is a necessity to have in the clinics young physicians who intend to pursue special studies in the branch of diseases of the skin and syphilis, and from them we usually select our assistants. In the final examinations we require the candidates to answer several questions on 176 THE MEDICAL ASPECTS syphilis and on its treatment. Syphilology is a special branch of medi- cine, and as such requires a specialist, a man who has given time to this study, who has acquired a special experience on the symptoms and complications of syphilis, and who is able to institute a special scien- tific treatment. Unfortunately, the advertisements of the so-called quacks, or better, charlatan doctors, in the daily newspapers are of such a nature as to impede our work of protection from syphilis. Their advertise- ments are based constantly on the old popular prejudice against mer- curial preparations. In our opinion reputable newspapers ought to refuse advertisements of the following character : " I am the only doctor who cures syphilis without mercury." " Take only my vegetable pills and they will cure you in three months." or, "I cure syphilis to stay cured," etc. Bombastic statements of this kind are dangerous for the public on account of increasing superstition, and at the same time the guarantee of sure cure causes the patient to quit treatment, and hence we see later on syphilitic affection of more severe and of deeper nature. It is an unpardonable carelessness, to say nothing stronger, that newspapers of high repute allow in their pages such ridiculous advertisements, which are purposely given out to cheat and defraud the people, with disastrous results for the public welfare. In some instances we have seen young men who have had no syphilis go for a trifling herpetic eruption to the advertising quacks. They were frightened in regard to their condition, and were treated for some time for a disease which they never had. In one case of gangrenous stomatitis, the patient had been treated by a man who advertises that he cures syphilis with a decoction of herbs, and when the patient came under our treatment gums, mucous membrane of the mouth and parts of the tongue were a gangrenous mass. Many and many patients come under our observation affected with late symptoms of syphilis, and when we tell them that their trouble is syphilis they will hardly believe it for the reason that someone had guaranteed to them a sure cure, and asserted that they were perfectly cured. The reader can easily imagine the sad consequences that asser- tions of this kind must produce in reference to the spreading of syphilis. When a man is persuaded that he is cured, he neglects any other treat- ment, and under this persuasion he will get married, infect his wife, have infected children and all the troubles which we have spoken of, besides those we will consider later on. We are positive that if the editors of reputable newspapers knew the sad consequences which advertisements of the kind have on the health of the man who is infected and on the future of his family, THE TREATMENT OF SYPHILIS 177 they would surely decline to accept and publish such misleading state- ments. Statements promising a sure and permanent cure can be given out solely by charlatans, who with bold effrontery for the sake of their venal interest, try to take all the money from the ignorant patient who trusts to their hands his health, his family, and his future. Those vultures of society, whether doctors or not, who speculate on the venereal diseases for the sole purpose of obtaining money from the patient who is ignorant of the affliction and ashamed to make a con- fession to a reputable physician — these quacks ought to be stamped out as the most dangerous means of the spreading of syphilis. We can say that physicians learned in the subject of venereal diseases and syphilis will be of the greatest help in checking their spreading. Prof. Kaposi, when speaking to the Congress of Brussels on the subject, — " What rules must we take to oppose the spreading of syphilis and of venereal diseases,' 3 stated that no matter what rules the authorities or the police would choose, the most important point of the struggle is always in the hands of the physician. He concluded that one of the best means to check these diseases was to institute in all the medical faculties clinics and dermatological institutes purposely for the study of syphilis and of the venereal diseases. Furthermore that these branches of medicine should be made the subject of obliga- tory examinations. In our medical colleges we have now the chair for Dermatology and Syphilology, and the chair for Genito-Urinary Diseases. The students are compelled to attend these clinics and at the end of the fourth year they must pass the examination on these medical sciences. The examinations consist in answering in writing five questions in der- matology and five questions in syphilology. In the same way in the State examinations there are always given three questions on subjects concerning syphilology, so as to ascertain just how familiar the young physicians are with the knowledge and the treatment of so important a medical, branch. This has been the only way to interest the young physicians in attending clinics and lectures in dermatology and syphil- ology. We were the first to lecture on these subjects in the medical colleges of Cincinnati and to institute clinics and laboratories for this purpose, and to-day we have the satisfaction of seeing the good results obtained after twenty years of constant work. EXTERNAL TREATMENT It would be foreign to the purpose of this book to give a detailed description of the treatment of syphilis, which is fully given in all text-books. We will limit ourselves to sketching our ideas for the 178 THE MEDICAL ASPECTS treatment of this disease, and for the way in which we- treat our patients in the hospital and in the clinic. Our treatment is local, and general or constitutional. Patients apply to the clinics with initial lesions already developed. In most cases the lesion looks angry and inflamed for the reason that the patient has been to a druggist, who has given him a piece of nitrate of silver, or of sulphate of copper, with which he has badly cauterized the chancre and the surrounding skin or mucous membrane. In con- sequence the prepuce is swollen, edematous, forming a phimosis, so much so that if the chancre is in the internal surface of the prepuce or up on the glans, it can scarcely be seen. In cases of this kind the glands of the groins are involved, painful and greatly swollen ; the patient can hardly walk, and he is referred to the hospital. He needs rest in bed and we use continuous bathing with a solution of corrosive sublimate, i to 2000, to 1 to 1000. The solution is also injected through a syringe between the prepuce and the glans. And in twenty-four to thirty-six hours the inflammation has subsided, the prepuce can be retracted and the ulcus can be easily treated. Then we begin the applications with emplastrum hydrargyri, which is prepared as fol- lows according to the formula of the British Pharmacopoeia : Hydrargyri 3ii Terebinthinae 01 wxx Cerae Flavae 3 i Resinae 3 i Styracis praepar ' 3i Emplast Plumb 3i It is an ointment of soft consistency and is easily spread on a piece of gauze and applied on the chancre. It is very effective and by a process of suppuration produces the involution of the infiltration in a short time. It must entirely cover the borders of the lesion, and must be changed two or three times a day. In our clinic the patient receives a bottle of solution of bichloride, 1 to 1000, for washing, and a quantity of emplastrum hydrargyri. When the inguinal glands are enlarged, when the syphilitic bubo is pronounced, we advise our patient to apply a piece of cloth covered with the same plaster on both inguinal regions. Emplastrum hydrargyri can be employed in this way for the initial lesions in any part of the body, and also for an endourethral chancre it can be used by making a kind of bougie with a piece of gauze saturated with the plaster. In cases where the prepuce is narrow and it is difficult to treat the chancre, we resort to circumcision. When the glans has been exposed we have found a bad-looking chancre showing gangrenous patches. In THE TREATMENT OF SYPHILIS 179 these cases we return to the applications of continued sublimate bathing, and then dressing with iodoform gauze until the surface is thoroughly clean. In some cases where the enlarged glands are greatly hypertrophic and tender, we remove them on both sides. The results obtained have been gratifying, and as we have already remarked in an article on syphilitic bubo, the removing of the glands has a favorable influence in the evolution of syphilis. In fact, in most of the cases so operated on, the constitutional symptoms of syphilis have come much later, and the eruption has been so very mild that it could scarcely be noticed. After having removed the glands the only local trouble following has been some edema of the penis and of the scrotum, which has lasted from one to two weeks, and has then disappeared with the healing of the wound. We do not believe the cauterization of the chancre to be of any benefit, and for this reason we have entirely abandoned this method. When the initial chancre is in a place where applications of plaster are impossible, as in the oral cavity, tonsils, etc., then we touch up the chancre with a solution of one per cent, bichloride of mercury in alcohol and ether, as used by Lang, or with a three per cent, solution of acid nitrate of mercury. In the past we have quite frequently employed excision of the hard chancre, with the view of preventing the development of syphilis. The excision of the hard chancre was at first recommended by John Hunter and Benjamin Bell, who considered the chancre as a local af- fection. They maintained that general infection followed its appear- ance after some time, making in this way possible the destruction of the syphilitic virus, by the early removal of the initial lesion. In the clinic of Prof. Auspitz we saw many cases of excision of the hard chancre, but the results in most of the cases were negative. Auspitz, 2 however, maintained the opinion that initial sclerosis was only a local symptom, and that the removal of the chancre was the true prophylactic means. He published on this subject an article referring to 33 cases of excision of the hard chancre, claiming success in 14 cases. Since then hard chancres have been excised by hundreds, so much so that Dr. Crivelli 3 was able to report 454 cases of excision of hard chancre, and Ehlers 584.* 2 Auspitz, H. " Ueber die Excision der syphilitischen initial sclerose." Vierteljahresch. fur Derm, und Syph., 1877, p. 107. 3 Crivelli. " Des signes precoces de l'infection syphilitique, comme contra- indication du traitement abortif de la syphilis." Arch. Gen. de Median, 1887, T. i et ii. 4 Ehlers, E. " Extirpationen af den syphilitische initial Lsesion." Copen- hague, 1891. 180 THE MEDICAL ASPECTS The idea of the bacillary origin of syphilis caused the initial lesion to be considered as the focus of elaboration of the syphilitic germ, and in consequence the removal of the initial lesion was considered to be the most logical prophylactic treatment. All over the world excisions of the hard initial lesions were practiced, and we, 5 also, reported twelve cases of excision of hard chancres, with three successful results. On the other hand, many syphilologists, considering the scarcity of the results obtained, and moreover the doubt which naturally was arising con- cerning the successful cases, as to whether they were really initial lesions of syphilis, condemned this operation as one of no value. Zeissl, M. Maurice, P. A. Morrow, Corral and many others referred to cases of excisions of the hard chancre in which the constitutional symptoms of lues were not prevented. No longer than two months ago, in Ward C of the City Hospital, a patient was admitted with hard chancre of the internal surface of the prepuce, complicated with phimosis. The case called for circumcision. The prepuce was removed, with the chancre, an abundant area of normal tissue being taken out. The resulting wound was thoroughly disinfected with a solution of bi- chloride of mercury, and then the internal sheath of the prepuce was sewed to the external with continuous suture. The whole surface was healing by first intention, when seven days after the operation, in the left interior portion near the frenulum, the wounds of the stitches became ulcerated, the two surfaces detached, opened up and formed a new, diffused, round, hardened ulcer, replacing the first which had been excised. After these results, we have entirely given up the idea of the excision of the initial lesion with a prophylactic scope. Indeed, from our microscopical specimens we have found that the area of infection in the lymph spaces and in the lymphatic vessels is much more extended than the chancre, and the lymphatics are already infected, so that destroying the chancre cannot be of any advantage when an infected area remains around it. For this reason we prefer the application of the mercurial plaster, which acts so beneficially, producing the regres- sion of the sclerosis. It seems that the mercurial plaster attacks the source of the infection, so that in a few days and in an admirable manner it causes the healing of the chancre. Once in a while cases occur where the initial lesion is marked with chancroidal ulcers, or is associated with condylomata. In these cases, too, our first attention is given to the chancroids, which are touched with a ten per cent, solution of sulphate of copper, and then dressed with iodoform or aristol powder. The papillary growths or 5 Ravogli, A. " The Excision of the Hard Chancre," the Cincinnati Lancet and Clinic, Nov. 12, 1883. THE TREATMENT OF SYPHILIS 181 excrescences are touched with a solution of resorcin, one dram to the ounce of distilled water and alcohol, or formalin in the same propor- tions. But the speediest way is that of scraping them out by means of a sharp curette, and then have them touched up with liquor ferri perchloridi, which stops the bleeding and cauterizes the papillae, pre- venting their possible relapsing. When indurated edema and lymphangitis are present, as men- tioned, the use of continuous bathing of the parts with I per iooo solution of bichloride of mercury has been found beneficial. The same bathing is used in cases of thick and dense papular or pustular eruptions, on which it acts promptly, producing their involution and regression. In the hospital we place the patient in a bath tub, dis- solving from one to two drams of sublimate in twenty-five gallons of warm water. In the clinics we give to the patients bichloride tablets gr. vii each, to the number of from six to twelve, one tablet to be dis- solved in one quart of hot water for bathing in the form of wet compresses. In cases of moist papules around the female genitals, with excoria- tions and abundant discharge, the sitzbath with the same solution of sublimate is used, and when dry the mucous patches are dusted with calomel powder, and then covered with absorbent cotton, in order to prevent the contact of the two surfaces of the skin, or of the mucous membranes. When the mucous patches of the body or of the genitals are ulcerated or have a tendency to hypertrophy, they are touched with a solution of acid nitrate of mercury, three per cent., continuing the same treatment with bathing and calomel dressing. All moist papules of the oral cavity, of the tonsils and of the nose, etc., are locally treated in our hospital and clinics. The students touch up the patches with a solution of bichloride of mercury, one per cent, in alcohol and ether. The patient then receives a two per cent, solution of biborate of sodium, with a little menthol and glycerin to be used as a mouth wash. In case of obstinate dry papules on the forehead, on the palms or soles, the patient is directed to bathe the hand or foot or forehead with a soloution of bichloride for fifteen or twenty minutes, and when dry cover the patches for a whole night with emplastrum hydrargyri spread on a cloth. When the papules of the hands or soles are covered with thick epidermic scales, or with callosities, then the use of green soap is recommended to remove the scales, and after a while the em- plastrum is applied. For the large papules of the face or of the body we use a mixture of calomel and traumaticin in the following propor- tions : Calomel 5i, traumaticin ov. This sticks on the surface without 182 THE MEDICAL ASPECTS the necessity of binding the parts. For the moist papules, which we sometimes find between the toes, the bathing with sublimate solution and the application of mercurial plaster have given us very gratifying results. In cases of diffused secondary superficial ulcerations of the lips or of the genitals we cover the surface with a salve containing white precipitate of mercury in the following formula: Hydrarg. praecip. alb g r . v i Acid, carbolic gutt. x Bismuth subcarb. / _ Zinc oxyd f aa 3 ss Vasilin flav 3 i M. f. — Unguent: apply on a cloth. Cases of syphilitic onychia and paronychia are treated locally with bathing of the hand in a sublimate solution, and then covered at bed- time with emplastr. hydrargyri spread on strips of lint. Sometimes we have to do with bad cases of syphilitic alopecia, which requires some local treatment. Usually a simple aromatic lotion to be rubbed on the scalp once a day has a beneficial effect, but when the alopecia assumes great proportions, then we find the applications of solutions of sublimate useful. We use the following mixture, to be rubbed on the scalp once a day: Hydrarg. sublimat. corr gr. xv Ammon. chlorid q. s. Aq. camphorat. \ ? .. Alcohol rect. J aa " 5 " Ad us. ext. In the case of gummata, emplastrum hydrargyri is the most bene- ficial application. When the gumma has not yet softened we apply the mercurial plaster spread on cloth in order to cover the gummatous growth and a good large area surrounding it. This produces the re- absorption of the infiltration so well and so easily that we have not cared to seek for anything better. We use the same application for syphilitic periostitis and for periosteal gummata, which, if not yet softened, in most of our cases have in a short time disappeared. When the gumma has undergone disintegration and suppuration is present, the best method is to open the cavity, scrape the internal surface with a sharp curette and pack the cavity with iodoform gauze. In cases where the ulcer has resulted from the breaking down of the gumma, the application of the emplastrum hydrargyri is very beneficial, helping to produce disintegration of the infiltrated edges and of the bottom of the ulcer. In the same way the sublimate bathing is our THE TREATMENT OF SYPHILIS 183 best resort, when we have to do with extending gummatous ulcerations which have been neglected. When the sublimate bathing has cleansed the ulcerated surface then the mercurial plaster will be of great benefit. In some cases, however, the application of the mercurial plaster is somewhat irritant, and the application of iodoform in the form of salve or as a drv dressing has always given good results. As a local treatment of syphilis we must insist upon the cleansing of the mouth, throat and pharynx by means of a mouth wash and gargles. The use of tobacco is strictly forbidden, in order to prevent irritation of the mucous membranes and the relapse of moist papules. In the clinic and in the hospital we dispense tooth brushes and tooth powder to every syphilitic patient who is unable to buy, and every time that the patient comes to the consultation we inspect his mouth for the purpose of preventing salivation. INTERNAL TREATMENT All external applications will be of no avail if they are not asso- ciated with a strong and heroic internal treatment : a constitutional treatment. The most recent works on the therapeutics of syphilis have more and more confirmed the opinion that the only remedy against syphilis is mercury, and that mercury is the specific remedy against syphilitic processes. There was a time when the syphilologists were afraid to administer mercury in the tertiary forms of syphilis and the treatment was limited to the use of the iodides. After the works of Neisser mercury has become the sovereign remedy not only in the secondary period, but also in the tertiary stage. Iodine is a great adjuvant remedy. That the administration of mercury in the tertiary form of lues is a right procedure is shown by the most plausible opinion expressed by Neisser, Lang and Lesser, that tertiary lesions are the product of the immediate presence of the luetic spirilla in the tissues. The action of the mercury is displayed on the micro-organisms, and by its direct action on them the relapses are prevented. Jadassohn 6 has joined in the views of Neisser and their ideas have been widely accepted, that the tertiary lesions of syphilis, and also the papular formations of the secondary period are the result of the organized virus, the spirochseta. This opinion seems to be much more tenable than that expressed by Fin- ger, 7 that tertiary symptoms are the product of the toxi-albumens, the result of the biological productions of the micro-organisms. Finger 6 Jadassohn, S. " Grazer Kongress d. Derm. Ges.," 1896. 7 Finger, E. "Die Syphilis als Infectionskrankheit." Arch, fur Derm, und Syphilis, 1890. 1 84 TH E MEDICAL ASPECTS based his views on the apparently non-infectious character of the terti- ary lesions. But with new observations syphilis in the tertiary stage has been found to maintain the same infectious nature, although on account of the depth of the process it is not so easily communicable as it is in the secondary period. With the views of Neisser and Jadassohn we find an easier explanation of the possibility of the coexistence of second- ary symptoms together with tertiary lesions, and also the transition from the secondary period to the tertiary. The quantity of the spirilla and their development are accountable for the greater or less severity of the symptoms, and in this regard there is a great deal of similarity to tuberculosis. In fact, in an acute miliary tuberculosis of the skin the number of the bacilli is large, while in a chronic form, such as in lupus, their number is scanty. In this way Jadassohn explains the apparently non-inoculability of the tertiary forms of syphilis, comparing them to the lesions of lupus vulgaris. To all that it is necessary to add the condition of the system of the infected patient and the faculty of reaction of the tissues, which is one of the most powerful factors in the evolution of the diseases. With these ideas in our minds we begin to treat our patients. The first question is : When do we have to begin treatment ? In our early years of practice we followed our old professors, and no con- stitutional treatment was begun unless the symptoms of secondary syphilis were in full blast. From this delay in the commencement of the treatment we can say that no bad consequences have ever followed, nor have we observed any more obstinacy in the disappearance of the symptoms. Satisfied with the results, we have continued to begin the treatment of syphilis at the time of the invasion of constitutional symptoms. The reply given by Fournier to this question " that it is necessary to begin the treatment of syphilis as soon as the presence of syphilis has been established," led us to commence our treatment immediately after the syphilitic nature of the chancre and the adenopathy had been found. For some years we have followed this method, with this re- markable observation, that in some few cases the treatment has greatly retarded, or has entirely prevented, the appearance of the secondary eruptions. This has proved that the quicker the remedy is given the more chances it has to show its corrective and preventive action upon the syphilitic diathesis. In these last years we have returned to the old principles, which is to cure syphilis constitutionally, when constitutional syphilis is clearly declared. As long as the patient shows a chancre he has a chancre, which will bring about syphilitic constitutional symptoms, but so far the patient has not yet syphilitic diathesis. In this regard it THE TREATMENT OF SYPHILIS 185 is interesting to recall the case reported by Dubois Havenith 8 where a man of sixty, three weeks after exposure, showed an indurated chancre on the prepuce. Although it was a characteristic initial lesion, yet it was not followed by any adenopathy ; the chancre healed up and after he had watched the patient for over a year, no syphilitic symptoms could be found. In the discussion Barthelemy 9 and Aubert stated that they had met with identical cases of chancres which were not followed by general syphilitic symptoms. Cases of this kind are not rare and nearly every man interested in syphilological work has ob- served some cases of chancres which remained without apparent syphi- litic consequences. This is already a good reason for advising the patient to wait for the constitutional symptoms before commencing treatment. But the most important question for us is that while the patient has the chancre he has not yet syphilis. The syphilitic germs are working their way, they are preparing their toxins, but so far remain limited in the lymphatic system. In fact, we find that syphilis produces a decided effect on the blood, which is revealed in a form of leucocytosis. Stoukovenkoff, Biegaski and d'Amore established the fact that under the influence of the syphilitic poison there is a rapid decrease in the proportion of hemoglobin, as well as in the number of red blood corpuscles, and parallel to this an increase in the white blood elements, especially of the lymphocytes. The changes of the blood in syphilis were well studied by Ernest Becker, 10 in order to determine the quantity of erythrocytes and leuco- cytes. In two cases with roseola and general adenopathy he found a marked leucocytosis with predominance of the lymphocytes. The re- lation of the polynuclear to the lymphocytes was 65 130, representing in a cubic millimeter 3000 lymphocytes instead of the normal 1200 to 1500. In patients affected with initial sclerosis without constitutional symptoms the blood was found in a normal condition. These observations have a tendency to show that the hard chancre is really the local focus, where the syphilitic spirochsetse are germinat- ing, but so far the infected person has not yet the syphilitic diathesis ; the toxins resulting from their germination have not yet reached the general circulation and for this reason the constitutional treatment will be of little or no benefit. The remark that waiting those few days we let the organism become impregnated with syphilitic germs has not much value. We 8 " Comptes rendus du Congres intern, de Derm, et de Syphil. tenu a Paris en 1889." Paris, 1890. 9 Quoted by Rob. W. Taylor, " Pathol, and Treat, of Ven. Diseases." Phila- delphia, 1895. 10 Becker, E. " Haematologische Untersuchungen." Deutsche mcd. Woch enschr., 1900, pp. 35, 36. 1 86 THE MEDICAL ASPECTS cannot give so large a quantity of mercury as to paralyze the develop- ing germs, and the remedy introduced into the general circulation will find no germs to fight. It is true that in a few cases we have found through an early treatment some delay in the appearance of the erythem- atous eruption, and in a few cases we did not see any eruption what- ever, but this we find to result injuriously for the future of the patient. He thinks that he has never had syphilis, or that he has had a very mild case, and in consequence neglects his treatment, which is the only safeguard against late grave affections. Taylor, 11 after over twenty-five years of constant study, concludes that the best plan is to wait until the onset of the secondary stage, before beginning a mercurial course. Indeed, so far, nobody has ob- served any real damage for the patient proceeding from the delay of a few days before beginning treatment. No danger is so great and so bad for the future of a patient as to have had a doubtful diagnosis, and to remain throughout his life in doubt whether or not he has syphilis. Furthermore, it is very bad for a patient who has never had syphilis to remain, on account of a wrong diagnosis, under the im- pression that he is suffering from syphilis. It is, therefore, our duty to wait for the constitutional symptoms, to show us that the patient is suffering with syphilitic diathesis. In mercury we have a remedy which directly attacks the syphilitic virus, but it is not a preventive for syphilis. In consequence, waiting a few weeks before commencing treatment does not expose the patient to any danger; on the contrary, it is rather better. When no constitu- tional symptom is present, we have no idea of the severity of the disease, and it is nearly impossible to institute a good rational treatment. In these circumstances we have seen physicians prescribe small doses of mercurial preparation, which has no power over syphilis, which is showing up with its lesions, notwithstanding the patient is taking the medicine regularly. This kind of mercurialization, as Taylor says, tends to lower vitality and impair nutrition, inducing a run-down of the general condition, which will tie our hands when the moment comes to use the proper doses of the remedy to fight severe syphilitic affec- tions. Indeed, in the primary stage of syphilis, while waiting for con- stitutional syphilis to begin, it will be much better to try to fortify the stomach and increase nutrition, thus preparing the system for the successive treatment. At the same time we must examine the mouth of the patient, have his teeth placed in good condition, so that when the treatment has to be given we may avoid the complication of saliva- tion, which prevents us from continuing the use of the drug. In some cases it is necessary to begin treatment before the eruption 11 Taylor, R. W. 1. c, p. 823. THE TREATMENT OF SYPHILIS 187 has shown on the skin. Quite often the general symptoms of reaction are so much accentuated that a quick treatment is the only relief. We have had patients, who, while still having the chancre in the way of cicatrization, with the beginning general adenopathy, have suffered with rheumatic pains all over the body, and with fever of a remit- tent character ranging between 102 to 103 F. In these cases specific treatment must be commenced at once, and only under this treatment we see the acute reactive symptoms gradually disappear. While under treatment, when the patient was relieved of these pains and the fever had entirely gone, a roseolar eruption of a deep bluish red color spread all over the chest, back, arms, abdomen and thighs,, showing the infectious nature of the disease. In cases of this kind it would be unwise to wait for a roseolar eruption to show the constitu- tional onset of the disease ; the general symptoms of pains in the joints and of fever were enough to testify to the general diathesis. In the same way in cases of a large and badly ulcerated condition of the initial lesion, with a tendency to spread, a well-directed constitutional treat- ment, although before the appearance of the general diathesic symp- toms, has had a good influence in checking its spreading and hastening its healing. From all that we have said it will clearly appear that in the ordinary cases of syphilis, before beginning treatment we prefer to wait for the constitutional symptoms. Another vital question is how to administer this treatment, con- stantly or intermittently, and how long it ought to be continued. In this regard there are two principal opinions : one, which is followed by Caspary, Kaposi, Pick, is the so-called symptomatic treatment, because when the symptoms disappear treatment is stopped ; the other, which has been established by Fournier, continues the treatment whether the symptoms are present or not in a continuous intermittent way. Neisser has accepted the ideas of Fournier, and with very few exceptions he has introduced the method of treatment into Germany. They start with the belief that syphilis is a chronic disease, and must therefore receive a chronic treatment. Mercury causes surely and quickly the regression of the syphilitic symptoms, and it is also capable of prevent- ing or delaying consequent relapses. For this reason mercury is the true and reliable remedy, which must be used in a chronic manner in this disease. It is necessary to keep in mind the fact that the organism gets used to the drugs, and the drug loses its therapeutic efficacy on account of the continuous administration ; for this reason it is better to make some intervals in the treatment, or, as Fournier says, treat the disease with a chronic intermittent treatment. 1 88 THE MEDICAL ASPECTS In fact, we have no clinical nor physical signs by which we can be sure that the virus is entirely out of the system. By clinical expe- rience we know that syphilis can break out again suddenly and entirely unexpectedly. Moreover, we all have observed cases of individuals who have been considered perfectly cured for years, yet who have shown signs of hereditary syphilis in their children. In order to avoid these consequences, we agree with Fournier and Neisser, that the treatment must be chronic and intermittent so as to free the organism of the syphilitic virus, and prevent in this way other relapses. Nobody can foresee the severe consequences which may come from a case of syphilis, nobody can state that syphilis has been perfectly cured, or is still latent in the system, and consequently, re- gardless of the mildness of the symptoms, every case of syphilis must be treated for years with mercurial preparations. In regard to the methods of administration of mercury, we find ourselves in the necessity of using the different ways of application according to the conditions of the patient, the place where we treat the patient and the nature of the syphilitic symptoms. We have always found ourselves unable to say that we treat the disease only by internal administration of the remedy, or only by inunctions, or intramuscular injections. Every method is good ; but every one has its disadvantages, and for this reason it is better to change accordingly. In the clinic, a patient who has come with a hard chancre receives an emplastrum hydrargyri, which he uses on .a piece of muslin to cover the lesion, and is directed to apply two other pieces on both groins for the affected glands. He receives for internal medication only a mixture of iron, quinia and strychnia as a tonic, if his general nutrition was somewhat faulty. We direct the patient to come to the consultation once a week, and when we find erythema of the pharyngeal ring, and spots of roseola begin to appear, we prescribe a solution of I per iooo of bichloride of mercury, which has the name of Liquor VanSwieten. The formula is : Hydrarg. bichlorid. corros gmm. 0.90 Alcohol 9 6 -°° Aq. Destillat 928.00 This solution contains exactly 1 to 1000 of sublimate in weight, which is two and one-half centigrammes for each 32 grammes ; in consequence a tablespoonful contains exactly 1 centigramme and one-fourth. The patient takes one tablespoonful of this solution twice a day, one immediately after his breakfast and one after his supper, diluted in one gobletful of water. This gives to the patient half a grain of sublimate per day. In our hands, as well as in the hands of other THE TREATMENT OF SYPHILIS 189 practitioners, this solution has given excellent results. We do not like the sublimate in pillular form on account of the uncertainty of the complete dissolution of the pill in the stomach, and furthermore on account of the possibility of some injurious action of the pill, which dissolving in one limited part may harm the mucous membrane of the digestive tract. For these reasons we find that the remedies in pillular form are rather unreliable, and this recalls the great therapeutic axiom, Corpora non agunt nisi sohita. With that tablespoonful of 1 per 1000 of bichloride diluted in water, we get a beneficial local action on the mucous membrane of the pharyngeal ring, and a solution of mercurial salt which is easily ab- sorbed by the stomach. In several hundred patients of both sexes coming to our clinic yearly, we have never found one who has com- plained of cramps or of other gastric troubles in consequence of this medication. It is very convenient, especially for working people, to take this medicine with their principal meals and not to have to think any more about taking medicine during the day. In private practice, especially among women, we advise the same doses, only more frac- tioned, for instance four dessertspoonfuls a day of the sublimate solution diluted in Vichy water, as recommended by Brocq. 12 Very seldom has it happened that we have found anyone who has any repugnance for this remedy so administered, and in those few cases after a short time they could take the medicine without any trouble. INJECTION TREATMENT Under this medication the patient begins to feel much better, much more cheerful, but the eruption shows plainly. Then we begin the treatment with the injections with gray oil, according to the formula of Lang: Metallic mercury 30 is in- corporated by stirring in a mortar with a mixture of Lan- olin anhydric 15 Cholorof orm 50 When the chloroform has been entirely evaporated, the lanolin with the mercury has formed the unguentum lanolinatum forte. This is then mixed with oleum vasilini in the following proportions : Unguent, lanol. fort 9 Ol. Vasilini 3 This is the gray oil, which must be warmed each time before using in order to have it fluid and ready. In place of the oleum vasilini, we 12 Brocq, L, " Les doses fractionnees de bichlornre et de bijodure de Mercure," etc. Festschrift f. M. Kaposi, 1900. 190 THE MEDICAL ASPECTS have substituted the fluid albolin, which maintains the oil at such a consistency that it can be injected without warming the mixture every time it is to be used. In private practice, clinical and hospital, before making the injec- tion we dip the needle and part of the Pravaz syringe in boiling water. The nurse rubs the skin in the anatomical region chosen for the injec- tion (the gluteal region) with a tampon of cotton saturated in alcohol, and then the injection is made by thrusting in the needle with one quick blow in a horizontal direction deep into the muscular masses. The needle is one of the ordinary size and length. The ring around the piston of the syringe is set to give as many drops of gray oil as we intend to inject. Three rings of the screw gives five drops of the gray oil. We begin with five minims, which according to the symptoms we raise to ten and twelve. The gluteal region of the right side is used for the first injection, the left for the second, so that all the odd numbers are on the right side, and it makes it easy to remember the number of the injection. In the beginning of the treatment we give two injections per week, but after two weeks, that is after four injections, one injection per week is sufficient, which we make with eight minims of the oil. It is necessary to recommend to the patient to remain with the muscles entirely loose at the moment of inserting the needle, and not to jerk or contract the muscles, as a sudden contraction might be danger- ous and break the needle, or at least make the injection painful. When the injection is well given, no pain follows, but the following day the patient feels a kind of numbness, and the place where the gray oil has been injected is found to be somewhat hard, but in a few days this disappears entirely. It is entirely the opposite with the injections of corrosive sublimate, which we have used for so many years, also with good results. We have injected the old I per cent, solution, as used by our friend and teacher, Heinrich Auspitz, deep under the muscular masses, but the patient is immediately affected with an acute pain in the place of the injection, which lasts for several hours. For the same reason we have given up the injections of cacodylate of mercury, ac- cording to the formula of Brocq, on account of the unbearable pain which had constantly followed the injection. As a consequence of the injections with the gray oil, notwithstand- ing the best care for asepsis, once in a while it happens that some patient has an abscess. The place where the injection was made be- comes hard, swollen, red, and pains, and in a few days fluctuation is found. We are in the habit of opening the abscess as soon as the fluctuation is perceptible. There comes out a quantity of thick, bloody serum, containing shreds of necrotized connective tissue, together with THE TREATMENT OF SYPHILIS 191 minute granules of metallic mercury. It is difficult to explain the reason of the abscess, when we consider that for every injection we use the same precautions of asepsis. The abscess is much more liable to come in women than in men, so that while we have not had an abscess in private practice or in the clinic, in the female ward of the hospital several abscesses have occurred following the injections with gray oil. The abscess is not painful, as a rule, and fortunately it heals readily, but in one case the abscess was deeply seated between the mus- cular masses. Although the abscess is an inconvenient complication, yet it is not of such importance as to diminish the value of this method of treatment. In our hospital ward we have used the intravenous injections with 0.1 per cent, sublimate solution, as it was introduced in 1893 by our clinical professor, Guido Baccelli, of Rome, and then practiced by Jenuna, Colombini and Campana in Italy, by Goerl Newnan and Lewin in Germany, and by Ernest Lane in England. The injection has been done following his technique. The flexion surface of the elbow is selected for the injection. The surface must be perfectly sterilized; a bandage is tied around the arm just above the elbow in the same way as it was used for bleeding. The vein then swells up, filled with blood. With the two fingers of the left hand the vein is held, and with the right hand the needle of the syringe is inserted into the vein. By push- ing out a drop of the solution, which if not appearing under the skin, we are sure that the needle is in the lumen of the vein, then an assistant removes the bandage, so as to take off the pressure, and the fluid is gently and gradually injected into the vein. The needle is removed, and a piece of gauze is placed on the wound and this is bandaged. The syringe full contains one c.c. of solution 0.1 per cent., which represents 1-64 of a grain of corrosive sublimate. The dose has been increased by using a 0.2 per cent, solution, and Blaschko has increased the dose to the amount of 0.6 per cent. A great deal has been claimed for this method, by which the mer- cury is introduced directly into the blood and taken by the shortest way to the diseased places. The presence of mercury in the system, al- though introduced in such a small amount, is felt by the patient, who has a metallic taste in his mouth, and Baccelli claims to have seen patients become salivated five or six minutes after the injection. One hour after the injection the presence of mercury could be demonstrated in the urine, and it disappears the following day. But when the injec- tions are continued daily, the presence of mercury can be found in the urine one or two weeks after the last injection, as stated by Blaschko. Moreover, there is no doubt that in the florid stage of syphilis, either 1 9 2 THE MEDICAL ASPECTS spirochsetse or toxins are to be found in the blood, and introducing the mercurial preparation directly into the blood will attack and destroy the syphilitic virus. In cases of syphilitic arteritis, and much more in the cases of cerebral syphilis, it seems to be the ideal method of medication to bring the remedy directly into contact with the intima of the dis- eased vessels, or with the vessels surrounding the nervous cells. Tommasoli, 13 in a recent article, considers this method the abortive treatment of syphilis. He claims that a certain number of intravenous injections from 6 to 8, and from io to 20 milligrammes each, given in the beginning of the constitutional symptoms, will kill the disease. Tommasoli is so well pleased with the method that he would compel every physician to use this method in the beginning of every case of syphilis. Ernest Lane in a paper which he read before the International Congress of .Dermatology in London, said that he had adopted this method of intravenous injections in the treatment of syphilis in every case which had come under his care, for the period of nine months. The greatest advantage which he could find was the rapidity with which the patients could be brought under the influence of mercury. We had occasion to see some cases selected by him in which the symptoms had greatly improved under a constant treatment of 45 in- jections into the veins, with a solution of 1 per cent, of cyanide of mer- cury. The results, when compared with the method of gray oil injections between the muscular masses, or even subcutaneously, do not show any improvement over it. The same results which we obtain with four or six injections, made at the intervals of one week one from the other, were obtained with forty intravenous injections practiced every day. We are sure that this is already a good ground for dis- carding this method. In our C ward we selected six cases of papular and papulo-pustular syphilides, which we began to treat with intraven- ous injections of 0.2 per cent, solution of sublimate. We were com- pelled to desist from our experiments because the patients refused to have any more injection, complaining of unbearable pain from the point of their injection, radiating towards the shoulder. We cannot say that the injections caused any thrombotic deposits in the vein, as was the case with M. Dinkier, in which a total obliteration of the lumen of the vein took place, but we will always insist that with the ordinary sub- cutaneous injections we are able to obtain good results in an easier way. In cases where we wish to obtain a rapid mercurialization, espe- cially in the hospital wards, on account of threatening syphilitic nervous symptoms, or in cases of 'iritis, iridocyclitis, then we resort to the injec- tions with calomel, which in our opinion acts much more quickly and 13 Tommasoli, P. Ann. de Derm, et de Syph., Dec, 1902. No. 12, p. 1073. THE TREATMENT OF SYPHILIS 193 much more powerfully than any other remedy. Calomel by subcuta- neous injections was the first remedy which opened a new era in the treatment of syphilis. We must be grateful to the genius of Scarenzio, who was the first to inject calomel and to show the wonderful results, which have entirely revolutionized the old disagreeable methods of treatment. For a few years in the early days of our practice we applied subcutaneous injections with calomel, which we did by mixing five grains of it with water and mucilage. The injection was made in the external region of the arms or on the external region of the thighs into the subcutaneous tissue. The results were absolutely remarkable, but after nearly every injection an abscess followed, which made the method rather objectionable. Furthermore, after one injection severe cases of stomatitis followed, which compelled the discontinuance of the treatment. It was for this reason that w r e readily accepted the method of Lewin, used so extensively by Auspitz, which consisted in the injec- tion of a solution of 1 per cent, sublimate under the muscular masses. Although the injection of sublimate did not act so promptly as the calomel, and although its action was not continuous like that of the calomel, it being necessary to repeat the injection too often, yet it was preferable to the calomel on account of avoiding the abscess and the salivation. Here we enter into the important question of the soluble salts of mercury, or of the insoluble salts. The bichloride was the first soluble salt to be injected, and still maintains its reputation. Next came the cyanide, the peptonate, the benzoate, the cacodylate, which, displaying less power and not an equal therapeutic action, have been abandoned. For some time there has been used by Wolff, of Stras- bourg, and by Jullien the succinimide of mercury, which has given in their hands satisfactory results. The soluble salicylate of mercury, and also the biiodide of mercury in oily or in aqueous solutions, have been used with good results, but certainly not superior to those obtained by the use of the sublimate. The massive injections of sublimate in serum have been praised greatly by Cheron, but the experience of Jullien 14 is sufficient to place this method entirely under ban as dangerous and injurious. With the insoluble salts the action of the remedy is entirely dif- ferent. The remedy is placed in the tissues, and there it finds the appropriate ingredients for being transformed into a soluble prepara- tion, and is thus gradually absorbed, producing a soluble and a per- manent therapeutic action. These studies have been made by Scar- enzio, who, together with Smirnoff and Soffiantini, have tried doses of 14 Jullien, L. "A propos des injection mercurielles." Journal dcs Maladies eutanees et syphilitiques, 1902. 194 THE MEDICAL ASPECTS calomel from the smallest to the largest, have studied the local action and the general systemic action with such accuracy that not much remains to be added. Under the injections with calomel, the rapidity of absorption is indeed remarkable. By repeated analysis, Nicolich 15 demonstrated the presence of mercury in the urine from two to three hours, and in the saliva from four to five hours after the injection. Jullien showed its presence in the milk a few hours after the injection with calomel. We will use the wise and expressive idea of Jullien, that the injection of calomel is like a small chemical laboratory, which produces a soluble mercurial preparation gradually, and constantly until the supply of raw material is exhausted. This is not a simple opinion, but it has been proved by chemical analysis by Vigier, Frolow and Girard, who several months after an injection with calomel, in the resulting indurated focus, were able to demonstrate the presence of mercury. It is undeniable that when the insoluble mercurial preparation is injected in the sub- cutaneous tissues, or better, between the muscular masses, an inflamma- tory process takes place, which produces and organizes a membrane, as in the abscesses, the pyogenic membrane which encapsulates and surrounds the injected remedy. By means of asepsis, true suppuration cannot occur, but there is displayed the action of the leucocytes against the remedy which acts as the intruder. Picardi 16 made some interesting experiments in the laboratory of professor Bizozero, to demonstrate the absorption of calomel in the peri- toneal cavity, showing that it depended not only on the fluids, but also on the elements of the tissues. The granules of calomel act like any other indifferent substance ; they cause an immigration of leucocytes, which surround and take them into their body, and so they are trans- ported into the lymphatic glands. The leucocytes show a phagocytic power with regard to the calomel and a positive chemiotaxis. This, however, cannot last long and some calomel always remains, contrary to what happens with other indifferent powders. This is explained by Picardi by the fact that, when the calomel begins to be changed into sublimate, the leucocytes in the immediate vicinity are poisoned and are unable to continue their work of opposition. Picardi, however, experimented on the peritoneum, where the absorption is so very active, while we make our injection in the connective tissues of the muscular masses. Here the activity of the circulation is less, and according to Jullien, the leucocytes appear somewhat later, when bichloride has al- 15 Nicolich. " La cura della sifilide col metodo del Prof. Scarenzio," Trieste, 1898. 16 Picardi. " Sul riassorbimento delle injezioni di calomelano." Policlinico, Rome, 1896, No. 18. THE TREATMENT OF SYPHILIS 195 ready been formed, and in consequence they cannot approach and dis- play their phagocytic power, and therefore the quantity of calomel is left there to undergo the gradual chemical transformation. For this reason particles of calomel are not found in the lymphatic glands after the injection, but it reaches them rather in the form of bichloride, pro- ducing a mild swelling. With the rules of asepsis, to-day the so much lamented abscesses in consequence of the injections w T ith calomel have been rendered not so frequent. We have returned to its use, diminishing the dose, which was formerly too high. Scarenzio himself, later on, used the highest dose of 10 centigrammes, which is 2 grains. In our clinic we never exceed the dose of 1 grain or 5 centigrammes of calomel for the first injection, and one-half grain for the successive injections, which we repeat once a week, or once every two weeks, according to the symptoms. From the results which we have obtained, we can agree with the conclusions given by Fournier : that the treatment of syphilis with the injections -of calomel is active and powerful; that the results obtained are very good ; and that in some cases these results are won- derful, displaying an extraordinary therapeutic intensity. One drawback to the injections with calomel is the salivation, which has started in some cases a few days after the first injection, and which has sometimes lasted for a long time after ceasing the use of every mercurial preparation. For this reason we reserve the Scar- enzio treatment for those cases which require a rapid and intense action. In obstinate cases of miliary papular syphilide, in cases of glossitis, laryngitis, iritis, of ulcerated gummata, etc., the injection with calomel has always given splendid results. Moreover, in the cases of syphilis affecting the nervous centers, where a powerful and speedy action is necessary, the injection with calomel will give the most satis- factory results. For the ordinary cases of syphilis which come every day to the clinic, to the hospital and to private practice, we prefer our routine treatment, such as we have already described. INUNCTIONS In the beginning we stated that we are not exclusivists in the treat- ment of syphilis, and that we apply every method of introducing mer- cury into the organism of the patient that will effect his cure. Even the oldest method of introducing mercury through the skin by rubbing is not laid aside. This method was of the greatest service in the fifteenth century, in checking the ravages of the new epidemic, as it was called, or the Neapolitan or French disease. The inunctions with mercurial 196 THE MEDICAL ASPECTS salve have been looked upon as a godsend for humanity. Unfortu- nately, the method was so badly applied, the administration being made without rules and in an excessive quantity, so that from its abuse all kinds of injurious accidents occurred, especially stomatitis, which caused not only fear, but a horror of mercury. At that time it was believed that salivation was a beneficial effect obtained by the remedy, which was driving the syphilitic poison out of the system through that flow of saliva. As a consequence, every patient in order to be cured of syphilis had to be salivated, and when the saliva w r as flowing out of his mouth, when there was present in the mouth that unbearable odor, that was the moment for rejoicing, because the bad humors were leaving the system and the cure was progressing. To-day we know that salivation is only a complication, or better, a disagreeable occurrence, which we can avoid to a certain extent. Salivation compels us to subside treatment and lose time which could be of great value for the health and for the future of our patient. To-day we have entirely abandoned the administration of all de- purative beverages and decoctions, which were given during the inunc- tion treatment, after having recognized that they are not only useless, but injurious to the stomach and to the general nutrition of the patient. Neither do we take any interest in keeping our patient confined, nor in subjecting him to a vapor bath before using the inunction. We usually treat our syphilitic patients by means of the inunc- tions in the hospital wards. In private practice, most of the patients find the inunction treatment objectionable on account of its soiling their clothes, and arousing suspicion amongst others. In the same way they find it objectionable on account of the loss of time when tired out after a day's work ; they must rub themselves for twenty-five or thirty minutes going to bed. In our clinics, too, the inunctions cannot be applied, and the patients ask for some other method of treatment rather than take them. In the hospital wards, however, the patient has nothing to do, and finds it pleasant to spend half an hour rubbing. In the use of in- unctions, hairy parts must be avoided as much as possible. When the mercurial ointment is rubbed on regions having many hairs, it often irritates the follicles and causes a form of dermatitis and folliculitis. For rubbing, we use the ordinary unguentum cinereum, which is made of mercury incorporated with lard, of equal parts. To-day, however, the mercurial ointment prepared with vasogene, containing thirty-three per cent, of mercury, is better applied. Vasogene, accord- ing to the studies of Goldmann, 17 Ullmann, and others, is much more 17 Goldman, J. A. " Die therapeutische Verwendung des Teer Vasogen." Monatshefte fur pract. Derm., IQ02, B. 34. THE TREATMENT OF SYPHILIS 197 easily absorbed than an ordinary mercurial salve prepared with lard. We can agree with the conclusions of the authors mentioned, 18 because since we have introduced the vasogen mercurial salve we have found more active action and not so frequently do we meet with signs of irri- tation of the skin, dermatitis and folliculitis, which have often followed the inunctions with the ordinary Neapolitan ointment. It is interesting to know how the mercury is introduced into the system by means of the inunctions. In general, we can state that mer- cury is introduced in the skin mechanically in the same chemical and physical condition as it is in the gray ointment. It is, however, not impossible that the finely divided mercury mixed with the vehicle may find on the skin or in its pores materials with which it can make com- binations and be absorbed in this way. We must also keep in mind that mercury volatilizes on the surface of the skin, and it is also absorbed in the form of mercurial vapors. In this case, however, the lungs will take part in the introduction of mercury by inhalation, and by the absorption occurring on their surface. Kirchgauer has pub- lished some of his ideas on the action of the mercurial vapors in the inunctions, and Remond, Menget, Welander and Neisser have had so much faith in their action as to establish a method of treatment by linen sacks filled with mercurial ointment. We must confess that we are somewhat skeptical on this subject, and we rather believe in the mechanical introduction of the compressed mercury, finely divided, into the pores and follicles of the skin. There is no doubt that mercury, which so easily vaporizes, must impregnate the atmosphere with mercurial vapor, arising from the rubbing of the ointment, which is inhaled by the patient. We do not believe, however, that it goes far from the patient, for the reason that if this atmosphere penetrated far, our nurses in wards C and O would be constantly salivated. From the microscopical examinations made by Juliusberg 19 on pieces of skin removed soon after the inunction, it results that no mer- curial globules are found under the epidermis or in the tissues of the corion, but they are found in the follicles of the hair and in the open- ings of the sebaceous and of the sweat glands. Filhene 20 was also of the opinion that the epidermis does not allow the passing of mercury through its cells, but that the absorption is made through the sweat glands, sebaceous glands and hair follicles. 18 Goldmann, J. A. " Erfahrungen iiber den therapeutischen Effect der Qnecksilber Vasogen salve," same, B. 35. 19 Juliusberg, F. " Experimentelle Untersuchungen iiber die Qnecksilber Resorption bei der Schmier Kur." Arch. f. Derm. u. Syph., 1901. B. lvi, Heft 1. 20 Filhene. "Ueber die Durchgangikeit der menschlichen Haut fur teste und fliissige Stoffe." Berlin klin, Wochensch., 1898. 198 THE MEDICAL ASPECTS In regard to the way in which mercury is absorbed through the skin by means of the inunctions, it seems that it is taken up in the form of small metallic globules by the leucocytes, and in this way carried in the lymph vessels and in the general circulation. This was the idea of Auspitz, 21 which was followed by Oesterlen, Eberhard, Overbeck, Blomberg, who claimed to have found small globules of metallic mercury in the corium and in the subcutaneous tissue after the inunction with mercurial ointment. Many others, on the contrary, have denied the presence of metallic globules in the tissues of the skin after the inunction, and they believe, therefore, that mercury musr undergo some chemical changes and is absorbed in a different combina- tion, which cannot be seen under the microscope. Baerensprung 22 be- lieved that the efficacy of the gray salve was due entirely to the oxydul of mercury, which is formed by combination with the fat, and in this way is absorbed. The presence of this oxydul of mercury in a recently prepared salve has-been found through the researches of Wings and Anuschat to be so insignificant that it cannot surely be the cause of its absorption. Mealhe, Voit and Fiirbringer have found no necessity of any presence of oxydul of mercury in the unguentum cinereum, but they believe that the oxydation of the mercury takes place just exactly where it is rubbed, and this mercurial oxide with the secretion of the skin makes a soluble preparation, which is easily absorbed by the skin and introduced into the circulation. This, however, is nothing more than a hypothesis, and as to the soluble mercurial salts made with the secretions of the skin, so far nobody has been able to demonstrate their existence. At any rate it would be necessary to establish not only the manner in which mercury enters the system by means of the. inunctions, but also the quantity which is introduced. We are unable to say anything posi- tive as to whether the mercury is absorbed from the tissues, or from the leucocytes as small globules, or is changed into a soluble chemical prod- uct, easily absorbable into the system. Nor are the experimenters named able to state whether a large quantity of mercury vaporized dur- ing the inunction is taken in by the pulmonary epithelium, because no mercurial globules have ever been demonstrated in this epithelium. On the other hand, they have all demonstrated the presence of mer- cury in the urine some time after the inunction. The quantity of mercury in the urine was much more abundant when the inunction was made in the ordinary way, and much less when it was made under a 21 Auspitz, H. " Ueber die Resorption ungeloster Stoffe durch die Epi- dermis." Arch. f. Derm, und Syphilis, 1871. 22 Baerensprung. " Ueber die Wirkungweise der Quecksilber praparate und ihre Anwendung bei Syphilitischen." Ann. der Charite, 1856. THE TREATMENT OF SYPHILIS 199 cover of impervious cloth. This would seem to speak in favor of some absorption through the lungs of mercurial vapor produced by the action of rubbing the mercurial ointment. We know, however, by experience, that mercury is introduced into the system by means of inunctions, and the frequent cases of salivation following this method are a sure proof of its absorption. We are, however, not very much in favor of this method as a general and ordinary treatment, but we use it mostly in special cases. In tertiary syphilis, when a mixed treatment is required, in individuals already emaciated and cachectic, we prefer to subject these patients to the in- unctions. In the same way in the female department, all the syphilitic patients who refuse the mercurial injections are treated with the inunc- tions. At the end of the syphilitic treatment before discharging the patient we often advise him to take a course of twelve inunctions. We reserve this method of mercurial ointment inunctions rather for the hospital and for private practice, and have abandoned it in the clinics. The quantity of ointment to be rubbed is from 1 to i-| drams, and the inunction is made every other day. Only in cases where a quicker action is required do we direct the patient to anoint every day. The time employed for rubbing is from fifteen to twenty-five minutes. The patient himself makes his inunctions, and the nurse, with the hands protected by gloves, gives the inunctions only in cases of paralytic patients, or in children affected with congenital syphilis. The regions which are chosen for rubbing are the same as those used by Professor Sigmund. First, the hollows of the feet. Second, the internal regions of both legs. Third, the internal regions of both thighs. Fourth, both sides of the chest. Fifth, the internal surface of both arms. Sixth, the flexion surface of both forearms. The quantity of the salve, 3 i to 3 iss, is divided into two parts for both sides of the body. The patient must rub hard, with the palm of his hand, until the salve is nearly dry. We caution our patients not to wash the skin soon after the inunction, in order to avoid dermatitis, and to cover the surface with a flannel bandage. In this way the salve remains in contact with the skin for several hours. On the fol- lowing day the place rubbed is washed with soap and warm water, and when dry is dusted with rice powder. The inunctions can be continued for two weeks, rubbing every dav, and for four weeks, rubbing every other day. It is necessary to examine the mouth of the patient every day, and when signs of saliva- tion appear, to cease their use immediately. 200 THE MEDICAL ASPECTS Although by this method we have obtained and do obtain good re- sults, yet it has many inconveniences which make it distasteful and disagreeable to the patients, and doubtful and unreliable for the physi- cian. Our patients, especially in private practice, object to this method on account of soiling their clothing, and for this reason they seriously ask whether there is not some other method of treatment. The soiled clothes may expose their secret and make known to everybody that they are under specific treatment. Furthermore, it quite often pro- duces eruptions in the form of folliculitis, or of erythema, or of mer- curial eczema, which compels us to discontinue the use of the inunctions. For the physician this method is doubtful and unreliable for the simple reason that we know that the patient rubs one dram of mer- curial ointment, but we do not know how much of it is absorbed. We do not know how long the patient rubs the salve in, and with what strength he anoints. Sometimes, after many inunctions, we do not see any noticeable results, and all at once we find our patient badly salivated. Consequently we use the mercurial inunctions mostly in the hospital, where they are carried out with exactness, under the surveillance of the nurse, and the patients are not afraid that the soiled clothing may reveal their trouble. We also use the inunctions as above mentioned in our private practice at the end of the treatment, and the patient is advised to go if possible to some thermal place where the inunctions can be carried out without so many inconveniences, with the beneficial aid of the thermal bath. We must again see our patient in the clinic, to whom we have given twelve injections of from 5 to 10 mms. each of gray oil, at intervals of one week. In the ordinary cases we find that the syphi- litic symptoms have nearly entirely subsided, or that very little remains of them. The improvement showing the beneficial action of the remedies on luetic symptoms, and on the other hand some loss of weight of the patient, prompts us to abandon for a while the use of mercury while we continue the use of iron tonics. After the patient has remained three weeks without mercurial treatment, we begin again the use of the solution of bichloride, or if it is more convenient we give the pills of protoiodide. Judging from our experience we have slight objection to the protoiodide pills, which we use in a dose of £ grain each. We prefer the protoiodide at the time when syphilis begins to show papules, when there is already a tendency to infiltration. We find that the protoiodide still maintains its reputation, which it had so widely gained at the time of Ricord, under the name of pills of Ricord. We give in our clinic usually THE TREATMENT OF SYPHILIS 2 OI thirty pills of J grain each, and we direct our patients to begin to take them, one after each meal for three days, and then every three days increase one pill until he reaches the dose of two pills after each meal. When the patient takes six pills a day we direct him to continue the dose for three weeks and then discontinue. The six pills give gr. 1^ of protoiodide, which is considered a sufficient dose, especially after the patient has undergone other treatments, and there are no symptoms urging a stronger mercurialization. Although the protoiodide is considered to be an irritant for the mouth, often producing salivation, yet in our practice we have but rarely seen cases of stomatitis from the use of the protoiodide. In one case we had very severe stomatitis with some gangrenous patches of the gums and of the mucous membrane of the mouth, associated with a grave dysentery. It was a patient who had attempted to treat himself, without medical direction, and for nearly four months con- tinued the use of the protoiodide pills, taking at a dose from eight to ten pills per day, without intermission. With this exception we have found that in most of the cases the protoiodide is well tolerated, and constitutes a convenient and good remedy. The patient buys a small vial containing 100 pills and after each meal takes one, two or three, according to the direction. The pills contain the same ingredients as the formula of Ricord, except that they contain J of a grain of protoiodide. Hydrarg. Protoiodid gr. 25 Extr. Op. Theb gr. 15 Thridac gr. 25 Conserv. Rosae q. s. This makes a pill, pasta to be divided into 100 pills. During the treatment with protoiodide pills we advise our patients to take them intermittently, leaving from two to three weeks' interval in order to rest the stomach and much more the intestines. In fact, the sublimate soon shows its irritant action on the stomach, while the protoiodide shows it in the intestines, provoking temporary attacks of diarrhea and of dysentery. For this reason the pills always contain a small dose of opium to counteract the intestinal irritation. The patient continues his treatment with the pills in the way we have described for five or six months, and after this period he takes another course of treatment with gray oil injections, or with inunc- tious of mercurial ointment. The injections are given one per week, and if no persistent symptoms are present, eight or ten injections are sufficient. The treatment must be regulated according to the symptoms. In 202 THE MEDICAL ASPECTS some cases there are no symptoms present, and a few injections will be sufficient for the second course of treatment, but when the patient has ulcerated papules of the throat, relapsing papular eruptions on the body or on the scalp, the treatment must be kept up constantly. FUMIGATION Mercury succeeds in curing any case of syphilis, but, as I said above, it is necessary to know how to handle it and how to ad- minister it in the different cases. In very grave syphilitic cases, when we have had no results from the inunctions, or from other methods, we have resorted to the mercurial fumigations. It is an old method, which was considered a great deal in the first epochs of the treatment of syphilis, for the reason that it quickly brought about salivation, but it has been recently nearly abandoned. We use the method of fumigations only in special cases, like those of an extensive ulcerative process, or large multiple gummata with a cachectic general condition, in cases of syphilis of the internal organs and also of the nervous system, when other methods have failed. In our hospital wards we have a wooden cabinet where the patient sits with his head out. Under the chair is placed an apparatus for producing vapor. It consists of a japanned tin box, with a movable lid, hollowed out like a saucer with a pedestal and a small alcohol lamp. In the little cup in the middle there are placed fifteen grains of calomel, and the hollowed lid is filled with water. The lighted alcohol lamp is put inside of the box and the whole apparatus is placed under the stool. Vapors of sublimated mercury are given off and surround the patient. We leave the patient in for fifteen minutes ; after this time the skin is found covered with drops of water. In private houses having no cabinet we can substitute a blanket, which is tied around the head, leaving the face free, and covering the patient as he sits on a chair. After the bath the patient must be put to bed and the perspiration kept up. There are no unpleasant sensations and it can be applied every other day without discomfort. Lalouette 23 claimed for this method certainty and convenience, and he stated that with twenty or twenty-five fumigations any case of syphilis could be cured. It has been favored by Langston Parker, Henry Lee, Bumstead, Duncan, Wilders, Horteloup and others, all claiming quick and sure therapeutic results. We have used this method with satisfactory results in only a few selected cases, when other methods had failed. When the patient improved we have given him treatment with other ordinary methods. The treatment with fumigations causes stomatitis much sooner than 23 Quoted by Fournier. THE TREATMENT OF SYPHILIS 203 other methods, and we find it uncertain on account of our being unable to calculate the power of absorption of the skin and also of the respiratory organs for the vaporized remedy. After reviewing all the different methods of treatment, we come to the conclusion that we cannot limit ourselves exclusively to any method of treatment; we must use every one according to the exigencies and conditions of the case. But we must say that for a routine treatment in ordinary cases in private practice and in clinics, the injections with gray oil fifty per cent, are the most convenient, and have given us very good results. We can join our observations with those of Sacazo, Magnol, Georges Thibierge, LePileur, Jullien and many others, who have had large experience in this method of treatment of syphilis, and accept the conclusions of Lang, that it has given us unusually satis- factory results in a great number of cases. We have made it the routine treatment of the syphilitic patients, in private practice, in clinics and also in the hospital wards. It is also the method which is mostly preferred by the patients, avoiding the trouble of taking so much medicine, which they say spoils their stomachs, also avoiding the soiling of the clothes, as in the inunctions, and they can keep their secret trouble from the observation of others. The method by injections has been severely blamed for producing infiltrations, abscesses, and embolus of the lungs. In our practice, clinics and hospital, we must confess that once in a while some abscess occurs from gray oil injections. In private practice, where we have given the injections we have had, in several thousand cases, but very few cases of abscesses, and even in the clinics, where we let the students give the injections, we have seen only a few of them formed. In the hospital wards, where the nurses give the injections, in the male department we only remember to have seen one or two cases of abscesses, while in the female department we were obliged to stop for a while this method of treatment for the reason that every injection became an abscess. Before using the gray oil, it is necessary to see that it is perfectly fluid and sterilized, that the syringe is sterile, and that the skin where the injection is applied is thoroughly washed with alcohol. In some cases a few days after injecting the gray oil there remains in the depth of the tissues a hard lump which, however, does not produce pain, and gradually disappears. In most of the cases no hardness remains and the patients scarcely remember where the in- jection is to be made. In the selection of the method we do not find much influence in the different seasons, and we try to adapt the method of treatment to the exigencies of the affection, and possibly to the convenience and to the conditions of the patient. In fact, we find patients who cannot 204 THE MEDICAL ASPECTS come to the office frequently enough to take the injections, others are so sensitive that they cannot bear the little prick of the needle without suffering, and for this reason we are quite often compelled to choose another method. The time to continue treatment is one of the most important points which we try to impress on our patient, in order that he may not neglect to be treated, although he thinks he is well. We have already stated that, at the period of invasion of the syphilitic constitutional symptoms, we give our patient a solution of I per iooo of sublimate, and soon after we begin with the injections of gray oil. In ordinary cases we give injections twice a week for two weeks, and then one injection per week until we reach the number of fifteen. Usually all symptoms have disappeared by this time, and we stop the injections and also the solution of sublimate, for from two to four weeks. After this time of rest, if no other cutaneous symptoms are present and there remain only few mucous patches of the mouth, we prescribe the pills of protoiodide, which the patients take intermittently from three to four weeks, with two weeks rest. If other cutaneous eruptions appear we stop the protoiodide and resume the injections with gray oil, from two per week at first and then one per week, giving in all twelve injections more. In the second year the treatment is subject to the symptoms, and to the tolerance of the patient. If no symptoms are present the patient continues with the protoiodide pills in an intermittent manner, or if symptoms of the mucous membranes of the mouth and throat keep appearing, it is better for him to take the solution of sublimate. In the second year we give two more courses of injections of gray oil con- sisting of eight injections each. If it is possible at the end of the second year, we let our patient take a course of twelve inunctions with mercurial ointment. The treatment is entirely subject to the appearance of the symp- toms. In many cases the patients, as soon as they see no more erup- tions, cease to come and also stop taking medicine. Then they come back with new eruptions, with some more severe symptoms on the mucous membranes, and in these cases we must insist on the injections or on the inunctions as long as symptoms appear. In some cases after five or six years of good and well-directed treatment, symptoms are still persistent, and treatment must be kept up with courage and firm- ness. In some cases after ten or twelve years, especially when the treatment has been neglected in the beginning, it is necessary to con- tinue with heroic medication, in order to subdue the persistently relapsing symptoms. We excuse ourselves from speaking of idiosyncrasy for the THE TREATMENT OF SYPHILIS 205 mercury, because so far a true case of so-called idiosyncrasy has never come under our observation. If the patient could not swallow liquor VanSwieten, we have given him pills ; if he could not stand the pills w T e have given him injections or rubbing, until we have found the way to administer the remedy without making it hard for the patient to take the medicine. We recognize that the patients addicted to the use of alcoholics, and those who are very anemic, cannot stand the remedy well, and must be continually watched on account of stomatitis, which unexpectedly interrupts the medication. Sometimes the anemia appears suddenly during the treatment, and then it is necessary to abandon the latter. Bad hygienic conditions, disturbances of the gastro-intestinal tract, and especially tuberculosis, are the predisposing causes. Indeed, tuberculosis is the most dreadful complication of syphilis, and when it has produced an anemic condi- tion, it is necessary to be careful in the administration of mercury. There are also cases of tuberculosis complicated with syphilis, which under the mercurial treatment have shown remarkable improvement. PHYSIOLOGICAL ACTION OF MERCURY Any way the mercury is administered, it is introduced into the system by the fluids of the body, is brought into the general circulation, and is then expelled into the secretions and excretions. Through the circulation it reaches every organ and we can say every tissue, but it is not found in them in an equal amount. According to the studies of E. Ludwig, E. Zillner, K. Ullmann 24 and J. Pal, the greatest amount of mercury is found in the kidney, next in the liver ; the bile, however, contains only small quantities. The intestines and the spleen have shown large quantities of mercury, while the bones, muscles, brain and lungs contain very small quantities. Under mercurial treatment the blood always shows the presence of mercury, as it has been found by Welander 25 after the inunction treatment. Mercury is found in the secretions, so it is detected in the saliva, in the sweat, in the bile and in the milk. It leaves the system through the excretions, and has been demonstrated in large quantities in the urine and in the feces. Indeed, a few hours after the introduction of mercury into the organism, it has been found in the urine, especially if it has been given by subcutaneous injections or by inunctions. The absorption of calomel administered through the mouth is well known, 24 Quoted by Lang. "Acquired Syphilis." Twentieth Century Practice, vol. xviii 25 Welander. " Untersuchungen iiber die Absorption und Elimination des Quecksilbers bei der unterverschiedenen Verhaltnissen ausgefuhrten Einrei- hungscur." Arch, fur Derm, und Syphilis, 1893. 206 THE MEDICAL ASPECTS and cases of stomatitis have quite often followed a dose given as a laxative. In our own practice a patient affected with nephritis took some six grains of calomel in small and repeated doses for diuretic purposes, and three days afterward he was affected with a severe case of stomatitis. The presence of mercury in the urine is not temporary, but is constantly found while taking the remedy, and also sometimes after the patient has terminated his treatment. A certain quantity of mercury is retained by the tissues, where it remains for a long time. Landsberg demonstrated the presence of mercury in the urine ten months after having discontinued the treatment, and Welander found mercury in the same excretion from six to twelve months after the last mercurial inunction. Lang in two patients was able to demonstrate mercury in the urine seventeen and twenty-three months respectively after the last injection with the gray oil. From all the observations referred to we can with certainty assert that mercury administered in any form and by any method is posi- tively absorbed, that a great quantity of mercury is eliminated from the system through the urine and the feces, but that a certain quantity is retained in the tissues of the skin. Now the question comes how mercury acts on syphilis, or in other words, in what way it causes the regression of the syphilitic symptoms. The scientific world had for a long time accepted the theory of Mialhe, that every mercurial preparation, before it displays any therapeutic action, must be changed into sublimate, and that as such would attack with its poisonous properties the syphilitic germs forming albuminate of mercury and in this way carry them away from the system. The opinion of Boerhaave, however, could not be forgotten ; he claimed that the action of mercury was a mechanical one, and that the mercury acted as infinitely small globules in the blood and in the tissues, affecting the virus of syphilis. This question was recently resumed by J. Justus 26 who, in order to investigate how mercury acts on the syphilitic lesions, followed, on the one side, the histological changes, and on the other the biochemical alterations as they occur in the papula, the true and characteristic syphilitic manifestation. He excised papules, especially of the moist kind, in sixty different patients, and of these made a series of sections. Under the mercurial treatment he found that the characteristic infiltration made up by the numerous small leucocytes gradually disappeared and the plasma cells were no longer found, as they are converted into connective tissue fibres. The 26 Justus, J. " Die Action des Quecksilbers auf das syphilitische Gewebe, ein Versuch zur Losung der Frage nach dem Wesen der Specifischen Therapie." Archiv. fur Derm, und Syphilis, B. 57. THE TREATMENT OF SYPHILIS 207 same changes occur inside of the blood vessels, which have been af- fected by syphilitic angioitis, where the infiltrating cells are reabsorbed, and the plasma cells are changed into fine connective tissue elements. These changes took place in the syphilitic papules, not through the constitutional treatment alone, but also through the local application of mercurial preparation on the syphilitic lesions. In order that he might find the globules of mercury in the tissues and in their cells, he treated the excised papule for one to two days in a solution of fourteen per cent, of chloride of zinc, and after washing, exposed the specimen for several hours in a solution of sulphurous acid, where constantly fresh gas was maintained. The specimen so treated was then hardened in alcohol, mounted in celloidin and then cut in sections. Under the immersion lens the plasma cells showed a large quantity of small black granules, with a remarkably diminished affinity for the ordinary stains. Moreover, in the specimens were found granules of sulphide of mer- cury of different sizes, scattered about in the thick connective tissues, and in the elastic fibres of the deeper layers of the derma. Some discol- oration was found in the endothelium of the blood vessels. Justus, judg- ing from his observations, believes that mercury is taken into the circulation as such, and displays its action at first on the endothelium of the blood vessels, and secondarily through them it is carried to the cells of the syphilitic infiltrations. It is taken up by these cells and it is combined with their albumin. In this biochemical combination mer- cury re-enters the lymphatic system and reaches the excretory organs, taking away those albuminous productions, results of its action on the syphilitic infiltrations. In the same way mercury is combined with the hemoglobin of the red corpuscles, and destroys a great number of them, but it attacks only those red corpuscles which have been already degenerated on account of the deleterious action of the syphilitic virus. In a like manner in regard to the tissue cells in the syphilitic lesions, mercury attacks their protoplasma only when they have undergone syphilitic alterations. The infiltrating cells, which are the result of the deleterious action of the syphilitic germs, have very little resistance, and mercury easily combines with their albumin, destroying them and so rendering them easily absorbable by the lymphatic vessels, and then they are carried away from the system through the excretory organs. The same experiments were, after a while, repeated by Pollio. 27 He excised moist papules in patients after they had received two, six and twelve injections each with two grains of salicylate of mercury. without having used local treatment. After treating the specimens in the same was as Justus, he found the same dark granules in the syphi- 27 Pollio. " Ueber die Aktion des Quecksilbers auf das syphilitische Gewebe." Archiv. fur Dermat. und Syphilis. 1902. Bd. 60. 208 THE MEDICAL ASPECTS litic tissues, but they were not in any relation with the quantity of mercury injected. He, therefore, also began to study non-syphilitic tissues, which he treated with a solution of chloride of zinc, and then exposed to the action of the sulphurous acid. They too showed the same abundant black granules. Therefore Pollio came to the con- clusion that the presence of those black granules in the tissues was not produced by globules of mercury, but was a precipitate of the chloride of zinc, which is found in all tissues treated in the above mentioned manner. If w r e cannot, at present, establish with certainty the action of mercury on the sy^philitic tissues, w T e can say that mercury is a specific for syphilis, and that any case of syphilis, at any period, will yield to its action. Its action on syphilitic tissues is so well known and so decisive that in case of doubt between a syphilitic ulcer and another kind of ulcer, the test of the mercurial treatment will clear the diag- nosis. It is necessary to know how to handle the remedy, its energy of action, its indications and contraindications, the value of the different preparations and the various methods of administration, in order that we may apply the treatment to the different cases with success. If mercury would give success by administration through the stomach alone, without any other care, any nurse or druggist would be able to cure syphilis by giving to the patient a vial of mercury pills. But in our practice we see quite frequently disastrous results from so reckless an administration of the remedy. Stomatitis. — The most annoying trouble caused by the mercurial treatment is salivation, which comes suddenly in spite of all the care and attention given to the mouth. In some cases it may be considered as a sign of a sufficient mercurialization, and then it is necessary to discontinue the mercurial treatment and energetically treat the stoma- titis. In this affection of the gums we see an inflammation which is caused by the irritant action of the mercury in the saliva as a predis- posing cause, but as the determining cause we must see the presence of bacteria, which produce inflammation of the tissues already altered by the elimination of mercury. This condition is shown by the peculiar metallic taste which is complained of by the patient in the beginning of the stomatitis, together with an exaggerated flow of saliva from the mouth. The gums, especially of the lower jaw T , appear somewhat red and at the point where they are attached to the teeth show a kind of grayish line formed by some exudation. The gingival pyramids be- tween the front teeth are swollen, and also the hard palate behind the incisors. In some cases only the gum surrounding the last molar is affected ; it appears swollen and detached from the crown of the teeth. THE TREATMENT OF SYPHILIS 209 In severe cases the process may involve the borders of the tongue, the cheeks, the lips and also the tonsils, at times in patches, and at times in large surfaces. On account of the swelling- the teeth show inden- tations on the borders of the tongue, and on the mucous membrane of the cheeks, with resulting ulcerations. The odor exhaled from the mouth is disgusting and unbearable. In some grave cases the affection spreads to the periosteum of the alveoli, which causes the teeth to be pressed out of their sockets. This condition gives the patients the idea that the teeth are elongated. The teeth may become loose and fall out. In some cases the inflammatory swelling of the soft parts may produce extensive gangrene. Fortunately cases of this kind occur very rarely to-day, for the reason that the mouth is constantly watched during the mercurial treat- ment, and as soon as symptoms of stomatitis appear the treatment is suspended, and the stomatitis is energetically treated. We can say that in our clinic, hospital and private practice in a large number of syphilitic patients, mercurial stomatitis occurs very rarely. According to our observations, cases of stomatitis have occurred mostly as a consequence of taking pills of protoiodide of mercury, or of the injec- tions with calomel, and of the inunctions. While during the treatment w r ith sublimate solution, either taken through the mouth, by baths, or by injections, and with gray oil injections, we have very seldom found cases of salivation. Of the cases of gangrenous stomatitis which have come under our service, one has been under the treatment of a quack, who claims to treat syphilis by vegetable products, and another was treating himself with protoiodide pills of mercury in enormous doses. We have also observed a case of severe stomatitis with a necrotic con- dition of the whole mouth and of the tonsils, in a boy twelve years old affected with pseudo-leukemia, who showed unmistakable symptoms of hereditary lues. He received two injections with five minims each of 50 per cent, gray oil at intervals of three days one from the other. On account of his extreme anemic condition the mercurial treatment was stopped and changed to that of iron tonics and arsenic. Nearly three weeks after the two injections he showed signs of severe stomatitis. In some cases salivation occurs after small doses of mercury, but it usually appears during mercurial treatment ; cases occur where stomatitis comes some weeks and even a month after mercury has been discontinued, as observed by Jullien. As a prophylactic means for stomatitis, we observe cleanliness of the mouth, and as stated, in the hospital and in the clinics we have tooth brushes which are given to the patients, and tooth powder also for their use. The patients who have stumps of decayed teeth are referred to the dental college to have their teeth placed in good order. 2IO THE MEDICAL ASPECTS As soon as we notice the gums of the patient have become red and the patient speaks of a metallic taste in his mouth, we stop immediately any mercurial treatment and also external mercurial applications. The patients then receive an iron tonic treatment internally and hot baths to promote sudation. A solution of chlorate of potassium in pepper- mint water is given to rinse the mouth twice a day, and during the time the patient uses a solution of a few drops of tincture of myrrh in water. In severe cases it is necessary to touch the gums and the ulcerated patches with a solution of nitrate of silver three per cent, or with tincture of iodine, or to tampon with pieces of iodoform gauze, so as to prevent the ulcerated surfaces from touching each other. The injurious action of the mercury is sometimes displayed on the gastro-intestinal tract, in the form of a catarrhal condition. The di- gestion is then disturbed, the patient suffers colicky pains, has fre- quent watery stools, and sometimes also with some blood ; it is a form of mercurial dysentery. The intestines are the chief emunctory for the excretion of mercury, and they are liable to feel its effects in whatever way it is administered. The stomach, especially through the administration of the sublimate, is affected with acute and chronic dyspepsia, which compels us to discontinue the use of the remedy. In several hundred syphilitic patients which we have treated in the manner above described, we can assert that very seldom has it occurred that we have been compelled to stop mercurial treatment on account of mercurial dysentery. Mercury also acts injuriously on the kidneys and there have been cases of albuminuria and cylinduria which have been cited as conse- quences of mercurial treatment. According to Welander and Lang, these conditions of the kidneys, with the exception of cases of excessive abuse of mercury, were only temporary symptoms, which are not accompanied by any detrimental results to the organ. We remember a medical gentleman who had suffered from albuminuria since his boyhood, as a consequence of scarlet fever, who was affected with syphilis. He came under our treatment and he was greatly concerned about the injurious action of mercury on his chronic albuminuria. We treated him with intramuscular injections of a one per cent, solution of sublimate. We examined his urine every day during treatment, and we saw no change in the quantity of the albumin. The gentleman got well without experiencing trouble on the part of the kidneys. As consequences of mercurial poisoning there have been mentioned disorders of the nervous system, and of the voluntary and involuntary muscles, tremores mercuriales. In cases of acute hydrargyrosis it may develop a real polyneuritis. Cases of this kind have been observed as the result of mercurial poisoning in consequence of handling mercury THE TREATMENT OF SYPHILIS 211 in professional work, and only exceptionally following the therapeutic use of it. MERCURIAL POISONING When we referred to the method of inunctions with mercurial ointment we pointed out frequent eruptions caused by the irritant action of the mercurial ointment on the skin. We must, however, mention some peculiar toxic erythema, which sometimes is observed as a consequence of medicinal hydrargyrosis. In these cases the erup- tion is no longer the result of the local irritation, or of local poisoning, but it is due to the general action of mercury, as it occurs after its internal, or its subcutaneous administration. The eruption occurs in the form of erythematous patches, oval or discoid in shape, sometimes raised up and resembling a wheel of urticaria. Small purpuric spots the size of a pin-head are found mixed up with the erythematous patches, more frequently on the legs. In some cases the erythema assumes a fiery red color, with exudations, which raises up the epi- dermis in the form of blisters. Fever accompanies this eruption, to- gether with anorexia and general depression. The course is rather acute, the inflammatory symptoms soon subside, and abundant desqua- mation on the affected region ends the affection. In our practice we have but rarely seen cases of toxic erythema due to the use of mercury. It is difficult to explain how mercury, which is in general so well tol- erated in the medicinal doses, can, in certain cases, have such injurious results as to produce even death. Nicolich reported the case of a robust man who was addicted to the use of alcohol, and who died after the sixth inunction of mercurial ointment. Lesser 28 reported another case of fatal poisoning in a woman following the administration of two and one-half decigrams of salicylate of mercury in three separate injections. These unfortunate results are to be explained only from the standpoint of an excessive intolerance for mercury, which in most of the cases is caused by tuberculosis, malaria, alcoholism, degenera- tion, anemia, hemorrhagic diathesis, and all individual conditions which have influence on the production of the toxic effects of mercury. For this reason, when we find individuals poorly nourished, with scrofu- lous habit, who are suffering with suppurations, we must be careful in the administration of mercury. In these cases a tonic treatment asso- ciated with the use of iodine will improve their general nutrition, and then they will be able to stand the use of mercurial preparations. We have never seen dangerous symptoms from mercurialism in our practice, and we can say that when the necessary precautions are taken there very seldom occur the unpleasant results to which we have referred. 28 Lesser. Berliner Dermat. Gesellschaft. 4. Marz, 1902. rep. Monatsheft. filr prakt. Derm., April, 1902. 212 THE MEDICAL ASPECTS THERMO-MINERAL BATHS The application of hot baths and a milder climate make the elimination of mercury from the system more active, and in conse- quence the doses can be pushed to a somewhat greater extent, and so obtain more ready results. For this reason there have been established many thermo-mineral bathing resorts, which are considered, or at least advertised, as the Mecca of the syphilitic patients. In the United States we have Hot Springs, Arkansas, where a sulfosaline water comes out of the ground at a temperature of 120 to 130 F. This is taken from the different bath houses, hotels and sanitary establishments, and is used for drinking and for bath purposes at the temperature at which it comes from the ground. The patient takes his bath at first at a temperature of 96 °, which is gradually increased to ioo°, and more if the patient can bear the temperature. His head is refreshed with a towel dipped in fresh water. The per- spiration begins to run abundantly from his body, and after ten or fifteen minutes he is taken out of the bath, rubbed dry, and left for a few minutes' rest on a couch. After he has taken some rest the attendant rubs him with mercurial ointment from one and one-fourth drams to two drams for from fifteen to twenty minutes. The rubbed regions are then covered with a piece of lint or with a piece of linen, and then bandaged. This treatment is repeated every day or every other day, according to the gravity of the case. We have already expressed our opinion in reference to the thermo- mineral cure of syphilis, and we consider it good only as an auxiliary treatment, helping to improve the general nutrition. Indeed, the Southern climate, the tepid air and the blue sky cheer up the patient, and his appetite increases and helps to make him stronger and better able to stand the mercurial applications. Moreover, the hot bath in- creases the functions of the skin, provokes abundant perspiration, and helps the excretion of mercury. For this reason we believe the ther- mo-mineral cure to be a valuable auxiliary in the treatment of syphilis. We do not believe in any medicinal property of the water of Hot Springs, but only in the effect which is obtained from the hot baths. This is sometimes abused so much that patients have become neuras- thenic from the weakening action of the hot water. We remember some of our patients affected with secondary syphilis, who, under the impression that in Hot Springs they would have been cured much more quickly, went there, and came back in a neurasthenic condition. They could neither sleep nor eat, their pulse was very quick, and in- stead of gaming, they had lost considerably from the abuse of the hot baths. In the tertiary period of syphilis, when the patient needs rest, better climate, and strong mercurialization, we have seen much better THE TREATMENT OF SYPHILIS 2 H results from the thermo-mineral treatment. Indeed, if we are not much inclined to send our patients to Hot Springs during the secondary period of the disease, we find it advisable to send the patient there when he is threatened by symptoms of the nervous system, or by a degenerative condition of the internal organs. IODIDES The other remedy which has proved so valuable in the treatment of syphilis is iodine, which has been used as such ever since its dis- covery in 1811. We must be grateful to William Wallace, of Dublin, who employed iodide of potassium in syphilis, and was the first to point out its energetic action against the malady. In 1836 he published in the Lancet the results of his experience with the new remedy. To Ricord, however, is due the credit of having studied more thoroughly the action of the iodide of potassium, and having limited its applica- tion to the special line of the tertiary syphilitic manifestations. The iodide of potassium is a remedy that is easily absorbed and immedi- ately spread into the system. Twenty minutes after taking a dose of iodide of potassium it can be demonstrated in the urine. It shows the most remarkable action upon the syphilitic infiltra- tions of the tertiary nature, which soon dissolves and causes their absorption. It relieves pains produced by specific inflammatory process either of a neuralgic form or of a continuous boring nature, as in cases of exostosis. We have seen cases of phagedenic ulcers destroy- ing the skin stop their destructive action and heal up under the influence of this powerful remedy. In cases of syphilis of the nervous system the action of the iodide of potassium is absolutely wonderful. For a time there was the belief that iodide of potassium acted so well on syphilitic lesions for the reason that it had the power to set free the mercury which had been previously taken. Mercury would accumulate in the system and remain inert, and the iodide of potas- sium would exhume this mercury and set it to work. This, however, is not the case, because, as Fournier wisely remarks, the iodide of potassium has produced its beneficial effects in many cases of late lues where mercury had never been given. According to Lesser, 29 the iodide of potassium would circulate in the blood not in the form of an organic combination, but as an alka- line iodide, and its action is due to its combination. He claims, too. that the iodipin, which is a combination of iodine with oil, on pene- trating into the tissues forms alkaline iodides and in this way displays its beneficial action. Sellei, 30 following the ideas of Richet and R. 29 Lesser. " Ueber das Verhalten der Iodpraparate, speciell des Iodkaliums und Iodipins im Organismus." Arch. f. Derm. u. Syph. Bd. 64. H. 1 and 2. 1903. 30 Sellei, Joseph. " Beitrage zur Frage der Wirkung der Iodalkalien und des Iodipins bei Syphilis." Monatsheft. f. prakt. Derm., June, 1902. 214 THE MEDICAL ASPECTS Balint, that in the administration of the bromides, removing chlorides from the diet, the system becomes much more sensitive to the action of the first, believed that the same could have been true for the ad- ministration of the iodides. He found, however, that a diet rich in chlorides has no influence whatever in preventing iodism, and also that a diet with less chlorides does not increase the action of the iodides. We can say in general that the iodide of potassium is usually well tolerated, although in large doses it does not badly affect the stomach ; on the contrary there are cases where it increases the appetite. In our experience we give iodide of potassium in the clinics, in private practice and in the hospital in large doses with beneficial therapeutic effects, and without any bad consequences from its administration. Yet once in a while cases occur where a small dose of iodide of potassium has been the cause of much trouble. Quite frequently patients taking iodide of potassium complain of a salty or metallic taste in their mouths. Ladies especially, who are taking iodide, complain of this bad taste, which is more annoying in the morning and which they attribute to bad breath. Many others complain of cold in the head; they find a stubborn flow of mucus from the nose, coryza iodic a, which like any other coryza is accom- panied by a sensation of obstruction of the nose, sneezing and a dull headache. Yet this iodic coryza does not last during the whole treat- ment, usually the patients acquire a certain tolerance for the drug, and the affection becomes scarcely noticeable. Nearly everybody under the treatment of iodide of potassium shows acne pustules on the face, which resemble an eruption of acne vulgaris. The eruption is made by a limited number of small red papules surmounted by a small pustule, which on breaking forms small crusts. The number of the pustules is limited to a few which easily heal, but the persistency with which they return, especially on the face, forms for the patient a disagreeable feature of the treatment. But this is not all ; we have seen eruptions from the iodide of potassium attaining enormous proportions, in the form of large red pustules associated with edema of the face. In other cases large pustules were coalesced and were covered with thick crusts resembling somewhat a papulopustular syphilide. It is remarkable that these eruptions did not come after the drug was used for a long time, but only a few days after the iodide treatment had been commenced. In consequence of the use of the iodide of potassium, bullous eruptions have appeared, which have been described under the name of iodide pemphigus. The bullae resting on swollen surfaces are found mostly THE TREATMENT OF SYPHILIS **5 on the face, neck, and some on the arms and hands. Other types of eruptions from the iodide have been described, in the form of thick pustular eruptions, and others somewhat ulcerated, where it was dif- ficult to differentiate the iodic eruption from a syphilitic eruption. Carl Berliner 31 refers to several cases in his practice of patients over- loaded with iodide preparations, for the reason that the lesions caused by the iodide had been mistaken for syphilitic eruptions. Douglas W. Montgomery 32 described a tuberous eruption from iodide of potas- sium, which simulated histologically an epithelioma, showing ulcera- tions on a swollen base. Another order of troubles caused by the iodide of potassium, although fortunately rare, is an edema of the respiratory tract, which .we have had occasion to observe several times. The edema affects the larynx and extends to the trachea and also to the mucous membrane of the bronchial tubes. The affection is one of an inflammatory nature and caused by deep alterations of these organs. Fournier 33 refers to some cases, which have ended fatally, where the post-mortem showed edema of the upper portion of the larynx, of the vocal cords, of the epiglottis, accompanied with an acute congestion of both lungs. The few cases we have had under our observation have all recovered, but have caused sufficient fright to the internes and to the nurses. We remember a patient, a butcher by trade, who came into our private practice with symptoms of tertiary syphilis. We prescribed for him a saturated solution of potassium iodide to be taken in ascending dose, beginning with ten drops after each meal in water. He took ten drops after his breakfast and ten drops after his dinner, and was soon after affected with flushing of the face, swelling of the eyelids, diffi- culty of respiration, aphonia, all owing to the edema glottidis, which fortunately on account of the small dose was not so serious as to menace his life. We do not know exactly the reason why the iodide, so valuable ? remedy in some cases, acts so strangely as to jeopardize the life of the patient in others. It has been attributed to the quality of the drug, to to impurities contained in it, but the same drug has never produced any trouble in other patients, who were taking the remedy out of the same bottle. It has, therefore, nothing to do with the quality and the purity of the remedy, but the reason must be sought rather in the individual condition of the patient. Someone has advanced the theory 31 Berliner, Carl. " Zur differential Diagnose der Syphilis und syphi- lisahnliches Arzneiexantheme." Monatsheft. fur prakt. Derm., 15 Aug., 1902. 32 Montgomery, D. W. The Journal of Cutaneous Diseases, February, 1904. 33 Fournier, Alfred. " Traitement de la Syphilis." Paris. P. 415. 2l6 THE MEDICAL ASPECTS that the iodismus is connected with some trouble of the kidnevs and is due to a scanty elimination of the remedy by the urine. In our cases, however, this theory cannot be admitted, when we had symptoms of edema glottidis after the ingestion of fifteen grains in two doses, and in other cases also after smaller doses. In these cases the accumula- tion of the remedy is entirely out of the question. It is necessary, there- fore to admit, with Fournier and others, the existence of an individual idiosyncrasy for the remedy, which in a few individuals is capable of bringing about such dangerous symptoms. For this reason we always recommend that our patients begin the treatment of the iodide of potassium with small doses of from five to ten drops of the saturated solution three times a day diluted in a large quantity of water. When we have tested the tolerance for the remedy, then we begin to increase the dose, bringing it up to large quantities per day, according to the indications of the individual case. Although the iodide of potassium has been administered hypo- dermically and by rectal injections, yet we have always preferred the method of ingestion. We have never found a patient who could not swallow the solution of iodide, especially when diluted in large quan- tities of water. In many cases we advise our patients to dilute their medicine in half of one cup of milk, which is easily taken and does not produce any irritation on the stomach. In case of a dyspeptic condition, when the stomach cannot retain the solution of iodide, we can give it associated with an elixir of pepsin, or in some more palatable formula. The following has been recommended by Fournier : Potass. Iodide 25. Anisette de Bordeaux 150. Syrup Simpl ' 350. M. It is also recommended to dissolve the daily dose of iodide in a sufficient quantity of water, which is used for drinking purposes during the meals. In this way the remedy is taken with the food, and will not produce any irritation of the mucous membrane of the stomach. We always avoid the use of the iodide in pills, for the reason that the pill dissolving in one part of the stomach is capable of irritating the part of the mucous membrane which it touches. In reference to the doses of the iodide, they are different, accord- ing as it is used in a preventive or in a curative way. In our practice we do not use the iodide of potassium unless it is late in the treat- ment. This remedy, although a very valuable one, must not, in ordinary cases of early syphilis, be used. It finds, however, indica- tions in some special cases of early syphilis when its invasion is accom- THE TREATMENT OF SYPHILIS 217 panied by acute rheumatism, pain or severe headache. In these cases it is the most valuable remedy for relieving the pains. When the patient begins to show signs of inflammation of the periosteum, the only remedy to relieve the nocturnal pains is the iodide. But if there are no such indications, the treatment of syphilis in its early period is based on mercury, and this is the only remedy. When our patient has taken mercurial treatment for a year and we do not see other symptoms, then we give him some iodide treat- ment for a preventive purpose. In this case, we begin with the dose of ten drops after each meal, and gradually increase it to twenty-five and thirty drops in half a glass of water. This is an ordinary dose ; but when we have to do with cases where the nervous system is threatened, where we need a prompt therapeutic action, then the dose will be at first from two drams to four drams per day, but such ex- ceptional doses as mentioned before have to be reserved for excep- tional cases only. Indeed, Fournier very wisely remarks in reference to these high doses, that it is of no use to give ten bottles of Seidlitz to purge a patient, when we can obtain the effect with an ordinary dose. In individuals who have been badly affected by the iodide of potassium, or when the dose has to be increased to a very high degree, we have used the iodide of sodium, which is somewhat milder in its effects. We find that it is better tolerated, is less depressing, less irritating, and does not act so severely on the kidneys. Its action, however, when compared with that of the potassium iodide, is less reliable, so that we use it only exceptionally in our practice. We can say that a valuable addition has been recently made to the iodides therapeutic by the use of iodipin. This is a combination of sesame oil and iodine and it is prepared in the strength of ten and twenty-five per cent. The idea comes from Winternitz, 34 who was trying to obtain a preparation where the iodine could be combined with an organic substance, and from which it could not easily be separated. The symptoms of iodismus, having their cause in the iodine free from its alkaline combination, led him to think of a preparation which could be carried to the affected tissues, maintaining the iodine strongly combined. One combination of iodine with albumin gave the iodal- bacid, and the other with oil gave the iodipin. According to Noble and Welander, a short time after the ingestion of an alkaline iodide, free iodine is found in the saliva and in the urine, and they rightly attribute to the free iodine the therapeutic efficacy of the remedy. The action of the alkaline iodides is not very permanent, because after twenty-four to forty-eight hours nearly all the iodine has disappeared from the organism, very little remaining for the therapeutic appropria- 34 Winternitz. Dentsch. Med. Wochenschr., 1897. 2l8 THE MEDICAL ASPECTS tion. Consequently large doses are necessary in order to maintain a certain quantity of the iodides in the system. We can say that with the iodipin all the lamented inconveniences have nearly disappeared. The iodipin is prepared by E. Merck, of Darmstadt, and by that firm is placed on the market. The combina- tion is of ten and twenty-five per cent. The first is used for internal administration, in capsules to avoid the disagreeable taste, and the second is mostly used for subcutaneous injections. We have had experience with this preparation for over four years, and we agree with Klingmuller 35 that the iodipin by subcutaneous injections is to be considered one of the best ways to administer iodides. The method is easy and simple, the action of the iodides is sure, strong and per- manent, thus avoiding the troubles which are caused by other iodide preparations. In a few cases where the patient could not come to get the injection, we have given the iodipin in capsules, in the quantity of one teaspoonful per day, which has been well tolerated by the stomach and is quickly absorbed, without causing gastric disturbances or symptoms of iodismus. Frieser finds that iodipin does not set iodine free in the stomach, but as soon as it comes into the intestines it is readily absorbed. Sternberg has found the reaction of the iodine in the saliva, sixty-five minutes after ingestion, in case of normal stomach. In the few cases where we have used iodipin by ingestion it has rendered good services. The usual way of administering iodipin is by subcutaneous injec- tions. It is necessary to have a special syringe, much stronger and larger, with larger and longer needles. It has been recommended that the iodipin be warm before using, which we never do, as the tempera- ture of the room keeps the iodipin fluid and ready for use. We in- ject one syringeful into the scapular region every other day, or even every day, injecting first on one side and then on the other. We insert the needle from above downwards obliquely into the sub- cutaneous tissue, and thus the oil is squeezed into the tissues. At the moment of injection, the patients complain of a burning sensation, which in a few minutes subsides. We have never seen an abscess following the injection of the iodipin. In cases where we find a mixed treatment necessary, we reserve the gluteal regions for the gray oil injection, and the scapular regions for the iodipin. Blomquist, 36 Welander, 37 and Sellei 38 have demonstrated the 35 Klingmuller. " Iodipin in subcutaner Anwendung bei tertiarer Lues." Berlin, klin. Woch., 1899, No. 25. 36 Blomquist. Arch. f. Derm. u. Syph., 1901. 37 Welander. Arch. f. Derm. u. Syph., 1901. 38 Sellei. Monatsheft f. prakt. Derm., June, 1902. THE TREATMENT OF SYPHILIS 219 presence of the iodine in the urine sixty-five minutes after the injec- tion, but in most of the cases it is found one, two or three days after the first injection. The presence of the iodine in the urine is easily found by taking a quantity of urine, six or ten gmms., to which a small quantity of starch solution is mixed and then well stirred. Then a few drops of fuming nitric acid are added, and the presence of the iodine is revealed through a thin veil of a blue color on the urine. The iodipin is absorbed as such from the place of injection, and enters into the general circulation as a firm combination of iodine and fat, and only in the depths of the tissues are the alkaline substances capable of taking the iodine from the combination, thus forming alka- line iodides with the alkalies of the organism. It is easy to understand the reason of the more permanent action of the iodipin compared to that of the ordinary alkaline iodides, which lose their iodine while in the stomach and the intestines, causing iodismus, with all the troubles we have above mentioned. In the cases of Klingmuller, iodine was demon- strated in the urine and in the saliva only two or three days after the first injection; and in the urine two months after the last iodipin in- jection there could be found traces of iodine. The great advantage of the subcutaneous injections with iodipin is that we can reach a therapeutic efficacy of the iodide treatment with- out exposing the patient to the inconveniences of the iodismus, and keep him for months under the action of the iodine, until we have obtained the expected results. We must state from our experience that the efficacy of the iodipin has been shown to be far superior to the ordinary ways of administering iodides. In our hospital wards iodipin has given us the most satisfactory results. In cases where a few drops of the solution of iodide of potassium could not be toler- ated, injections of iodipin repeated every day did not produce any systemic trouble, and gave the desired results. A few weeks ago a patient affected with syphilitic basilar meningitis, who for six months had been totally blind, had been treated in a sanitarium with inunc- tions of mercurial ointment, and with the ordinary solution of iodide of potassium, without results. He was brought under our treatment and subjected to iodipin injections; in a few days he was able to see somewhat, at first with only one eye, but afterwards with the other also. He is reported as still improving. The iodine treatment is usually reserved for the tertiary lues, and in these cases we can see its wonderful efficacy. In the cases, how- ever, of tertiary syphilis, where we find that the patient has taken in- sufficient or no mercurial treatment during the secondary period, we give the iodine treatment, but we cannot entirely leave off mercury. 220 THE MEDICAL ASPECTS Here we must use both remedies, the most efficacious ones we have against syphilis. In our hands the severe last cases are treated with mercurial ointment inunctions, and the administration of the iodide of potassium internally. In cases of severe affections of the nervous system, where an energetic treatment is required at once, we give injections with gray oil and injections with iodipin simultaneously. In these cases we give the injections of the gray oil every two days, and injections of iodipin every day, and even twice a day. In this way we have a strong and energetic mixed treatment, which has, in many cases, given excellent results. The beneficial action of this treatment, and the involution which it brings about in the pathologic products of syphilis is so apparent and sure that we have used this treatment in cases of doubt, as a test treatment, to ascertain whether the affection was of a specific nature or not. We remember an ulceration on the glans penis, stub- born and proliferating, which had all the appearance of a carcinoma. It was in a gentleman who strongly denied any possibility of infection. A piece was examined by a pathologist, who was greatly inclined to believe in the cancerous nature of the infiltration, and the amputation of the penis was considered the only means of saving the life of the patient. In spite of all his assurances that he had never had any syphilitic trouble, we gave him a strong mixed treatment as a test treatment, and an emplastrum hydrargyri on the locality. In a few weeks the ulcer healed up, giving us the certainty that it w T as nothing more than an ulcerated gumma. We know well that ulcers of a tubercular or of a carcinomatous nature are rather irritated than bene- fited by this treatment, while syphilitic tertiary processes react promptly under a treatment of iodides and mercury. In a case in which a child is born with congenital syphilis, both parents, although they show no apparent symptoms of the disease, must be subjected to a mixed treatment. In these cases when we have no special symptoms to fight, and when the treatment must be con- tinued for some time, we use a milder treatment so that it may be tolerated by the system for a longer time. It is necessary to give the patient some intervals of rest from the treatment. Although in some cases, obstinate symptoms have not yet entirely disappeared after several weeks of strong treatment, it is advisable to rest for a while and then begin the treatment again. In this way it will show much more efficacy than if continued for too long a time. When the symptoms have disappeared the patient cannot give up treatment and he must continue with the remedies intermittently. In the second year we continue the treatment, but stop it for periods of THE TREATMENT OF SYPHILIS 221 from four to six weeks, so as to afford a rest. In the third and fourth year, if no symptoms are present, we advise our patients to take a course of treatment two or three times a year lasting six weeks. In some cases the mercury and the iodides are given alternatively. We give the patient a course of eight or ten injections with the gray oil, one injection per w r eek, and when he has taken the injections then he takes iodides for three or four weeks. In determining the time that the patient has to continue the treat- ment we are guided by the condition of the lymphatic glands. As long as the glands, especially of the cervical region, are enlarged, hard and perceptible to the exploring hand, we advise the patient to take a course of treatment at least twice a year. We believe in the ideas of Fournier, namely, that the treatment must be intermittent and must extend over a period of several years. Syphilis develops symptoms and pathological products at intervals, and in consequence the treat- ment must be given at intervals. When treatment is given inter- mittently it will not only cure the symptoms which are present, will not only produce the involution of the syphilitic products, but will also prevent possible relapses. The idea of Fournier, with his repeated and chronic treatment, is to prevent new outbursts of the disease. The objections raised by Lang to the continuance of the treatment for so long a time, advocating rather an opportunistic treatment, are not so forcible as to make us recede from our views. We know very well that the course of syphilis is so variable, we also know that in a great many cases after a very mild eruption, the disease has shown itself no more and it has been considered entirely cured. But we can- not forget that a great many of these cases, after ten or fifteen years, have shown symptoms of general paralysis or of ataxia. The neurol- ogists teach us that syphilitic diseases of the nervous system are mostly found in patients who had passed a very mild stage of con- stitutional syphilitic symptoms, and as a consequence they did not care much for a long and thorough treatment. In the matter of determining how long the patient has to continue with his treatment, as already stated, we must be guided by the qnality of the symptoms, if superficial and easily yielding to the treatment, or if deep, frequently relapsing, and stubborn to the action of the remedy. The general condition of the patient has also to be taken under con- sideration. A man strong and in good general condition will tolerate a much longer and much stronger treatment than another who is weak, debilitated by alcoholism or by some other diathesis. The patient must remain under the supervision of his physician, and as long as the lymphatic glands are still hard and perceptible, the patient needs to receive more treatment, which will be given at lono- intervals. 222 THE MEDICAL ASPECTS Whenever the patient sees any lesion which reveals a possible relapse, he must see his physician again so as to determine whether more treat- ment is advisable. In some rare cases where the specific treatment is not easily toler- ated we may derive some benefit from the use of some depurative de- coction, such as sarsaparilla, dulcamara, etc., which in association with fresh air, good nutrition, ferruginous preparations, and rest from ordi- nary business, will improve the general system of the patient and make him able to stand the specific treatment. In cases of old ulcerative syphilis in individuals in an emaciated condition, we often prescribe the Zittmann decoction, which from the sixteenth century has main- tained its reputation. We have seen the Zittmann decoction ordered freely by our revered teacher, Professor F. Hebra, with admirable results. It is a decoction made of several different remedies ; the most interesting of all is the sarsaparilla, cinnabar and calomel. The principal action of these decoctions seems to be that of the diuresis and diaphoresis, causing an increase in the tissue exchanges, which is beneficial in the treatment of syphilis. Of course to-day nobody would prescribe these decoctions as the principal treatment for syphilis when we know that they have little action on the syphilitic infiltrations on account of the small quantity of calomel they contain. But they can still be used, as H. Zeissl 39 advises, as coadjuvants, while under the mercurial treatment, or after. Zittmann decoction has the following formula : Rad. Sarsaparill. cone 5 x ii inf. cum Aq. fontis ob lxxii diger. p. horas xxiv dein add intra sacculum linteum 1 pulv. sacch, alb yaa 3 vi alumin. crud J Calomel , 3 iv Cinnabar 3 i Coque ad col. lib xxiv Sub finem coct. add ] Sem. anisi vulgaris J-aa 3 iv Foenic j Fol. sen ) _ . Rad Hquir |aa 3 iss Exprime et per pannum cola. This is the formula of the decoctum Zittmanni fortius, strong; there is another formula for the decoctum Zittmanni mitis, or weaker, which is as follows : 39 Zeissl, H. " Lehrbuch der Syphilis." Erlang., 1871. THE TREATMENT OF SYPHILIS 223 Rad. Sarsaparill. cone % vi Additis speciebus a decocti fortiore residuis coque cum Aq. font ob lxxii ad colatur ob xxiv Sub finem coctionis add. Cortic. f ructus citr Sem. Cardamom, minor Cortic. cass. cinnam Rad. liquir Exprime et per pannum cola. aa 3 iii These decoctions were formerly given in exorbitant doses. The patients after taking a good dose of calomel and jalap, were compelled to drink one pound of the strong decoction, hot, at once, while remain- ing in bed to wait for a profuse sudation and also for the catharsis. Every day the patients had to take such large doses of the decoction that in a short time they were suffering with catarrh of the stomach and of the bowels. In our practice we use between six and eight ounces per day of the strong decoction, taken half in the morning and half in the evening. When the patient begins to complain of diarrhea he must immediately stop its use. As far as experience goes, the dose above mentioned is well tolerated, and in cases of syphilitic cachexia, in patients with a run-down system, who could not bear an ordinary treatment, we must confess that the decoctum Zittmanni has given us beneficial results. While in Germany the decoctum Zittmanni had gained so great a reputation, in Italy they used the Pollini decoction, which consisted of nearly the same ingredients. A great many depurative decoctions have been placed on the market with different names and different trade-marks. In all, sarsaparilla is one of the most important ingredients, the decoctum Vigaroux, the syrup Cuisinier, the Roob Laffecteur, in which there was also some sublimate. For all these different beverages, widely advertised by the firms, and sometimes recommended to the physicians in their offices by special agents, we can say that it is much better to keep away from them, and remove the idea from the public mind that the physician recommends such and such mixtures, and therefore they can continue the treatment without consulting their physician. INDIVIDUAL PROPHYLAXIS In France in 1899 a pamphlet was issued under the title Hygiene and Morals, by the Ligue de la Moralite publique, of which Dr. Good 40 was the author. It was purposely written for a son of sixteen, to explain to the male youth that sexual continence is not at all injurious 40 Good, P. 77 Conference Internationale pour la Prophylaxie de la Syphilis, etc. Bruxelles, 1903. 224 THE MEDICAL ASPECTS to the health, but on the contrary is greatly advantageous. That a young man must early have his sexual appetite satisfied is only a vulgar prejudice which has no scientific base, and is entirely against hygiene, which commands the continence of the young men. The idea of early satisfying the sexual appetite is that which exposes young men to acquire venereal diseases, which are the inevitable results of debauchery. This small pamphlet, written in an easy style, was soon translated into many languages and was distributed among young students, soldiers, etc., in order to place them on their guard by giving them a knowledge of the peril of syphilitic and venereal infection. Valentine 41 has followed this idea, and in a pamphlet, " The Bov's Venereal Peril," in plain and easy language explains to young men the dangers by which they are continually surrounded. Valentine, and with him many others, are advocating public lectures to the young people on these subjects. It seems, however, that conversations in this matter between the father, the teacher, the minister and the adoles- cents are more appropriate and capable of bringing about better results. It is a great mistake in fathers, teachers and ministers, and educators in general, who, knowing the necessity of placing the young on their guard against those monstrous diseases, yet on account of the difficulty of approaching so delicate a subject, or through an ill-conceived modesty, conceal from the young men the danger which is impending. The treatise on this subject, written from a purely moral and religious standpoint, does not bring much benefit to the young man, unless it is shown in its social and medical relations. The way in which young men reason is, " if God has forbidden intercourse between the two sexes outside of marriage, why has He given a want to satisfy when marriage is impossible?" But when we succeed in showing that this want is not so urgent as eating and drinking, that it diminishes the vital forces in the young men, that it makes them unable to follow their classical studies, then we impress upon them the necessity of the continence. The medical part is that which shows the wages of the sin, the awful results of syphilis in young men, and will exercise a great influence on them, putting them on their guard against intercourse with public or easy women. If young men do not get some knowledge in the matter of sexual hygiene, they will learn the opposite from some profligate companion, who will very likely lead them into immoral houses, and will expose them to the danger of venereal diseases. The pamphlet is considered the best means of reaching the young man, and the pamphlet must treat the question of sexual hygiene in reference to the social, moral and medical standpoint. The pamphlet 41 Valentine, F. C. " The Boy's Venereal Peril," from the Journal of the A. M. A., July 4, 1903. THE TREATMENT OF SYPHILIS 225 of Good was followed by another magnificent pamphlet written by Dr. Fournier under the title A nos His quand Us auront 18 ans. For our American families and for the American boys, the pamphlet of our esteemed friend, F. C. Valentine, is excellent, clear, brief and to the point. We wish that a large number of copies of this article could be distributed to all high schools, universities, colleges, military institutions, regiments, barracks, etc., in order to reach as many young men as possible. Indeed, the spreading of the venereal diseases and syphilis is due to prostitution, clandestine and public. Although this danger is well known, yet all efforts against prostitution, as we will see later, have remained of no avail, and clandestine prosti- tution especially is beyond the reach of the authorities, and has proved to be the principal cause for spreading syphilis. If the young man who has never heard of these diseases and has been infected with syphilis, had known the gravity of this disease, the individual danger for his future, the danger for his family, he would never have gone into that house and exposed himself to the infection. The ignorance of the disastrous consequences of syphilis is often the cause why many young men expose themselves to infection. More- over, when they hear from the profane mouth of a companion, speak- ing lightly and sometimes jokingly about the loathsome ailments, they lose all fear, and will surely become infected. The old assertion of Paul proves true, that obscene talking and bad example corrupt good moral character. To avoid this and its sad consequences, it is mani- fest that young men need enlightenment so that they may be able to understand the peril in which they are placed in going to the houses of prostitution. Queyrat, in speaking on this important subject of the individual prophylaxis with reference to venereal diseases, called attention to the great wrong of the ministers of the Gospel of every denomination, who, with the efforts of their eloquence, try to demonstrate that the bodv is despicable matter, and only the soul is of importance. The genital organs they call the organs of shame, debasing nomenclature of the organs of reproduction, from which we come, and from which our children are to come, and which ought to be considered the noblest organs, in which the hope and the future of the race are based. The hygiene of the sexual organs must be taught as one of the most im- portant parts of the welfare of the generation. When the genital organs are neglected and not kept cleansed of the presence of the perspiration and sebaceous matters, they become irritated and inflamed, increasing the sexual appetite. It ought to be the duty of the family physician to advise circumcision in male children when the prepuce is too long or too narrow, when it is often the cause of general troubles. 226 THE MEDICAL ASPECTS In this regard it is interesting to enter upon the old question, whether circumcision can lessen the susceptibility of the individual to syphilitic inoculation. It is undeniable that prejudice has played a great role, and the idea of preserving circumcision as a religious rite has shown great advantages based more on sentimental grounds than on truthful observations. In our opinion we have found initial lesions of the male organs among people who had been circumcised, as well as among people uncircumcised. From our records of many years' stand- ing we are unable to find any difference in the number of primary lesions among circumcised and uncircumcised. Moreover, we have found the largest number of primary hard chancres in the sulco balano preputiale, and only a few on the external or internal sheet of the prepuce. In this case circumcision has afforded very little protection. Our observations are not much different from those of Gottheil, 42 as we agree with him that amongst the circumcised population of immigrants syphilis is not so common, not on account of their being circumcised, but on account of their earlier marriages and of a better standard of sexual morality. Breitenstein, 43 who has been a physician in the Dutch Indian army, referred to his experience of twenty-one years among the Euro- pean and Malayan soldiers. He has found that syphilis among the natives, who are all circumcised, is much less frequent than among the uncircumcised Europeans, although they are equally exposed to the possibilities of infection. There is no doubt in our mind that circumcision is desirable on account of cleanliness. In cases of an accumulation of the smegma, often balanopostitis is the consequence, with frequent excoriations of the internal surface of the prepuce and of the glans. This condition of tenderness of these parts in the case of exposure to the contagium will render the inoculability of syphilis certain. We know in our venereal wards how troublesome a long prepuce is for the treatment of chancres. It usually becomes edematous and cannot be pulled back without causing pain, and exposing the patient to paraphimosis. This cannot happen in circumcised persons, and from this point of view we can say that circumcision is an advantage as a preventive and cura- tive measure. However, as we have already said, there is no necessity for youths to go around and expose themselves to venereal infection ; we find that circumcision does not have to be practiced indiscriminately in all male children for this purpose. It must be practiced only on those 42 Gottheil, Wm. S. Progressive Medicine. Vol. iii, 1903, p. 164. 43 Breitenstein, H. Dermat. Centralblatt, ref. Monatshefte f. prakt. Derm., Feb., 1903. THE TREATMENT OF SYPHILIS 227 children where the prepuce is very long-, and it is consequently diffi- cult to clean the glans, and in all cases where the prepuce is too narrow. In some cases we have found that it had only a small hole, scarcely allowing the urine to pass. In these cases circumcision is not only advisable, but it must be done of necessity. The reading of the letter of Dr. Valentine is to be advised at the age of puberty, insisting always on the important point of sexual con- tinence and that a man ought to maintain his chastity until his mar- riage. Victor Hugo in his Lettres a la Fiancee wrote to Madamoiselle Foucher, who was afterwards Madame Victor Hugo, as follows : " Je considererais comme une femme ordinaire, c'est-a-dire comme bien peu de chose, une jeune fille qui epouserait un homme sans etre morale- ment certaine par les principes et le caractere connu de cet homme, non seulement qu'il est sage, mais encore, et j 'employe expres le mot propre dans toute sa plenitude, qu'il est vierge, aussi vierge qu'elle- raeme." 44 These few words ought to be taught and impressed on the mind of every young man as a protection against the silly talking of misguided companions. We can say that the true prophylaxis rests a great deal with the conscience of the young man. The instruction on the sanitary matter will make him cautious, he will try to behave himself, but if he has no purity in his moral principles, with all the instructions he is liable to fall. Indeed, boys who are raised with immoral principles are great sources of hygienic and moral danger among the innocent and honor- able in their lives. With their habits of body and mind, they are capable of spreading disease and corrupt thought among other boys. In strong and vivid colors, Valentine has brought before young men the dangers coming from corrupt boys. When a boy who seems in every respect a fine fellow is boasting among others of his sexual experience with girls, he must be avoided by the other boys ; they must know that with his lies he is trying to corrupt them. In the same way he points out someone, who, with improper acts, may insult the manhood of the other boys, and he deserves to be severely thrashed. Others, selling immoral books, pictures, etc., are spreading corruption among young men, and they must be not only avoided by moral young men, but also brought to justice and severely punished. The excitement of the sexual appetite increases the desire for pleasure, and exposes one to the danger of acquiring venereal diseases. The detriment to the individual from syphilis and venereal diseases is 44 Translation — " I should consider an ordinary woman — which means one not worthy of high esteem — a girl who would marry a man without being morally sure of the principles and the known moral character of this man. She should know not only that he is wise, but also, and I use the proper word in its strict meaning, that he is virgin, just as virgin as she herself is." 228 THE MEDICAL ASPECTS very great, and it is calculated that one-eighth of all the patients in the hospitals of New York are inmates of those institutions on account of venereal diseases or syphilis and their consequences. These, how- ever, who are laid up in the hospitals are only a small fraction of the large number of those who, being infected, are still walking the streets and trying to attend to their occupations. It is not only the uncultured and uneducated man who is the victim of syphilis through his unbridled passions, but also the cultured, educated and intellectual man is equally often so unfortunate as to be infected. In our experience, however, we must say that syphilitic infection is much more frequent in the lower classes of society, amongst uncultured people, than it is amongst the better classes. We have already seen that syphilis is a disease which can be contracted entirely outside of the venereal act; we have seen that over twenty-five per cent, of all cases of syphilis have been inoculated accidentally, without anything being known of the danger of infection. It is, therefore, the duty of the physician to instruct his syphilitic patient of the danger of spreading syphilitic contagium. A young man who has been unfortunate enough to become infected with syphilis must know that he cannot kiss his mother, his father, his sisters or brothers, because his poisoned kiss can give syphilis to those whom he loves best. He must not permit anyone to use cups, glasses, spoons, forks, etc., which he has used, if not first washed. When we consider how easy the transmission of syphilis is, we will not be so much surprised to see the spread of syphilis amongst innocent people in factories and in places where many people live together. In their ignorance, they exchange pipes, or moisten pencils, take tools into their mouths, use drinking cups which have been used by a syphilitic companion in a like manner. It is therefore advisable for everyone to be careful and not drink from a cup used by others, without having it well rinsed, to avoid possible infection. The idea of the transmission of syphilis from the infected man to his wife, the idea of having syphilitic babies, must remain in the mind of a young man. This will keep him from exposing himself to the contagium by fear of the danger ; but it is not all ; the most im- portant point is the prevention of immorality. The greatest means of prevention of the spreading of syphilis as an individual prophylaxis is morality and sobriety, which form the fundamental base of the family, of the state, and of society. Syphilis is a monstrous disease, which not only poisons the life of the unfortunate who becomes in- fected, but infects his family, weakens the generation, being thus a constant menace to the individual himself, to his family, and to society. XI THE TRANSMISSION OF SYPHILIS TO THE OFFSPRING DIRECT TRANSMISSION The question of direct transmissibility of syphilis concerns the duration of the period of contagiousness. It would be easily settled if we could be able to establish positively the duration of this period, in which the infected subject continues to be a possible source of con- tagion to others. If we were to accept the contradictory statements of our patients, and also the misleading reports of isolated cases re- ported by physicians, we should easily come to the conclusion that there is no limit to the duration of the .contagiousness of syphilis. Not rarely do patients try to disguise truth to mislead the physician, in order to cover some mistake of their life. It is a difficult task to establish a priori a certain time after which syphilis is no more inoculable. In our experience, we find somewhat risky the assertion of Hutchinson x to permit and even encourage mar- riage, when two full years have elapsed from the date of contagion. In several cases it has happened that we have made the diagnosis of syphilis, and the patient has been astonished, saying that his physician had assured him of his perfect recovery after two years from infec- tion. When advised to postpone marriage he has replied that he was already married, under the assurance of the two years' cure. It is not correct to state that syphilis after two or three years is no more directly inoculable. In our opinion, each case must be studied by itself, and then, according to the past symptoms, to the time elapsed, to the treatment employed before, and to the present condi- tion, we can give our advice concerning marriage. After the classic works of Langlebert, Velpeau, Gibert and Ricord, the contagiousness of the secondary manifestations of syphilis has been generally recognized, and to-day it is out of the question to say that as long as the secondary symptoms are recurring, marriage must be forbidden. After the initial chancre, the most dangerous of all syphilitic manifestations are the mucous patches, papula humida, or condylomata lata, which in most of the cases convey the virus to the other party. Physicians and laymen commonly assert that if no sore 1 Hutchinson, J. Third International Congress of Dermatology. Transac- tions, 1898. 229 230 THE MEDICAL ASPECTS is present, syphilis cannot be communicated. We are of the same opinion, but the great difficulty is to prove that no sore is present. The mucous patch is formed in a moment, and the syphilitic patient, with the best of care, is often unaware of the existence of a patch on the genitals or on his lips. Mucous patches are sometimes formed on the back of the tongue, in the tonsils, and their secretion, virulent and infections, mixed with the saliva, may carry the contagium. A mucous patch, which is nothing more than an excoriated papula on the macerated skin, or on the mucous membranes, is a characteristic early eruption of syphilis, so that when we see one of these manifestations there is no doubt of the existence of syphilis. Some years ago we 2 published the records of syphilitic cases which had occurred in a period of five years in our private practice. Of 216 syphilitic patients recorded for that length of time in our books, 159 were men, 51 women, and 6 infants. In order to see the frequency of the mucous patches in the different stages of syphilis, the cases were separated into those of the early period, or secondary stage, and into those of the late period, or tertiary stage. We have found that 116 cases belonged to the secondary period and 94 to the late stage of syphilis, and 6 cases were of congenital syphilis. Mucous patches were present in the first period of the secondary stage in 102 patients of the 116, and in 24 of the 94 patients affected with tertiary syphilis, and in 2 of the congenital syphilis. This shows that mucous patches are very frequent during the sec- ondary stage, and they still show up in the beginning of the tertiary period. The anatomical regions which are affected in preference by the mucous patches are the lips, which showed the affection in 38 cases, the labia majora and minora in 12 cases, and in 11 cases the tongue, and in a like number the anus was affected. The frequency of the mucous patches on the lips explains how it is that the initial lesion of syphilis in women is often found in the mouth and in the tonsils. In our experience, we have often had occasion to see initial chancre of the tonsils in women, which could only with difficulty be detected. We sometimes find the presence of secondary symptoms of syphilis in a woman, and with careful observation we cannot succeed in finding the initial lesion. The pain which accompanies the chancre in the ordinary cases is very mild ; the whole trouble is referred to tonsilitis, and thus the initial lesion passes unobserved. There is no doubt that as long as mucous patches are formed, the disease is still directly communicable. Mucous patches usually appear 2 Ravogli, A. " Syphilitische Plaques." Monatshefte fur Prakt. Dermat., 1893, p. 78. TRANSMISSION OF SYPHILIS TO THE OFFSPRING 231 in the first period of the secondary stage, and at times they are the only symptom affecting the tonsils or the tongue for months, and re- lapse with persistence. Landouzy reported a case of infection of a lady through late mucous patches on the tongue of her husband, which produced a chancre of the tonsil. The mucous patches had reappeared four years after every symptom had completely disappeared. We have seen patients affected with mucous patches of the tongue five and ten years after the infection, after a long treatment, as they claimed, and nearly three years after all other symptoms had disappeared. These cases, however, are only exceptions, which ought to be kept in mind. In a general way mucous patches, after three years, appear only rarely. The occurrence of the syphilitic lesions seems to be connected with irritations applied on the anatomical regions, and possibly to the pathological condition of the blood and lymph vessels in this disease. The alterations of the vascular system are greatly connected with the virulence of syphilis, so much so that where these alterations are least, the virulence of contagium is also least. The formation of papules is of frequent occurrence, where a mechanical stimulus has been applied. In this regard Campana 3 stated that the greater the vascular irritability, the clearer is the evidence of the recent date of the syphilitic process, and the more contagious is the syphilitic virus. Tarnowsky was able clinically and also experimentally to confirm the assertion that vascular irritability in syphilitic subjects lasts for a certain period of time, and gradually diminishes in proportion to the advanced date of syphilis. This observation, although it proves that syphilis is virulently contagious in its early period, does not exclude the possibility that syphilis may be also contagious in the later stages. Gumma has been considered as a non-contagious manifestation; it is the result of the localization of the syphilitic virus in the lymphatic nodules. It has been repeatedly inoculated without positive results. We must, however, consider that gummatous products have under- gone caseous and fatty degeneration, which is a condition unfavorable to the vitality of the infecting germs of syphilis. The ulceration of gummata is the result of the casefication of their elements, and con- sequently the gumma is not capable of producing infection under ordinary circumstances. We have said under the ordinary circumstances, because cases of direct infection from gummata have been recorded. Delbanco 4 found 3 Campana, R. "Duration of Period of Contagion in Syphilis." Third Int. Congress of Dermatology. 4 Delbanco, E. " Zur Infectiositat des Gumma." Monatshefte f. prakt. Derm., Bd. 38, No. 12, p. 586. 2$2 THE MEDICAL ASPECTS a married couple, of which the woman had all the symptoms of second- ary syphilis, and the man had two ulcerated gummata of the penis, one underneath the glans, and another in the deep fold between the penis and the scrotum. The man had been infected fourteen years pre- viously, and had undergone an insufficient and an irregular treatment. Excluding all possibility of reinfection, he concluded that the infection of the wife was directly carried from the ulcerated gumma on the penis of the husband. This is, however, not the only case reported of infection from late syphilitic gummata. Similar cases have been referred to by Fournier, 1875, 5 Landouzy, 1889, 6 Ehlers, 1894, 7 Sack, 1901, 8 and Feulard. 9 In all these cases reinfection was entirely out of doubt, and the lesion which carried the infection was one of the gumma type. The obser- vations shake the foundations of the old assertion that gummatous productions are no longer capable of conveying infection. Neisser 10 remarked that all those who have denied the inoculation of syphilitic virus from late gummata, speak, nevertheless, of a certain infectious- ness of these products. He believed, however, that in the products of late syphilis there is some difficulty in inoculation, which is due to the anatomical regions, usually attacked and from which the virus cannot be easily conveyed. In this regard Neumann " maintains the statement of Ricord, that products of tertiary syphilis are not capable of inoculation, "nor con- veyable as such by heredury. They, however, in consequence of the modification or of a peculiar degeneration of the syphilitic virus, con- stitute the origin of scrofula. Neuman plainly recognizes that the products of tertiary syphilis are not entirely non-infectious, but they have much less infectiousness than those of an early secondary syphilis. Furthermore, parents affected with tertiary syphilis, or either one of them, can have children free from syphilis. Indeed, during the period of gummatous formations, the diminution of inoculability in the prod- ucts of syphilis, as also of the transmissibility to the offspring, is remarkable. The degenerated elements of the gummatous products do not 5 Fournier. Quoted by Feulard. Duration of period of contagion in syphilis. Third Int. Cong. Derm. 6 Landouz}^. " Verhandlungen des 1st. Intern. Dermat. Kongress, 1899." 7 Ehlers. " Verhandlungen des IV Kongress der Deutsch. Derm. Gesellsh." Breslau, 1894. Ref. Von Jadassohn. 8 Sack. " Verhandlungen der Gesell. Deutsch. Naturforscher und Aerzte zu Hamburg." Abt. Derm, und Syph. II. p. 424. 9 Feulard, H. Third Intern. Congress of Derm. Transactions, edited by Pringle, 1898. 10 Neisser, A. " Ziemsen's Handbook der Spec. Path, und Therap.," p. 681. 11 Neumann. " Nothnagel's Handbuch." TRANSMISSION OF SYPHILIS TO THE OFFSPRING 233 retain, in ordinary circumstances, the infectious qualities, and so also the sperma of the persons so affected is no longer capable of trans- mitting the disease to the offspring. Neuman referred to cases of individuals affected with gummata of the testicle who have been capable of generating children free from syphilis. These observations have a tendency to show that syphilitic lesions of a gummatous char- acter are to be considered more as localized alterations. The trans- missibility of syphilis through gummatous productions is not only to be doubted, but, as Neuman says, the inoculability must be considered as extinct. Virchow accepted a physiological distinction between secondary and tertiary lesions of syphilis, resting on the inoculability of the first and on the non-inoculability of the latter. Hutchinson said that the tertiary stage of syphilis begins when the specific virus is dead, so that the tertiary lesions are only the result of the vulnerability of the tissues induced by the virus. Lang maintained that tertiary syphilis is the result of the presence of the virus in the tissues, which still remains there although greatly modified. Baumler thinks that the syphilitic virus itself by irritating the normally reacting tissues, is the cause of the secondary lesions ; while in the gummatous productions it is no longer the action of the specific poison upon the normal tissues, but in all probability that of an irritation produced on tissues already changed by the presence of the specific virus, and modified in their reaction by the previous blood poisoning. Finger explained the tertiary lesions of syphilis with the toxin theory. Gascoyan considered tertiary syphilis merely a conse- quence of the disease. Experiments have been made in order to clear up so interesting a question. Didiers 12 inoculated several healthy men with the blood of individuals affected with tertiary syphilis, without positive results. Finger made thirty unsuccessful inoculations with the secretion of cutaneous and subperiosteal gummata in individuals who had never had syphilis. The results of the inoculations and the way they had been carried out have given reason for doubting to many observers who, resting on the basis of the clinical observations, maintained the inoculability of syphilis through the gummatous productions. Delbanco claimed that : if gumma can inoculate syphilis, it has to contain syphilitic virus. Gumma, therefore, still contains living virus. Late syphilitic pro- ductions are not different etiologically from the lesions of the sec- ondary period. To-day we can say with satisfaction that this ques- tion has been settled by positive argument, as the spirochaeta has been found in the gummatous productions. 12 Quoted by Lancereaux. Delbanco, L. C. 234 THE MEDICAL ASPECTS After all the above considerations, we can say that the gumma is only rarely inoculated, but we cannot state that gumma is not directly inoculable. We have seen cases of ulcerated gummata in married men who had never infected their wives, and their children were healthy and strong, never having shown any sign whatever of syphilis. The opinion that the micro-organisms of syphilis are greatly diminished in tertiary lues finds great probability, and we think that the spirochaetee, on account of the saturated condition of the tissues of the system, cannot produce symptoms of a general order, but only localized lesions. The views of Campana concerning the caseous de- generation of the gumma explains well the difficulty of inoculation, because, when the experiments have been made with the serum taken from ecthymatous eruptions, the inoculation has taken effect. Indeed, Lassar 13 is right when he says that in the question of the duration of the period of contagion in syphilis we find ourselves, like our predecessors, confined to the observation of cases. Syphilis may remain transferable until the morbid process has become extinct, and that, given a suitable opportunity and favorable circumstances, the disease may again become contagious. It is beyond doubt that con- tagion in the late stage of syphilis, if it occurs at all. is very rare. Lassar concludes that the experience of the past does not help us ; experimentation teaches us quod non; clinical observation yields but an evasive answer. I therefore prefer to confess : ignoramus ! Feulard, too, expressed himself in this regard that as far as we know at present it is impossible to establish fixed rules to define the time of the duration of the contagiosity of syphilis. We have already expressed our opinion that the papula is the lesion which transmits syphilis, and as long as moist papules, are repro- duced, syphilis is still contagious. As to the reason of the recurrence of the papules, we agree with Feulard, that it must be found in the use of tobacco and of strong alcoholic liquors. In the male ward for venereal diseases in our hospital, among the patients addicted to the use of chewing tobacco, we find obstinate patches on the tongue, lips and throat, while they are not so common among the females in Ward O. That syphilitic gummata in certain peculiar circumstances may inoculate syphilis, we find quite possible. In our practice we have not yet observed a case of direct transmission of syphilis from a gumma, but we rely upon the cases referred to by Delbanco. Sack, and others already mentioned. Gumma is a productive specific inflamma- tory process caused by syphilitic virus, and the virus in order to pro- 13 Lassar, O. Third Intern. Congress of Dermatology. TRANSMISSION OF SYPHILIS TO THE OFFSPRING 235 duce such infiltrated masses must be still alive. Histologically, it is difficult to distinguish an initial sclerosis from a gumma ; both are pro- ductive granulomata, showing infiltration and proliferation of the con- nective tissue. Giant cells which are present in the infiltrating elements of the gumma are also found in the initial sclerosis. They are the result of the irritation of the decaying cells on the living tissues. The same alterations in the tunics of the blood vessels and of the lymph vessels are found in the papule as well as in- the gumma. All shows that the same virus is the cause of the lesions of the secondary and tertiary period. The virus seems to have somewhat lost its infectious- ness, either on account of the diminished quantity of the germs, as Jadassohn thought, or on account of being damaged by the process of hyaline or caseous degeneration, to which the infiltrating elements of the gumma are subject. For this reason the direct transmission of syphilis through gum- mata is only an exception, and we can say that in ordinary circum- stances, after three years when mucous patches do not recur, the danger of the direct inoculation is nearly passed. This statement might suggest that after three years from the infection a man can get married without fear of infecting his wife. Although there is some truth in it as to that, which we call direct transmission of syphilis, we must consider another danger for the woman, which is the indirect transmission of syphilis from the fetus, known as syphilis by conception. SYPHILIS BY CONCEPTION A syphilitic husband, by seminal infection, generates a syphilitic fetus, the mother has never been infected, but at the end of the pregnancy she shows symptoms of syphilis. She does not show any direct transmission of the disease by inoculation, but the infection is effected through the uterine circulation from the syphilitic fetus. In this case the woman is infected by the poison which the ovum has received in the fecundation, which has multiplied and developed with its growth, so as to infect the whole child, and through the nutri- tive changes of the fetal life the poison is conveyed into the system of the mother. Fournier, in his beautiful work, " Syphilis and Marriage," calls attention to this mode of infection, which by many authors has been left without consideration, and by others has not even been believed. We must confess that we were in the class of the non-believers in this mode of infection. In syphilological experience, we quite often think a woman married to a syphilitic man to be perfectly free from syphilis, and yet 236 THE MEDICAL ASPECTS we will find later on that she is really infected. Colles law is a proof for this assertion. If the mother is immune from taking ulcers by her own syphilitic child, this is the result of her being affected with syphilis, which renders her immunized. Any other healthy wet nurse giving her breast to a syphilitic child will surely be infected with chancre of the breast, and consequent syphilitic symptoms, while the mother never shows any chancre, and is apparently not affected. Cas- pary 14 referred to a very striking case on the subject of healthy mothers of syphilitic children, where he showed that the immunity of the mother, giving birth to a syphilitic child, is produced by the presence of syphilitic infection. It is of great interest for us to briefly refer to the case of Cas- pary : A married man, in 1872, acquired syphilis, during the period of acute symptoms he abstained from sexual relations with his wife, but when the symptoms subsided he resumed the coitus. The woman never showed any manifestation of syphilis. In October, 1874, she became pregnant. In March, 1875, sne suffered uterine hemorrhages, and a few weeks later aborted. The examination revealed a gum- matous infiltration of the maternal portion of the placenta. The woman recovered, and never showed a symptom of syphilis. Caspary, in order to satisfy himself whether the woman was the subject of latent syphilis, persuaded her to be inoculated with the secretion of an active syphilitic lesion. She was inoculated in four places with the secretion of mucous patches, from a man suffering with the eruptive stage of early syphilis, who had not yet received any treatment. In every case the inoculation showed negative results. This proved con- clusively that she was affected with latent syphilis, which immunized her from the action of the virus. Consequently the Colles law will find in many cases its explanation in the latency of syphilis. There occurred in our practice a case of a lady who became infected from her offspring in utero, which evidently showed the truth of syphilis by conception. In November, 1890, a gentleman called on us for a hard chancre in the sulco balano preputiale, with beginning adenop- athy on both inguinal regions. In January, 1891, he showed marked maculo-papular syphilide of the whole body. He began treatment, but he only carried it out irregularly and insufficiently. We did not see him for a long time, as he claimed to have always been well. In 1894 he married a young lady in splendid health. In 1895 she gave birth to a child rather weak and delicate. From what we could learn, the child never showed any syphilitic symptoms. In 1897, towards the end of her second pregnancy, she began to feel bad, was feverish, and 14 Caspary. " Ueber gesunde Mutter hereditar-syphilitischer Kinder." Vier- teljahreschrift fiir Dermatologie. 1875, p. 437. TRANSMISSION OF SYPHILIS TO THE OFFSPRING 237 just after she was delivered she was covered with an eruption, and, as she said her genitals were covered with ulcers. We were called to see her some time after, and we found her suffering with papular syphilides, mucous patches of the mouth and tonsils, mucous patches of the small labia, and general adenopathy. The babe was weak, but not badly nourished, had a swelling of the third phalanges of two fingers, characteristic syphilitic dactylitis. The first child, at that time two years old, was a small, delicate little girl, of bright intelligence, who showed only a few hard, enlarged lymphatic glands of the groins and of the cervical region, but with this exception, nobody could say that she was syphilitic. The second babe, five months old, who had transmitted the infec- tion to her mother, had no other symptoms than syphilitic dactylitis, which belongs to the tertiary manifestations of syphilis. This con- firms our views that syphilitic virus in the secondary or tertiary stage is always the same virus, and that when communicated to a healthy person is liable to bring about the whole evolution of syphilis. In this case the man had been infected four years before his marriage, and he had undergone an irregular and insufficient treat- ment. He had no active symptoms, so he could not infect his wife. The first child was apparently well, and has never shown patent symptoms of syphilis. The second child had infected the mother dur- ing the time of pregnancy, and it was affected with symptoms of late syphilitic diathesis at its birth. This case has been for us a clear case of syphilitic infection by conception, and one in which the syphilitic child could infect its mother through the utero-placentary circulation. In these cases the evolution of syphilis is different from the ordinary cases in its origin and in its development. The woman was in good health, she never showed an initial lesion or any progressive adenopathy ; syphilis breaks out at once, accompanied with symptoms of acute general infection. Boulengier 15 has likewise found that a woman married to a syphilitic man who no longer shows symptoms of the disease, when she becomes pregnant may be infected by her own syphilitic child. Diday 16 found seven cases where syphilis had been transmitted by conception, and all seven children were deeply affected with syphilis. There is no doubt that when the mother has not been infected by her syphilitic husband, she will be infected by her syphilitic child, in the same way that a syphilitic mother will transmit syphilis to her developing child. 15 Boulengier. "La Syphilis par conception." Presse Medicate Beige, 1894. No. 37. 16 Diday, P. " Le peril venerien dans les families." Paris, 1881. p. 196. 238 THE MEDICAL ASPECTS The sperma contains the syphilitic germ, and at the act of fecunda- tion generates a syphilitic child through which the mother is infected. The woman so infected can either show symptoms of a severe case of syphilis, or she can have very mild and scarcely perceptible symptoms. It is true that in the woman it is sometimes very difficult to find the primary lesion which may be concealed. But in our case, the hus- band had not shown symptoms of syphilis for years, and her affection had begun to show at the end of her second pregnancy. The only explanation of the infection lays in the direct entrance of the virus through the utero-placentary circulation. The explanation and the proof of this statement is found in the following chapter. GERMINATIVE INFECTION The clinical observations in syphilis had given rise to the idea of a germinative infection long before the existence of the idea of a living contagium, according to the modern understanding". It is a fact that a cell containing a parasite may undergo its biological prog- ress, develop and live, containing the parasite in itself. The old statement that a cell containing a parasite is not subject to development has already been denied by the discovery of Pasteur upon the possibility of the spermatic infection in the disease of the silk worm, known as pebrine. He proved that the organisms of pebrine enter the eggs, and the cells of the sperma, and these cells containing the germ of the parasite are not destroyed, but retain the faculty of fecundation and the insect is again generated. Maffucci 17 succeeded in inoculating eggs of hens with tuber- culosis, showing conclusively that the bacillus tuberculosis does not prevent the development of the egg. The bacillus is taken up by the embryo and is embodied in the same, and after the little- chicken has been hatched, after nearly twenty days of incubation, tuberculosis breaks out. Maffucci, moreover, succeeded in finding tubercle bacilli in the albumen, and also in the embryo in the form of small nodules, which shows that the tubercle bacilli can undergo involution, taking a latent condition. This affords us the explanation for the latency in hereditary in- fectious diseases. We can now understand how it is possible that the tubercle bacilli remain dormant in the embryo, probably in the condition of larvae, or as a simple potentiality, and after the birth of the individual, sooner or later are capable of proliferation, starting a new tubercular formation. 17 Maffucci. Centralblatt filr Bacteriologie und Parasitenkunde. 1889. TRANSMISSION OF SYPHILIS TO THE OFFSPRING 239 The chronicity of tuberculosis, the slow development of the bacilli, is the explanation of their development only some years after birth. Johne, Bang, Leichtenstern, Gaertner, and others have succeeded in proving the heredity of tuberculosis by means of the inoculation of the eggs of birds. If that happens in tuberculosis, we do not find any objection in admitting the same possibility with reference to syphilitic infection. In syphilis the micro-organism, a spirillum, has been recently demon- strated, and it has been obtained to inoculate lower animals, but yet we will not be able to repeat the experiments as for tuberculosis. In syphilis we must follow so far the criterion of analogy and from that come to conclusions. Syphilitic virus is so transmitted from the father to the offspring in the sperma, and the fetus is thus generated with syphilis. In some cases the syphilitic virus remains latent in the system without inter- fering with the development of the fetus and without infecting the mother. The babe is born in good health, shows no signs of infec- tion, but after some time the lymphatic glands gradually become hard and enlarged, and syphilitic symptoms appear. In the case above referred to we had a healthy mother, who had given birth to an apparently healthy child, but the father was syphilitic. The mother did not have any specific trouble ; the child is now a little girl, in delicate health ; she. has never shown symptoms of syphilis, but her lymphatic glands are slightly enlarged. The second child, who was born with a syphilitic dactylitis, was the one which infected the mother. This child, in the conditions of a fetus, had syphilis in fact, and it was the cause of infection of the mother. Syphilis, like tuberculosis, may remain latent in the depths of the system for years without showing its presence at all, and then after some years a gum- matous or an ulcerative process shows as a new and difficult problem for the physician. In many cases syphilis kills the fetus in utero,, on account of the cachexia which it produces in its system, without showing any appar- ent syphilitic lesions. In several cases of miscarriages, and of chil- dren who died a few days after birth, and who were delivered in the venereal ward from syphilitic women, the post-mortem was unable to reveal any apparent symptoms of syphilis. In many cases the skin was found normal, no ulcerations, the spleen normal, and the epiphyses, which are often found affected with a chronic inflammatory process in syphilitic children, w T ere normal. The cause of death seems to have been in the lungs, in the form of pneumonia. The lungs were red, hard and infiltrated, and when cut a quantity of bloody serum was oozing out, which was in the 240 THE MEDICAL ASPECTS pulmonary cells. The fetus in these cases had met death more on account of a general cachectic condition than on account of a defined syphilitic manifestation. The infection of the fetus can be carried through the sperma as well as through the placenta. The sperma of a man who is still under the poisoning influence of syphilis carries the infection to the egg, and although the woman is entirely free from syphilis, the fetus receives the infection. The syphilitic virus is developed in the system of the fetus, and through the exchanges of nutrition between the fetus and the placenta carries the syphilitic infection to the mother. It may also happen that syphilitic virus remains latent in the fetal system; in this case the mother will receive no infection, although late in life the offspring may show symptoms of syphilis. The spermatic infection is therefore a fact which cannot be denied, and it remains as a menace for a healthy mother with a syphilitic husband. This is a fact to be remembered by anyone who thinks that syphilis cannot be communicated except from an ulcerative process, and that when no sore exists there is no danger of transmission of syphilis. Nobody can give any assurance on the prognosis of syphilis, and not rarely, on account of causes inherent in the system of the woman or on account of neglected treatment, there may arise cases of malig- nant syphilis, or at least of syphilis with deep and severe destructive lesions. In consequence, a man who has been infected with syphilis must not be contented with the two years so often established as the end of his quarantine, but must follow the advice of the physician and he will receive his clean patent when the physician will recognize him as scientifically cured. It is not merely a question of two years, but as long as suspicious symptoms of secondary infection are still returning, the patient cannot be advised to enter married life. He would be a continuous menace to the health of his wife and of his family. CONGENITAL AND HEREDITARY SYPHILIS From the above considerations we have seen that syphilis from the father is transmitted to the offspring as a sad and miserable in- heritance. If a man who has had syphilis has not had sufficient treat- ment or if sufficient time has not elapsed since infection and he enters married life before the virulence of syphilis is extinct, he is not only dangerous to his wife, but also to his family. Syphilis will be trans- mitted to his offspring by heredity. The question of congenital and hereditary syphilis is not yet defi- TRANSMISSION OF SYPHILIS TO THE OFFSPRING 241 nitely settled. Solger, 18 following the ideas of Matzenhauer and of F. Martius, would limit the word hereditary to all cases of infantile syphilis where the resulting symptoms are due to the union of the infection in the semen and in the egg. For all other cases he would keep the word congenital. He thinks that in syphilis there is not a true inheritance, but only an intra-uterine transmission of syphilis to the fetus. We see quite clearly the distinction between congenital 'and hereditary syphilis. When a babe comes into the world with syphilitic cachexia, or a few days after birth shows syphilitic manifestations, this is without doubt a congenital syphilis. In this case syphilis has been transmitted to the offspring as an intra-uterine infection just as any other infectious disease. When, however, a babe from syphilitic parents is born somewhat weak, or sufficiently healthy, and later on in life begins to show syphilitic manifestations, he has hereditary syphilis. In this case syphilis has not been transmitted as an infectious disease, but the germ of syphilis has been transmitted as a potentiality which will show later on in the form of syphilitic symptoms or rather as parasyphilitic affections. It is clear that the offspring in these cases has inherited syphilis. The transmission of syphilis from the paternal side only has been the subject of great controversy, and it has diminished in its interest from the observation of healthy families raised by men who had formerly been affected with syphilis. Cullerier, 19 Notta, 20 Charrier, 21 Durac, 22 Mireur, 23 Oewre, 24 Sturgis 25 have already brought out ob- servations, showing that paternal heredity is only of rare occurrence, and that children of a syphilitic father, who have not infected their mother, usually remain free from syphilis. Matzenhauer in a paper read at a meeting of the Society of Physicians of Vienna on February 6, 1903, on the heredity of syphilis, expressed doubt as to the existence of the paternal heredity alone, just for the reason that syphilis is communicable almost at any period. 18 Solger, F. B. " Hereditar oder Kongenital ? Ein Beitrag zur Frage von der Vererbung der Syphilis." Centralblatt. VII Jahrg., Heft 9, 1904. Ref. -Monatshefte f. prakt. Derm., Bd. 39. 19 Cullerier. " De l'heredite de la Syphilis." Paris, 1851. 20 Notta. " Memoire sur l'heredite de la syphilis." Arch. Gen. de Medicine, i860. 21 Charrier. "De l'heredite Syphilitique." Arch. Gen. de Med., 1862. 22 Durac, J. E. " De l'heredite de la syphilis." These de Montpellier, 1866. 23 Mireur, H. " Essai sur l'Heredite de la Syphilis," 1867. 24 Oewre. " Sur l'etiologie de la syphilis hereditaire." Ann. de Derm, et de Syphil. 25 Sturgis. " Sur l'etiologie de la Syphilis hereditaire." Ref. Ann. de Derm. et de Syphil. 242 THE MEDICAL ASPECTS He went on further to deny all direct transmission from the father to the offspring, as he considered hereditary syphilis to be only an mtra-uterine infection through the infected mother by the placentary circulation. In his opinion a healthy woman cannot have a syphilitic child. Riehl also considered the statement that tertiary lues, especially at the gummatous period, is not communicable as incorrect, and he thought it improbable that a man, who has syphilis with which to generate a syphilitic child would not communicate the disease to his wife. The dogmatic assertion of Ricord, that tertiary syphilis is not communicable by contact or by heredity, has been upset by the obser- vations of Landouzy, which have been confirmed by Fournier and have been later accepted by Arnozan, Hardy, Petrini De Galatz and Leloir. Mauriac considered a man who shows subcutaneous nodes just as suspicious as the one who has papules. He is saturated with syphilitic virus just as much as any other with papular or macular eruption. The question which is not clear for us is how a syphilitic father generates syphilitic offspring, which is killed in utero by syphilis, or shows deep manifestations of syphilis at its birth, and the mother is not infected. To us, it is the repetition of that which we have said already in reference to Colles law, that the healthy condition of the mother is only ephemeral. If the mucous patches on the mouth of her babe cannot inoculate the mother, that is a clear sign that she is immunized, and she cannot be inoculated with any other syphilitic virus. There is no doubt at all that syphilis is transmitted to the offspring fry the father through the semen in the act of fecundation. The ques- tionable point for us is whether the mother remains healthy. Observations taken from Ricord, Bassereau, Ruge, Hutchinson, Fournier and many others have all referred to cases of families where paternal heredity alone has caused infected children. Hutchinson 26 has clearly spoken in favor of paternal heredity when he wrote, " I am firmly of the opinion that in a large majority of instances in English practice, inheritance of syphilis is from the father, the mother having never suffered before conception." In so debated a question, with such different opinions, we must search for some arguments from clinical experience. In our practice we have treated many patients affected with syphilis for a period of several years; they have recovered and have married. At present they have several children, all healthy, intelligent, bright, and nobody 26 Hutchinson, J. Medical Times and Gazette, 1876, quoted by Fournier. TRANSMISSION OF SYPHILIS TO THE OFFSPRING 243 would suspect for a moment that the father had undergone a rather severe case of syphilis. Fournier reported 87 cases of syphilitic men who have married, and have never communicated syphilis to their wives, and have had a total of 156 children absolutely healthy. Of these 87 men, 20 only had married before the fourth year after the infection, 11 after the fifth year, 10 after the sixth, 4 after the seventh, 8 after the eighth year, 6 after the ninth year, 2 after the tenth year, 4 after the eleventh year, 2 after the twelfth year, 1 after the thirteenth, 1 after the fourteenth and 1 after the fifteenth year. All these men have married after a long treatment, and after a period when the contagiousness and the transmission power of syphilis can be considered as extinct. It must not be believed that all these cases have never again shown specific symptoms. Thirty-five of them have had syphilitic lesions after marriage, and also serious functional troubles, sufficient in some cases to cause severe disease and death. Yet they have never communicated the disease to their wives, nor have their children shown symptoms of syphilis. In this regard w T e cannot forget a very wise remark of our teacher, Sigmund von Ilanor, that we must not content ourselves with the observation of the children in their first years of life, the observation has to be continued during their entire lifetime, and very likely a moment will come when troubles appear which are to be connected with a specific taint. In our practice we had occasion to give treatment to a gentleman for a case of late syphilis, while he was married and already had children, who were perfectly healthy. He had married nine years after the infection, and it was several years since he had seen any sign of the disease. His children are now grown and have always been well. One young man was brought to us with a peculiar eruption on the soles of his feet, which was considered to be the result of corns. Local applications of emplastrum hydrargyri, and large doses of potassii iodidi cured the so-called corns. This shows that hereditary syphilis has to be divided into early hereditary syphilis and late hereditary syphilis. That a father still under the influence of an old syphilis may generate a child with the latent germ of syphilis, without communi- cating the disease to his wife, is a case of common occurrence. But when the father has syphilis so active as to generate a child which is killed in utero by syphilis, or comes into the world with congenital syphilis, we find it nearly impossible for the mother to have remained perfectly healthy. The quantity of the syphilitic virus, the time elaps- ing from the infection of the father or of both parents, the intensity 244 THE MEDICAL ASPECTS of the virus, have a great influence on the developing organism of the fetus. In fact, when the parents have had a recent syphilitic infection ; and they have had no treatment, or only an insufficient one, the babe will be killed in utero. Tarnowski 2T collected very important sta- tistics of 25 syphilitic families, in which there occurred 155 preg- nancies with the result of 57 still births and 98 living children. In another work Tarnowski 28 brings statistics of 30 other families, all of the Slavish race. In 29 of them lues came from the man, and in 24 the wife remained free from syphilis. Amongst 26 families there occurred 169 pregnancies of the first generation with the result of thirty-five per cent, abortions, and sixty-five per cent, living children. Kassowitz 29 brings statistics of 43 families, in which the father was syphilitic and the mother showed no signs of the disease. Mews, Hecker, Fournier, all have cases of families showing the heredity of syphilis from the paternal side only, where the mother has remained free from syphilis. In our experience we have had occasion to treat for a long time a large number of young men for syphilis in the secondary period. They have married when declared cured, and no taint of syphilis has been seen on their children. We have often had occasion to be consulted by young married couples, complaining that they had had the misfortune of several children born dead. We have found the husband, who had suffered syphilis, had received a few weeks' treatment, then after a year or so, having seen no more trouble, he had married. The wife had always been well, only she has been subject to miscarriage. In our next ex- perience the healthy condition of the wife is only apparent, and sooner or later she will show symptoms of syphilis. In a syphilitic family, where the wife, in spite of several mis- carriages, had remained free from syphilis, having always enjoyed good health, at the age of fifty, many years after, she showed an eruption of multiple ulcerated gummata on her left knee, which were witness that she was not absolutely free from syphilis. We do not dispute the paternal origin of syphilis ; the only point on which we do not agree is that of the wife's remaining absolutely free from syphilis after having had syphilitic children. We are posi- tive that if all those women married to syphilitic men, who have given 27 Tarnowski, B. " Descendance des Heredo-Syphilitiques" Compt. Rendus Congres. Intern. 1900, p. 307. 28 Tarnowski, B. " Ueber die Syphilitische Familie und ihre Nachkom- menschaft." St. Petersburg. 29 Kassowitz. " Die Vererbung der Syphilis." Wien, 1876. TRANSMISSION OF SYPHILIS TO THE OFFSPRING 245 birth to syphilitic children and have been declared absolutely free from syphilis, could have been seen later by the distinguished authors, they would have changed the word absolutely to apparently free. In our City Hospital, in M ward, only women of good moral character, belonging to g-ood families, are accepted, and one-third of those who come there to be treated for leg ulcers are affected with ulcerated syphilitic gummata of the legs. It is understood that there is no history of syphilis to be obtained ; sometimes there may be the history of a couple of miscarriages in the beginning of the married life. In all, they have always been in good health. We believe that when the syphilitic infection of spermatic origin is so active as to generate a syphilitic fetus which is killed in utero, the mother cannot remain absolutely free, but she will be only appar- ently free from syphilis. When, however, a man who has married several years after the infection and has been sufficiently treated, transmits through the sperma the syphilitic germ to the ova, then the germ will remain latent and inactive. In this case the babe is born well. The mother is free from syphilis. The germ of syphilis, however, transmitted by paternal heredity will develop in the organism of the babe and after several months, or even years, will show in the form of late hereditary syphilis. This will form the subject of another interesting chapter on the influence of paternal heredity on the production of various morbid conditions, of degenerations and physical and moral anomalies, which are the sad result of syphilitic inheritance. The syphilitic germ is introduced into the ovum from paternal syphilis. Its hereditary influence is manifest in various forms and degrees of severity. If a man affected with syphilis contracts mar- riage before it is extinct, admitting that his wife is lucky enough to escape contagion, less than one out. of every four of his children will survive. Paternal heredity has a great influence on the fetus, but when the mother is also infected, then the maternal and paternal heredity has a much more deleterious action. MATERNAL HEREDITY The syphilitic infection is brought to the developing fetus through the placentary filter from the maternal side. Observations show that the influence of maternal syphilis is much more potent and intense than that of the father, and also persists for a longer time. The infection takes place through the placenta, which has been considered an undeniable dogma and an established fact. New works. 246 THE MEDICAL ASPECTS however, by Wolff and Gartner have shown that the infection through the placenta is not so easily understood. Syphilitic infection through the placenta happens, and cannot be denied, although there is some doubt in regard to tuberculosis. The normal placenta is a perfect filter and does not allow the passage of strange bodies, capable of multiplying themselves, through it. The micro-organisms, however, coming into contact with the placenta, are capable of producing disease of this organ, such as emboli, hemorrhages, necrosis of the endothelium, and through this' they can effect an entrance through the walls of the placenta. It is through this morbid condition induced by the germs of the disease that the placentary filter may become permeable, and the spreading of the disease to the developing fetus be made possible. In this way only can we explain how it is that syphilitic women can give birth to healthy children. Indeed, we often find the placenta affected with gummatous productions and the child escaping every trace of infection. This happens especially in cases of tertiary syphilis, where the syphilitic virus is modified in the system and has lost its contagious properties. In the late period of syphilis the placenta seems to retain the infectious toxins of syphilis, leaving the offspring free from any trace of the disease. The peculiar anatomical structure of the placenta, and its physio- logical functions, are such as explain what influence it has in prevent- ing germs from passing through it, and thus explain many cases in syphilology which are still surrounded with darkness. Zeissl 30 referred to cases where the infection has shown itself in an alternating way, so that one child was syphilitic and the next was healthy, and so on. The placenta always offers pathological conditions in case of a syphilitic fetus. It is often smaller, badly developed, flabby, easily broken. The surface of the placenta which is adherent to the uterine surface, shows, at times, spots of hepatization and calcareous incrus- tations. Often the placenta is adherent to the surface of the uterus and it requires the hand of the surgeon to detach it. Virchow has found tumors in the placenta which were nothing but gummatous productions. In these cases the fetus either dies in utero on account of the diseased placenta, or if the placenta is only partially affected, the fetus suffers no evil effect and remains free from syphilitic infection. In reference to this matter we had occasion to deliver a lady for adherent placenta. The history of the family is not known, as it has so Zeissl, H. " Lehrbuch der Syphilis," Wien, 1871. TRANSMISSION OF SYPHILIS TO THE OFFSPRING 247 always been concealed. Some nine years previously we had been called in consultation by the family physician to see this lady. She was suffering with an extensive and destructive ulcer of both legs. It was a case of multiple ulcerated gummata. The general health of the lady was rather good, although she was suffering with pains resulting from productive periostitis of the tibiae. Antisyphilitic mixed treatment was ordered, which was followed, under the direction of her family physician. For more than two years we had heard nothing more of the pa- tient, when we were called by a midwife to remove the placenta in this same patient. She had given birth to a living child at full term, well developed and healthy. The placenta remained in utero and could not be removed. It was adherent to the whole surface of the uterine parietes, and it was necessary to detach it by the hand, and then scrape the endometrium with the dull curette and pack with iodo- form gauze. The placenta was inconsistent, flabby, easily broken, and spotted with foci of infiltration, yellow in color, round in shape, which were adherent to the decidua. The babe, as stated, was healthy, weighing eight and one-half pounds, well developed, showing no trace of syphilis. Some years after we were called again by the same midwife to help the same patient, who had an adherent placenta. With some difficulty the placenta was detached and removed, and -it showed the same conditions of infiltration in foci as in the previous case. The babe, healthy and well developed, had no trace of syphilis. The babe which had been previously attended was a little girl, at this time four years old, enjoying good health. She had never shown signs of syphilis and had never been sick one day. From the macroscopic and microscopic examinations of the placenta it w r as plain that those circumscribed foci of infiltration in the placenta were due to a gummatous process between the decidua and the placenta, causing infiltration and adhesions of the latter. The process, however, re- mained limited to the placenta itself, which did not allow the infection to be carried to the fetus. We have already quoted what Sigmund used to say, that when a babe is born of syphilitic parents, although apparently well, we must not content ourselves with its actual condition, but must follow it in all the periods of its life. Sooner or later syphilis will show its existence in that organism, although it has appeared perfectly free until then. These views, however, according to our own experience, are too pessimistic, and indeed tertiary syphilis at a late period seldom affects the fetus by placentary infection, especially if the syphilitic mother has undergone a good antisyphilitic treatment. In the second- 248 THE MEDICAL ASPECTS ary period, when syphilis is at its acute stage, like any other acute infectious disease, it passes through the placenta and infects the de- veloping fetus, which in most cases dies in utero. Ricord 31 speaking from his experience says that women affected with recent syphilis seldom have a child at full term, and that in the beginning of the eighth month they usually have a miscarriage. Barnes thinks, that syphilis produces a peculiar inflammatory condition of the mucous membrane of the uterus, which forms the decidua, and consequently it is spread to the placenta, from which the fetus receives its nourishment, thus causing the abortion. The fetus of a syphilitic mother or of both syphilitic parents, when dead in utero, is brought out with the skin macerated by the amniotic fluid. The epidermis is detached in large strips, the amniotic fluid has a foul smell and a turbid and foul appearance. When the fetus dies be- fore the fourth month of utero-gestation, no characteristic pathological alterations are, as a rule, to be found. After the fifth month the spleen is usually found increased and hypertrophic, maintaining its regular shape. In a syphilitic fetus dead after the fifth month of utero-gestation, there is often found a peculiar osteochondritis, to w T hich George Wegner 3 ' 2 was the first to call the attention of the pathologists. In the normal line between the diaphysis and the epiphysis of the fetal bone, exists a whitish layer, where the normal calcification of the cartilage takes place. In syphilitic babies this layer is larger, dry, hard, and instead of being a straight line shows indentations. This peculiar osteo- chondritis is the cause of a kind of sclerotic density mostly in the long bones of syphilitic children. From our personal experience we have found that this condition of the bones is not so constant as is generally believed. In ten post- mortems of fetus and infants born of syphilitic mothers in the venereal ward of the City Hospital, which have been born dead or have died a few hours after birth, we have found this condition of osteochondritis in the epiphyses of the bones in two cases only. Tke thymus is also often affected in the body of a fetus killed by congenital syphilis. When the mother is syphilitic in the secondary stage we have never seen a child escape infection. It is a question of degree, but everv child if it escapes death in utero, comes to light sometimes ap- parently free from syphilitic symptoms, but a few days or a few weeks afterwards the babe will show either symptoms of syphilis or of syphi- litic cachexia. 3-1 Ricord. " Lettres sur la Syphilis." Paris. 1852. 32 Werner. G. Virchow's Archives, 1870. TRANSMISSION OF SYPHILIS TO THE OFFSPRING 249 To the function of the placenta we can refer the case of twins of which one was syphilitic, and the other was free from infection. A case of this kind was reported some years ago by Jonathan Hutchinson. The illustration shows twins thirty days old, of which the first born showed syphilis pustulo-crustacea scattered on the auricula, chest and scalp. Its appearance is emaciated, the skin lacks panniculus adiposus, the face looks old. The other babe is much brighter, well nourished, and has never shown any symptoms of syphilis. The father shows remnants of old periostitis of both tibiae, with resulting induration and roughness of the periosteum. Deep scars of healed-up gummata are found in several regions of his body. He has no knowledge of infection. The mother came to our office in February, 1897, affected with syphilis ulcerosa of the tongue, a deep irregular ulcer on the left side from gumma. She was then in the eighth month of gestation. At the end of March she gave birth to the twins here represented, both of the male sex, one weighing nearly eight pounds, the other less than seven pounds. Both were weak and poorly nourished. The patient had been attended by a midwife, so we had no opportunity of seeing the placentae. The second born, who was somewhat better nourished, soon began to improve, and in a few days was looking healthy and has never been sick since. The first born, who was already weaker and poorly nourished, was affected with a stubborn diarrhea for several days, and took on that senile appearance peculiar to syphilitic children. With small repeated doses of calomel the diarrhea subsided, and the child grew better. A pustular syphilitic eruption appeared on his body. The child breathed with difficulty, and died with pneumonia in the early part of September. The other babe is now a big boy, enjoys good health, and has never shown any syphilitic symptoms. It seems quite clear in the case above referred to, that the syphi- litic infection has affected one of the twins and has spared the other. We can explain so interesting a fact only by the functions of the placentary filter, which has prevented the passage of the virus to one of the fetuses. In this case we cannot accept as an explanation the wearing out of the virus, as maintained by Diday. The woman was surely syphilitic, and both fetuses ought to have been infected alike, but one showed hereditary syphilis, while the other has so far appeared to be free from hereditary infection. The influence of the mother in transmitting the infection to the offspring is much more persistent, and much more pronounced, than 250 THE MEDICAL ASPECTS that of the father ; when both parents are affected the fetus will very rarely escape syphilis entirely. We have already seen that a man who was once affected with syphilis, but has undergone a good vigorous treatment, when married after a certain period of time, if his wife has not been infected, will have healthy children, probably without any syphilitic taint. When the woman is infected, then the transmission of syphilis by hereditary infection is certain, and much more persistent. MATERNAL HEREDITY ALONE It is interesting to bring this subject under consideration in order to show that the syphilitic infection is more stubborn and persistent when the mother is infected than in the case where the father alone is syphilitic. In the first years of our practice we were consulted by a young lady, then twenty years old. She was very anemic, and was suffering with anomalous affections of different kinds, neuralgia, catarrh of nose and throat, headache, rheumatism ; for nearly two years she was not able to obtain any benefit from the remedies ad- ministered. Some enlargement of the cervical glands caused us to suspect the presence of lues, and on questioning her she said that she had hemorrhoids. On examining the so-called hemorrhoids, we found them to be a mucous patch of the size of a dime, concealed in the folds of the anus. There was no more doubt about the girl's being syphilitic and she was immediately subjected to treatment with intramuscular in- jections of a one per cent, sublimate solution, and a tonic internal medication. The young lady improved very rapidly, and after ten or twelve injections she was so much better that she considered herself entirely well and gave up the treatment entirely. Nearly two years afterwards she was married to a healthy young man, and as we had charge of them as the family physician, we can vouch that he had never had syphilis. From this marriage the lady became pregnant, and at the seventh month of utero-gestation she brought to light a dead fetus, half decomposed in a foul amniotic fluid. Each year the same thing happened until she had nine dead children. The last children were born at full term, but after a few days they began to show unmistakable signs of hereditary syphilis. The hus- band has always remained well, and the lady has never shown any more symptoms of syphilis, enjoying splendid health. The knowledge of the cause of the unfortunate end of all her children has remained with us, and has never been mentioned even Plate XII I Twin Boys from Syphilitic Parents One infected and the other healthv TRANSMISSION OF SYPHILIS TO THE OFFSPRING 251 to the lady. We had often advised her to undergo treatment, but she never heeded the advice. She has often changed physicians, so once in a while we lost sight of her. Some years after she came back, crying about a horrible mis- fortune, that she was enceinte again. We promised her that if she would take a four months' treatment she would give birth to a healthy child. She consented and immediately began treatment, which con- sisted of inunctions with mercurial ointment one and one-fourth drams, every other night, and from 90 to 120 drops of a saturated solution of potassium iodide daily. The treatment was stopped for a few days, when symptoms of mercurial stomatitis began to appear, and as soon as they were better the treatment was resumed again. She kept on with her treatment for nearly five months. Then it was stopped. This time she gave birth to a healthy child, who has always been in splendid health. The process of ossification of the fontanellse has been regular, the teeth are normal, and he has been the blessing of that family. When he was three years of age he had spasms, for which they sent for us. It was an evident case of Jacksonian epilepsy, recalling the syphilitic taint from his mother. With a treatment of potassium iodid the epileptic attacks diminished and finally disappeared. He is now a grown boy, well nourished, strong, intelligent, has never been sick since, and appears to be the picture of health. This case has been referred to in all its details, for the reason that a case of syphilis in the mother alone is not commonly observed. It shows how the infection passes with more certainty and with more persistence from the mother to the fetus, and how the treatment is capable of saving the offspring from infection. STERILITY FROM SYPHILIS Ricord said that women with an old syphilis are usually sterile ; in our practice we have found exactly the opposite condition. In a large number of families where both of the parents were affected with syphilis, they have had a large and numerous progeny. If the question is to be considered with reference to the class of prostitutes, they are usually sterile. The reason, however, is not easily attributed to syph- ilis, because they are usually affected with chronic gonorrhea of the cervix and also of the endometrium. The cause of sterility in those women is to be found rather in a chronic gonorrheal process than in syphilis. In private practice we have been able to follow families where both parents were affected with syphilis, but no gonorrhea existed : 252 THE MEDICAL ASPECTS we have found the women rather prolific, and in a general way we can state that syphilis is seldom the cause of sterility in woman. Recent syphilis in woman as a cause of miscarriage is a fact, but the statement that syphilitic women are sterile does not agree with ordinary experience. Syphilitic women are usually inclined to erotic excitement, and syphilis seems to increase in them the tendency to lasciviousness. Syphilitic affections of the uterus, tubes and ovaries are not fre- quently found in practice. Jullien related one case of gumma of the size of a walnut on the cervix. In a great number of syphilitic women we have never met with such an occurrence. Primary chancres of the os uteri we have found several times. In the same way we have, in a few cases, seen mucous patches of the same organ. The hard chancre and mucous patches, however, are only temporary affections. They disappear after due treatment and do not leave any such permanent impairment of the organs as to prevent conception. Syphilis does not spare any organ or tissue of the body, and therefore the body of the womb, the tubes and the ovaries may be affected from this disease. Observations are rare and rather imper- fect. Gynecologists do not pay much attention to these cases, and so far no definite syphilitic condition of the womb, tubes and ovaries has been so described as to remove any doubt about their existence. It is possible that the ovaries are affected in secondary syphilis with a specific inflammatory process, with a tendency to resolution, as we observe cases of syphilitic epididymitis in man. Indeed, we often find women affected with secondary syphilis complaining about disturbances in the menstruation. This, although it may be the result of the general systemic affection on the blood through the syphilitic in- fection, may nevertheless be the result of a local secondary affection of the tubes and ovaries. Tertiary syphilis affects these organs in the form of gummata at a late period, as stated by Richet, 33 who found a case of gumma of the ovary. Lancereaux, too, referred to a case of well-defined tumor in the ovary, which disappeared after an antisyphilitic treatment. Cases of gummatous salpingitis were recorded by Buchard and Le- pine ; both tubes were hard and enlarged, and several gummata of the size of a hazelnut obstructed the passages. Fuller 34 also refers to a case of possible salpingitis from late syphilis, which resolved under large doses of iodide of potassium. From all the above considerations we may conclude that syphilis 33 Richet. " Traite pract. d'Anatom. Chirurg.," quoted by Fuller. " Syphilis of the Generative Organs. A System of genito-urinary diseases," etc. 1893. 34 Fuller, E. " Syphilis of the Generative Organs. A System of Genito- urinary Diseases," 1893. TRANSMISSION OF SYPHILIS TO THE OFFSPRING 253 has not a great influence in producing sterility in the woman. The syphilitic affections of the ovaries, tubes and of the womb, if secondary in character, are only temporary, easily resolving and not leaving any such permanent impairment of these organs as to prevent conception. Tertiary affections, deep infiltrating inflammatory processes, gummata, which have a tendency to destroy the affected organs, are capable of producing permanent alterations of the organs, and con- sequently of rendering the woman sterile. But syphilitic gummata of these organs have very seldom been recorded, so we can conclude that syphilis has very little influence in the sterility of woman. Jullien 35 followed up forty-three marriages of syphilitic persons and from them recorded 206 pregnancies, nearly five for each mar- riage, showing that syphilis does not usually favor sterility in the woman. The 206 pregnancies ended with the following results : Abortions 36 Children dead at birth 8 Children dead in the first year 69 Living 93 Of the 93 living children, 50 showed symptoms of syphilis and 43 remained perfectly healthy. In the books of our private practice from 1883 to 1894, we can trace 24 families of which both parents had been treated for syphilitic manifestations at various periods. In three cases healthy parents with healthy children became infected later in their married life, and the results were abortions. In these 24 families where both parents had been infected, 96 pregnancies occurred, four each, with the result as follows : Abortions, 35. Born living, 61. Of the 61, eight died in the first three months with syphilitic cachexia ; of the remaining 52, 9 showed symptoms of hereditary syphilis, mucous patches, ulcerations, papular eruptions, sucutaneous gummata, dactylitis, but all have recovered and are living. Six died of inter- current diseases, diphtheria, pneumonia, cholera infantum. Thirty- eight are well and have shown so far no symptoms of syphilis. From all these considerations we can deduce that syphilis does not prevent conception, although it kills the offspring or affects it in various manners. Children affected with hereditary syphilis are more liable to, and more easily affected by other morbid causes, and often they die from intercurrent diseases. 35 Jullien, L. "Documents sur la Syphilis Hereditaire." Jim. de Derm, et Syph., 1891. 254 THE MEDICAL ASPECTS SYPHILITIC IMMUNITY As long as a person is under the influence of the syphilitic virus he is not liable to be reinfected. The assertion that syphilis is not repeated on the same individual, or in other words, that whoever has contracted syphilis once, cannot be reinoculated (Ricord's law), has long ago been found untrue. Syphilitic immunity in infected persons is due to the saturated condition of the fluids and solids of their organism with syphilitic virus, and to the capacity of the organism to produce antitoxins to counteract the poisonous influence of the virus. The virus, however, in time and with treatment gradually loses its poisonous influence. This fact is ordinarily seen in every syphilitic family, when the first pregnancy ends in miscarriage, the second in premature birth, the third babe is born with some syphilitic manifestations, and the others well, showing only faint signs of the disease. From year to year the virulence of syphilis is bound to diminish, and gradually babes will be born with no signs of syphilis, or with so mild an infection that it will probably only reveal itself some time late in life. This diminution of the intensity of the virus occurs slowly and at times in a saltatory way. In some syphilitic families a healthy babe is born, and the next will show signs of hereditary syphilis. It seems that the syphilitic germs in the organism of the father, after a certain time and after some treatment, are unequally distributed in the organs and tissues. Moreover, there has to be taken into con- sideration the activity of certain cells of the organism, which on being conglomerated may offer so great a power of resistance as to render the germ powerless to spread its virulent influence. The result of an infected babe or of a healthy one may depend on mere accident in the presence of the germ in the spermatozoon. In this case it happens that the syphilitic germ from the father invades the developing organism of the fetus, and the mother remains intact. It seems that the mother must acquire a certain immunity against the affection afflicting the offspring, which protects her against infection. Colles' Law. — This material immunity has given origin to Colles' law, which was after a while confirmed by Ricord, Diday, Fournier and others. It can be thus expressed that mothers who bear syphilitic children from fathers affected with latent syphilis escape the disease entirely or pass through a modified form of it. Their children, af- fected with mucous patches of the tongue, of the lips, suckling the breast of their mothers do not infect her, but if thev were to suckle TRANSMISSION OF SYPHILIS TO THE OFFSPRING 255 the breast of any other healthy woman, she would be positively infected. It can be better understood to-day with the light of the recent bacteriological studies, and the difference between microbic virus, which infects directly, and its toxins, which, according to Jacobi, 36 may cause immunity to the mother. The spirochaetae of syphilis from the father invade the organism of the fetus, and the mother, by means of the toxins, acquires immunity against the affection afflicting the off- spring. Fellner explained this fact by analogy with cases of intra-uterine infection from variola. He collected a number of cases, where the mother remained healthy, or had only a mild eruption of variola, while the babe was born covered with pustules, or soon after birth showed a severe case of variola. Kassowitz 37 objected to the views of Fellner, for he claims that the immunity of the mother in the case of variola is only apparent, and has nothing to do with the immunity of the Colles law. Kasso- witz believes that the mother in spite of the infection of the fetus is immune, as many women in these circumstances, examined carefully at different times, have never shown signs of syphilis. A syphilitic fetus from a man affected with an old syphilis is not so virulently infected as in the case of a recent syphilis. In some cases of the kind the treatment of the father alone has been sufficient to obtain after a while healthy children, which could not have happened if the mother too had been infected. It has also occurred that a woman who has given birth to syphilitic children, after the death of her syphilitic 'husband has married a healthy man, and all the children have been perfectly healthy. In this way a woman may have healthy children from healthy men and syphilitic children from syphilitic men in alternation. The fact of possible infection of a child after a healthy one and the infection of mothers by conception always renders this kind of immunization rather doubtful and questionable. We have already seen that this law has been greatly diminished in its intrinsic value by the experiment of Caspary, above mentioned, which has positively shown that the immunity of these mothers is produced by the saturation of their system with syphilitic virus or with its toxins. We have already stated that the expression of absolute well-being, ought to be changed into apparent well-being, so as to reach the truth of their physical condition. 36 Jacobi, A. "Hereditary Syphilis." Am. Textbook of Gen. Urin. Dis. Syphilis, etc. 1898, p. 730. 37 Kassowitz, M. " Vererbung der Syphilis nnd placentare Uebertragimg der Variola." Wieii. Med. Wochensh., 1903. Ref. Monatshf. t. prakt Perm.. Bd. 38, No. i. 256 THE MEDICAL ASPECTS Prof eta's law. — From what we have seen, just the reverse of what happens to the mother may happen to the child, which coming into the world from syphilitic parents has an innate tendency, which pro- tects him at least temporarily from syphilitic infection. Observations of this kind have originated another not less celebrated law, known as the Profeta's law. " Children born from mothers infected directly before or during pregnancy, as a rule are born healthy, and remain, at least for a certain period of life, protected against the disease." This law finds an explanation in the power of the placenta, which being already formed is able to oppose a strong barrier to the en- trance of the syphilitic germ protecting the child with its mechanical action. Moreover, the child would be saturated with the toxins arising from the biological activity of the spirochaetse in the system of the mother, which gradually brought to the fetus, without producing in- fection, would be responsible for his immunity. Children from syphilitic mothers have always shown, at least for a certain time, immunity against infection, so that the mother with syphilitic manifestations may kiss, nurse, and give them her breast without fear. Profeta 38 published the result of his observations, and it was readily accepted by Diday, Fournier, Mauriac, Baumler, Hutch- inson, Kassowitz and others. The sense of this law was then extended to the influence of the father, and also to the mother, who, suffering with tertiary syphilis, are able to transmit a certain immunity to their children against acquired syphilis. Finger 39 then formulated Pro- feta's law : that children from syphilitic parents may be born free from syphilitic manifestations, especially when the mother alone is infected, and the infection has occurred after conception. Immunity can be transmitted to the fetus directly through the ovum or the spermatozoa. When the father or the mother affected with an old syphilis at the time of conception had their tissues and their systems so saturated with toxins arising from syphilitic processes that they could not be affected any more, they have transmitted as heredity a true immunity. The toxins also in the case of an infected mother can be brought to the developing fetus through the placenta and produce an intra-uterine inherited immunity. In support of this law there have been produced by Finger some observations of young men born of syphilitic parents who could have intercourse with syphilitic women without being inoculated. The ob- servations of Baerensprung of mothers infected during pregnancy, who having given birth to a healthy child, did not infect him with their kisses. 38 Profeta. " Sulla sifilide per allattamento." Lo sperimentale. Firenze, 1865. 39 Finger. " Ueber die vererbte Syphilis." Finger. Archiv. TRANSMISSION OF SYPHILIS TO THE OFFSPRING 257 Although the Profeta law has found in its support a long- series of observations from Profeta himself, and after a while it called the attention of Caspary, Finger, Ogilvie, Briiggeman and Gliick, yet it has received a strong blow from the observations of Tarnowski 40 on the syphilis binaria. Behrend in 185 1 had already referred to two cases of infection in children at the time of birth from their syphilitic mother. Mireur referred to a case of a child born free from syphilis, from syphilitic parents, who was infected by his father by a kiss on his lips when two years old. Cases of the kind have been referred to by a large number of observers and Finger himself has after a while called the attention to twenty cases of exceptions to Profeta's law. Tschlenow 41 together with Ogilvie 42 denies the existence of an inherited immunity from the father, and they believe that in the cases brought as a support of this hypothetical immunity, very likely little was known in reference to the anamnesis of the parents and of the concerned person. Upon the authority of Hutten, Mireur, Bar- thelemy, Eson, Erb, Goldflam, Paul, During, Pileur, Thibierge, Ogil- vie, Tschlenow, etc., cases of newly acquired syphilis have been ob- served in persons born from syphilitic parents, and among them some were after a while affected with parasyphilitic affections inherited by their father. The cases of Barthelemy, Blondel and Ogilvie, where the parties showed immunity for a certain time and then were infected with syphilis, would go to show only a temporary immunity. Syphilis of the father, so far as it concerns the immunizing of the offspring, seems to have no protective nor attenuating action on him. According to Ogilvie and Briiggeman the part of Profeta's law referring to inherited immunity from the father ought to be left out. It is not so, however, for that which concerns maternal syphilis, which if it is so constant and persistent in its transmission to offspring must nevertheless produce a more effective immunity. In fact, the papular 'form of syphilis of the mother seems to have an efficient protective action, in preference to the gummatous eruptions, which would be entirely inefficient. 40 Tarnowski, B. " Die atypischen Formen der Syphilis." Russ. Journ. f. Hant u. ven. Krank., 1901, No. 1. "Die syphilitische Familie und ihre absteigende Generation," 1901, H. II, 12; 1902, 1, 2, 3. "Die verdoppelte Syphilis und syphilitische Vererbung." Prakt. Wratsch., 1902, i, 2. 41 Tschlenow, M. " Zur vererbten Immunitat gegen Syphilis und iiber das sogenannte Gesetz von Profeta." Monatshefte f. prakt. Derm., Bd. 36, No. 9. 42 Ogilvie. " Congenital Immunity to Syphilis and the so-called law of Profeta." Brit. Journ. of Derm., 1899. 258 THE MEDICAL ASPECTS Any theory we wish to accept in reference to tertiary syphilis, whether the attenuated virulence of the spirochaeta, as Neisser and Jadassohn claim, or the diminished quantity of the same, according to Klotz, or the toxine theory as given by Finger and During, it is commonly admitted that an infected mother, when she has reached the tertiary period, has already passed the most contagious and in- fectious stage in the evolution of the disease. Consequently a child born at this time cannot inherit a true and effective immunity against syphilis. Exceptions, however, have been found and have been re- ported, and have been explained by Ogilvie by a peculiar irregularity of the contagiousness of syphilis. We have already seen that the inoculation of syphilis in its ter- tiary form is still doubtful. From our experience we have also seen that women affected with ulcerated gummata have given birth to healthy children. All tends to show that syphilis at that period is not easily inoculable, and it is also not easily transmitted to the offspring. Together with Neisser we refuse the idea of Ehlers, which was to establish as a dogma the non-infectivity of tertiary syphilis. In the same way the assertion of the non-transmissibility of tertiary syphilis to the offspring we believe with Fournier to be a mistaken one, and it must be considered as preposterous. All observations have a tendency to show that when syphilis has reached the tertiary period its virulence has been greatly attenuated, and its protective action in the children would be consequently dimin- ished. Immunity transmitted from tertiary syphilis to the offspring cannot be denied, but it is not so apparent as that proceeding from the condylomatous period, and must be also of not so long duration. Tarnowski believes that this immunity is gradually lost at the time of puberty. In this regard Tschlenow refers to two cases of infection in children of syphilitic women. In one, a little girl born healthy, of a woman with tertiary syphilis, at the age of five used to play with a babe affected with hereditary syphilis. A syphilitic initial lesion ap- peared on her lower lip with consequent symptoms of acquired syphilis The other occurred in a babe three months old, born of a woman who had shown secondary syphilitic manifestations. Although we do not see much immunity in these cases, yet Tschlenow claims immunity, which has been of a short duration only. In these cases we would rather deny, with Ogilvie, the existence of any immunity than admit a theoretical one, when the child escaped infection by some unknown or unaccountable reason. This reason may be found either in the time which has elapsed from the infection of the mother, or from the effect of a well-directed treatment, 01 Plate XIII Large Papular Eruption 1 Rupioid Form Child died of pneumonia DlATROPHY OF RlGHT HaXD AND Left Arm Child died of eclampsia Examples of Congenital Syphilis TRANSMISSION OF SYPHILIS TO THE OFFSPRING 259 from the influence of both. It is quite sure that if both children were infected, one after five years and the other after three, months, they were not syphilitic and they were capable of receptivity of the virus. Immunity, however, from syphilis is not to be denied. Tar- nowski referred to one of the most striking examples. The daughter of a syphilitic father was married to a man who had a papular syphi- lide ; in spite of repeated intercourse, she did not become infected. This could not have happened unless through the protecting power afforded by syphilis, wmich prevents a syphilitic person from re- infection. In our City Hospital, in O ward, we had under our service a colored prostitute nineteen years old affected with an eruption of ulcerated mucous patches of the labia majora and minora, and also of the tongue and tonsils. These symptoms were accompanied by general adenopathy, and showed a syphilitic infection in the condy- lomatous stage, between the eighth and the tenth month. The girl was of poor physique, weak minded, extremely pale, her right eye had a staphyloma cornese, the result of a parenchymatous keratitis. She had characteristic Hutchinson's notchy teeth, and the tibiae, somewhat bent anteriorly, were rough and uneven. All tended to show that she had been born with congenital syph- ilis. It was not possible to obtain a family history, from her nor from others, but from the symptoms it clearly appeared that it was a case of syphilis binaria. In this case hereditary syphilis did not afford any protection, or at least only temporary protection. We do not doubt for a moment that in the system affected with syphilis there must be a certain antagonism between the virulent element and the chemical products. From this antagonism must arise, as Pellizzari 43 has maintained, a certain refractory condition of the system at the period of the general manifestations, which ren- ders it immune from reinoculation of the virus. This peculiar con- dition prompted Pellizzari and many others to try the treatment of syphilis by means of the serum taken from patients affected with syphilis, when they have reached this degree of immunization. An important question, which in the present condition of science cannot be resolved, is whether these toxic products are the result of the biochemical functions of the syphilitic germs, or whether the toxins are produced from the chemical alterations of the pathological tissues. Another far more interesting question is whether those chemical products formed in the morbid foci are those which cause immunity, or rather whether those pathological alterations are capable 43 Pellizzari, C. " Tentativi di attenuazione della sifilide Atti dell' XI Con- gresso Medico Intern.," Vol. V. 2 6o THE MEDICAL ASPECTS of causing the organism to produce albuminous products, antitoxins, which would be capable of counteracting the others arising from the germ. Both these conditions of the system would explain the im- munity of the mother from her syphilitic child and of the child from the syphilitic mother. The capacity of the organism to produce antitoxins is believed by Pellizzari to be the cause of the benignity or of the malignancy of syphilis. The insufficient production of these antitoxins would leave the virulent element free to deteriorate the system, revealing itself in the most destructive forms of the disease. Returning to the question of immunity and more especially to the law of Profeta, we must confess that a great deal of theorizing has been done on this subject. We agree with Ogilvie and Tschlenow, that it is extremely rare, scarcely possible, that a syphilitic woman brings to light a babe entirely free from syphilis, and that after her delivery she show symptoms of a condylomatous nature, which are capable of infecting. Vice versa, it is fully as rare and scarcely probable that infection may occur in a babe through suckling one year after, when he could already have been infected by his mother. Ogilvie 44 does not believe much in cases of post-conceptional syphilis, and he finds, moreover, that an early infection of the babe may be easily mistaken for hereditary syphilis. Profeta 45 in replying to his remarks, published the observation of a case where the im- munity of the child was very apparent. A healthy babe born of a syphilitic mother could not be suckled by her on account of mastitis of both sides of the breast. Her sister, out of kindness, offered to give her breast to the babe. She was suffering with a recent case of syphilis and underneath both nipples she had mucous patches. The babe suckling those nipples, together with the serum from the moist papules, did not contract syphilis, thus showing immunity. Another not less striking example of immunity brought up by Profeta was that of a woman who became infected at the end of the seventh month of gestation. Secondary manifestations began to ap- pear just at the time of the delivery, in rather a severe form. She gave birth to twins, of which the first was healthy, the second syphi- litic. The mother had all the most varied eruptions of syphilis, but her breast was spared. The second babe was covered with eruptions from head to foot, with moist eruptions of the mouth. Both babies were together, and were fed at the same bottle. Any other babe would 44 Ogilvie. " Congenital immunity to syphilis and the so-called ' Law of Profeta.'" The Brit. Jonrn. of Derm., 1899. 45 Profeta,. G. " Variazioni su motivi di sifilide congenita e per allattamento." Giorn. Italian di mat. e della pelle., 1900, p. 165. TRANSMISSION OF SYPHILIS TO THE OFFSPRING 261 have been positively infected, and yet the uninfected one remained healthy, and at the age of nine had never shown signs of syphilis. Opportunities for infection were always at hand, and immunity only could save the child from being inoculated. In spite of such striking illustrations of syphilitic immunity, Gluck 46 denied entirely the immunity and the existence of Profeta's law. He maintained that either in cases of post-conceptional infec- tion, the babe is killed in utero, abortion, or comes into the world with congenital syphilis. Children born absolutely free from syphilis of a syphilitic woman at a period when she is still capable of infecting, are such a rarity that a law based on them cannot find any support. In those rare cases where a child is born of a syphilitic woman and is free from syphilis, Gluck advises that resort be had to artificial feeding, rather than to let the woman give her breast to the babe. He has no confidence in this so much talked of immunity. From our own observations in the venereal ward we must state that in several cases of post-conceptional syphilis we have seen babies born perfectly healthy from mothers affected with syphilis in macular and papular forms. In one case the mother had so thick an eruption of mucous patches of the labia majora that for our protection rubber gloves had to be used to deliver her, and to our surprise the babe was healthy, well nourished, and as long as it remained under our observation it did not show signs of syphilis. We agree with Tschlenow that the Prof eta law has been subject to much distention, or rather distortion, for which Profeta is not re- sponsible. We cannot deny this law, especially that which concerns post-conceptional infection ; we have had several cases where infection of the mother had occurred between the third and the sixth months of pregnancy. The babe which was born from a mother affected with mucous patches of the vulva, above referred to, was separated from her and was nursed artificially in the children's ward. It remained there for thirty-six days and did not have syphilitic manifestations in that time. From the observations of Profeta and others, we believe in an immunity given by the mother to the child and resulting from the presence of antitoxins in the system, an immunity which is found also in other infectious diseases. In syphilis it is so well marked that we find that a person while infected with syphilis cannot be reinfected. It is not beyond the range of possibility that the fetus already de- veloped in utero in the case of post-conceptional infection is saved by the compact structure of the placenta from the invasion of the syphi- 46 Gluck. " Ueber das sogenannte Profetasche Gesetz." Med. Wochenschr., 1902, No. 9. 262 THE MEDICAL ASPECTS litic germs, and is born free from syphilis, while, on the other hand, the toxins brought into circulation from the mother to the fetus have rendered it immune, an immunity which in ordinary cases is not of long duration. Cases of this kind are not very often met with, but their existence is undeniable. As to the immunity from a syphilitic father to his offspring, it is very questionable. Theoretically, however, we can admit that if syphilis is transmitted as a heredity a certain immunity can also be transmitted. The cases above mentioned, referred to by Finger and Tarnowski, are clear illustrations of transmissions of immunity against syphilis by heredity, but these cases are only exceptions and cannot form a law. Another important question is whether syphilis transmitted in a tertian* stage to the offspring is capable of protecting it from acquir- ing a new syphilitic infection. From the cases and from the exceptions of the Profeta law, we have seen that the inherited immunity is onlv of short duration, and children who had escaped contagium in the first months and years of life have been infected later on. In the case above referred to, although lacking a family history, it is clearly shown that the inherited luetic symptoms of a tertiary nature, if of any value for a certain time in immunizing the girl, did not keep her from being infected with a fresh case of rather severe syphilis. Another case was that of a young man twenty years old who showed dystrophy of the hands, with unmistakable signs of a periosteal syphilitic process of the tibiae and of the skull, and who came to the hospital with an initial chancre and macular syphilide. In this case it was clearly shown that if hereditary syphilis in the form of tertiary symptoms can produce immunity for a certain time, this immunity is lost after a while and a new infection can betaken, sypliilis binaria. A case of this kind has been reported by Petrini de Galatz 4T in a young man twenty-two years of age, who showed signs of past syphilitic affections of the bony system, together with a dystrophic condition of his teeth. Although the history of the syphilis was not clear, yet the condition of the frontal bone, and his teeth, was at- tributable to hereditary syphilis. He was under treatment for a maculo-papular eruption, which followed an initial lesion of recent inoculation. Petrini de Galatz considers with some reserve this case as one of possible reinfection, and of the kind considered by Tarnowski as syphilis binaria. Immunity at times is very perceptible ; children remain well while 47 Petrini de Galatz. " Un cas de stigmates heredo-syphilitiques et de syphilis acquise chez le meme individne." Bcitrage sur Derm, una 1 Syphilis. Festschrift fur Prof. Neumann, 1900. TRANSMISSION OF SYPHILIS TO THE OFFSPRING 263 exposed to a continuous source of contagium, and it seems that im- munity is increased, as was shown by the experiments of Ehrlich. The reason of immunity being increased or weakened is found in the systemic individual conditions, in the quantity of the poison, in the capacity of the body to generate anti-toxins, and in the peculiar predisposition of the system. It may remain for a certain time, and then ceasing its protective influence, the child may undergo syphilitic infection. In most cases these adolescents are liable to show no more syphilitic manifestations, but rather parasyphilitic forms. Often in childhood they are subject to eclampsia, later on to epileptic fits, which are relieved and sometimes cured by the iodides. Some will show an arrest of development tending to dwarfism, or others will remain in a condition of infantilism. From the effects of syphilis, nearly all of them have their system so liable to other diseases that they are quite frequently affected with tuberculosis, or die with other intercurrent diseases. Some other cases towards puberty will show late syphilitic lesions, which, as we have seen, belong to cases of retarded syphilis. The fact stands, that in all cases of syphilitic infection before conception or during pregnancy, if the babe escapes syphilis before it is born, any inoculation of syphilis is not possible between mother and babe. The babe exposed during embryonal life to infection on account of the nutritive exchanges between fetus and mother through the utero-placentary circulation would, had its condition been favorable, have been infected before its birth, after which it can be infected with syphilis only later on, when with the growth of the body his organism has been renovated, thereby losing its immunity. The immunizing power must be found in the toxins, and in the capacity of the system to produce antitoxins. If we are to accept the views of Finger the toxins would be excluded from reaching the system of the fetus by the placenta. The exceptions to the law would be the result of the condition of the placenta or of the system unable to produce anti- toxins. Hochsinger 48 for the exceptions to Colles' law gave us an explanation the inability of the organism of the developing fetus to produce toxins, which if formed would render the mother immune. In conclusion we can say that syphilis, like any other infectious disease, is susceptible to a certain degree of immunity, which is re- vealed in acquired as well as in hereditary syphilis, an immunity, however, which is usually not of long duration. 48 Quoted by Tschlenow, 1. c. 264 THE MEDICAL ASPECTS SYMPTOMS AND CONSEQUENCES OF CONGENITAL AND HEREDITARY SYPHILIS "When the father, or both parents, being tainted with syphilis, have a successful cohabitation, the syphilitic germ is carried to the ovum, where it develops in the first- formed cells, and every organ of the developing embryo is saturated with the disease. The virulence is too great, the frail organism cannot stand so deep an infection, and consequently after a few months it dies. When the fetus dies after the third or fourth month of utero- gestation, very few or no characteristic pathological alterations can be found in a macroscopical examination. When the fetus dies later, alterations are then quite remarkable. W T e have already had occasion to speak of pathological alterations in the maternal placenta in the form of gummatous foci in late syphilis of the mother, but in these cases we will find the fetal placenta more often affected in its villi, in the form of nodules, which compress the circulation. We have already found that the blood vessels entering the structure of a syphilitic placenta show the same peculiar alterations in their tunics which are so characteristic of the syphilitic angioitis. This causes an obstruction of the blood vessels and as a consequence of the imperfect develop- ment this organ appears small, flaccid, and easily breaks, and weighs much less than a normal placenta. In some places of the placentary stroma hemorrhagic infarctions are found where tissues have been destroyed, facilitating a direct communication of the germs. The amniotic fluid is turbid, sticky, dark and foul, the epidermis of the little body is macerated and is detached in large shreds. In many autopsies of fetuses dead between the fifth and the sixth months the gross anatomo-pathological alterations were very scarce, and with the exception of a somewhat enlarged spleen, nothing else interesting could be found. In some cases the liver also is found somewhat enlarged, the tissue is dark, congested, and interspersed with some yellowish points. These spots, somewhat resembling miliary tubercles, are nothing else than small cell infiltrations, with proliferation and induration of the interstitial tissues, gummatous in character. Hochsinger in 148 cases of hereditary syphilis found enlargement of the liver 46 times and in five autopsies enlargement of the spleen and of the liver, without icterus or ascites. Chiari. although he did not find marked enlarge- ment of the liver, noted a hyperplastic infiltration around the biliary ducts sufficient to explain the presence of the jaundice. Abraham Jacobi demonstrated a case of cirrhotic atrophy of the liver of syphilitic TRANSMISSION OF SYPHILIS TO THE OFFSPRING 265 origin. All these observations referred to show that syphilitic infec- tion produces early and intense ravages in this organ, and in many cases it is the cause of death. Macroscopic alterations of a gummatous nature are liable to be found in the pancreas, in the kidneys, in the testes and in the digestive tract in the form of infiltrations or ulcerations. In two cases of post-mortem in syphilitic babies born dead nearly at full term, we have found the lungs very dark, thick and deeply congested, interspersed with whitish nodules, showing an interstitial inflammatory process, to which death was attributed. The bronchial glands have been found enlarged in several cases. Demme found gummata in the thyroid gland in a case of retarded syphilis. It is not a rare thing to find the thymus gland affected with heredi- tary syphilis, and the works of Jacobi 49 have contributed a great deal to the elucidation of its anatomo-pathological alterations. As a vas- cular organ the blood vessels are deeply affected, and as a consequence a thickening of the whole organ has taken place. In some places, masses of hypertrophic connective tissues were found around the blood vessels, causing pressure, just as in the interstitial inflammations of the other organs. This hyperplasia seems to be characteristic of hereditary syphilis, and is accompanied at times with enlargement of the glands. Abscesses have been found in the thymus of syphilitic babies by Dubois and Haugsted, and hemorrhages by Fuerth and Weber. The heart, although very rarely affected, has been found in a few instances to show signs of fibrous myocarditis and gummata. In a fetus stillborn at the eighth month, Kantzow and Virchow found a myoma at the base of the heart and miliary gummata in the right ven- tricle. Syphilitic myocarditis was found by Hutchinson, and fibrous myocarditis and endocarditis by Wendt. The pericardium has been found with miliary syphilomata and obliterating adhesions. The pathological anatomy of the nervous system in the fetus has so far revealed very little. One case of cerebral syphilis in a babe ten months old was reported by Rosa Engelman. Two more cases have been referred by Rumpf, but it is the common opinion that cerebral gummata in babies are very rare, and Starr claims that their presence below the twelfth year is only rarely found. In reference to the spinal cord we will refer to the conclusions of G. Gasne, quoted by Jacobi, that the meningo-medullary changes in the fetus, infant and adult are identical, that the ganglia are infiltrated, but the nerve cells are mostly intact. He found fibrous thickening, or 49 Jacobi. Virginia Medical Monthly, May, 1895. 266 THE MEDICAL ASPECTS infiltration with small cells, in the septa and in the blood vessels. The process has been found disseminated mostly in the posterior surface of the medulla and of the meninges. When the fetus has escaped death in liter o, it is born, in some cases, somewhat prematurely, is anemic, of an ashy appearance, so poorly developed and so feeble that it survives only a few hours. In several of these cases, which we have had under our observation, the autopsy did not reveal gross perceptible alterations, with the exception of a small enlargement of the spleen, and in a very few instances symptoms of epiphysitis were present. Sometimes infants are born at full term showing eruptions of papules or bullae. They are then under so severe a degree of infection that they do not live more than a few days. Their general appearance is usually very bad ; the little body is wasted, the skin is wrinkled, their cry is weak, the nose stopped up, they have no strength to take the breast, and they usually die between the first and second week. In the majority of cases the infant is born apparently healthy, and only after a certain time shows the characteristic symptoms of syphilis. The earliest eruption we have seen in syphilitic children was the bullous eruption of the soles and palms, the so-called syphilitic pemphi- gus, which in one of our cases began three days, and in another five, after birth. The more intense the nature of the infection is, the earlier the cutaneous symptoms occur. Usually eruptions make their appearance between the second and sixth weeks. An interesting sta- tistical table taken from iooo cases of syphilitic babes by Miller of Moscow, and quoted by Holt, 50 tends to show the time when symp- toms are most apt to occur. ist week, 85 2nd " 138 3rd " 240 4th " 177 alter the 8th week, 140 In most of the cases the eruption is preceded by general svmptoms. The babe wastes away, his nose is affected with coryza snuffles, which prevents him from suckling, his cry is weak and hoarse, all showing that the mucous membranes are already involved in a catarrhal in- flammation. At this time a papular eruption affects the hands and face of the babe in the form of small papules, rather confluent, which after a while spread to the arms, body and legs. Mucous patches are seen on the lips, around the genitals and the anus in an excoriated or ulcer- ated form. The eruption is usually accompanied by a mild fever, 50 Holt L. E. " The Diseases of Infancy and Childhood," 1897, p. 1059. 5th week. 86 6th " 54 7th " 50 8th " 30 TRANSMISSION OF SYPHILIS TO THE OFFSPRING 267 99 to 101 . and in some cases with a tenderness of several joints due to acute epiphysitis. The joints may be slightly swollen, and the babe cries every time that he is handled on account of their tender- ness. In other cases of severe infection the babe's general nutrition suffers. He decreases in weight, becomes very anemic, whines and frets, especially at night. His face, wrinkled and drawn, takes on that characteristic aspect of an old person. His skin, destitute of panni- culus adiposus, is so wrinkled that it can be raised in large folds, and has taken on so peculiar a sallow color as to resemble cafe ait lait. In some cases the skin becomes dry, rhagades of lips, nose, ears, eyelids, mouth and anus are formed. Roseola appears in the form of large copper-colored spots, which soon, on account of increased exudation and infiltration, become elevated, forming papulae in the center. Gradually on account of the reabsorption of the effused ele- ments the papula fades out, and the epidermis covering them dries up, forming scales. In other cases, on account of increased exudation the epidermis is raised up in the form of vesicles, their serum on ac- count of the presence of the pus cocci in the skin is soon changed into a purulent secretion. This forms thick crusts which cover the surface of the excoriated lesions, which may convey the idea of a diffused impetigo. In other cases, however, the purulent secretion coming from distinct lesions when a superficial ulceration takes place in their center, they form a hard, dry crust, which is characterized as rupia. These peculiar eruptions are in some cases found together and un- doubtedly show the severity of the infection. Quite frequently around the anus and the genitals the skin is covered with moist papules, mucous patches, which are brown red in color, covered with a thin epidermis and raised above the level of the normal skin. The epidermis in these regions, macerated by the pres- ence of urine, feces and perspiration, is easily abraded ; the patches are excoriated and soon superficially ulcerated. The surrounding skin becomes inflamed in the form of a diffused intertrigo. Some mucous patches are found in the mucous membranes of the genitalia of the anus and of the lips and tongue. The fingers, especially the last phalanges, are bluish red, and sometimes show papular infiltration of the finger nails, syphilitic paronychia. Quite often we have found that children show syphilitic dactylitis. the bones of the phalanges swell, the medullary canal is changed into a large cavity, which increases and changes the size of the phalanx of the finger into a round or oval-shaped joint. The skin covering it is thin, bluish red, and distended. Sometimes the process is limited 268 THE MEDICAL ASPECTS to the bone, at other times the fibrous tissues of the joints are also involved. The mucous membranes are affected with catarrh, so that from the nose flows a purulent secretion which occludes the nostrils and prevents the babe from suckling. The conjunctivae are also inflamed, and the cornea is liable to be affected with parenchymatous keratitis. The iris and the corpus vitreum may undergo interesting changes. The rectum is sometimes prolapsed and painful on account of rhagades and mucous patches. The lymphatic glands are usually hard and sclerotic. It is not the enlargement which accompanies the de- velopment of acquired syphilis, but rather recalls the shrunken and sclerotic condition of the lymphatic glands several years after syphilis has entirely disappeared. Under the exploring hand they are felt like shot, hard and movable. Anemia is quite marked and the spleen is somewhat enlarged. If the babe is left without treatment or if this is used too late, the babe runs down to a marasmatic condition, col- liquative diarrhea begins, and the babe dies of inanition. In some cases babies are born without apparent symptoms of syphilis though suffering with a severe infection in the viscera. This condition may continue through infancy and accompany them in child- hood. Keim, 51 of Paris, called attention to the necessity of treating luetic newborn children, although they may not show visible syphilitic manifestations. He referred to a family, the father of which had been treated for nearly three years for a mild case of syphilis. The mother never had shown any decided symptom of the disease, but she was not well, and consequently during her first pregnancy was subjected to antisyphilitic treatment. The first child was born healthy and never showed any sign of lues. During the second pregnancy no treatment was given to the mother; she gave birth to two babies, of which one showed immediately after birth, but the other not until six months later, evident symptoms of infection. The babies began to lose weight, they became pale and anemic, with disturbances of the digestive organs, and especially of the liver. The liver is often affected. In some cases it is enlarged and hardened, and ascites is present. Jaundice appears, though not often, a few weeks after birth, a circumstance which differentiates it from the common jaundice of the newly-born. YVe have already called the attention of the reader to the epiphy- sitis which is often found in cases of congenital syphilis with syphilitic eruption. In some of the cases of congenital syphilis without apparent manifestations the babe may be affected with osteochondritis, which in the beginning may pass entirely unobserved, when there is an 51 Keim. La Syphilis. July, 1904. TRANSMISSION OF SYPHILIS TO THE OFFSPRING 269 absence of marked swelling. Gradually the bones are found some- what swollen and painful while the skin covering the swollen joint may appear red. The epiphysis may be separated by the diaphysis, and then marked crepitation is felt with some pain, not corresponding, however, to the entity and to the severity of the lesion. The humerus is affected in preference, and remains useless in pronation. This con- dition was named and described by Parrot as pseudoparalysis. It is not easy to determine how long syphilitic intestinal troubles will last, but in severe cases it is one of the determining causes of death in the form of colliquative diarrhea. An atrophy of the base of the tongue has been described by Lewin and Heller, 52 which has also been found in hereditary syphilis. The affection was described by Virchow under the name of atrophia Icevis basis Ungues. It consisted in a smooth depression of the pharyn- geal portion of the tongue, with an atrophic or hypertrophic condition of the lingual tonsils. Virchow established this alteration as a con- stant pathognomonic symptoms of lues. It is, however, not a charac- teristic sign of hereditary syphilis, but, as O. Seifert, Lewin, Heller and others have demonstrated, is mostly found in hereditary syphilis. Robinson, Fournier, Hyde and others have described as present in the mouth of the babies affected with hereditary syphilis, small, superficial, radiated, cicatricial patches in the form of leucoplasias, such as are found in adults with acquired syphilis. In our experience, however, we find in syphilitic adults a whitish thickened line of turbid epithelium, which runs from the angles of the mouth straight towards the molars, with small ramifications, but only rarely have we found it in the mouth of syphilitic babies. Congenital syphilis is the cause of interstitial hemorrhages in the form of petechias They affect the skin as purpura neonatorum and, as Mracek 53 has found, are the result of syphilitic alterations in the small and medium sized veins. Some hemorrhagic spots affect not only the skin, but have been found in the muscles, serous membranes, mucous membranes, the pleura, the pericardium, and even in the lungs and the glands. Jacobi has found hemorrhages of this kind in cases of severe congenital syphilis immediately after birth, or only a few weeks after. In rare cases hemorrhagic spots have been found under the periosteum with preference for the humerus. Syphilitic alterations of the blood vessels are repeated in the um- bilical cord. Franceschini 54 found the same specific inflammatory 52 Lewin and Heller. Virchow' s Archives, Vol. 138. 53 Mracek, F. "Syphilis hemorrhagica neonatorum," Arch, f. Derm, und Syphilis. 1887, XIX, p. 274. 54 Franceschini, J. " La Syphilis," July, 1904. Ref. Monatshcftc f. prakt. Derm., Bd. 39, No. 6. 270 THE MEDICAL ASPECTS process in the arteries as well as in the veins of the cord, accompanied by thick edematous infiltration of their tunics with thick and hardened places. Endoarteritis and endophlebitis are the causes of the altera- tions of the intima of these vessels, which may lead to their obliteration. From this condition of the blood vessels the Wharton layer suffers interesting changes; it is scanty, poorly developed, and shows a thick infiltration of leucocytes. When the cord is found in this condition it is a good sign for suspecting congenital syphilis, although the babe is born apparently healthy. When the babe is subjected to an appropriate treatment, and is helped along by proper feeding, it can be helped, yet if the infection is too deep and severe, the prognosis is doubtful. In very anemic babies, weak and low of weight, death may occur suddenly without a perceptible cause. Indeed, when syphilitic children are under treatment it is of great importance to keep note of their weight. In some cases it is possible from the weight of a babe to conclude as to the possibility of latent syphilis. Boissard and Deve 55 have seen children who in spite of their apparent good health do not increase in weight, and although the milk and the food have been changed, a diminution in their weight has constantly taken place and they have had a fatal end. In cases of this kind signs of lues are not found and so it is difficult to explain the reason for the decrease in their weight. Proof of the syphilitic origin of their denutrition is obtained from the result of the antisyphilitic treatment which in a short time shows its effect, the babe beginning to increase in weight. It is therefore of great importance to note the weight of the babe. A decrease in its weight may be a hint of the existence of latent congenital lues which otherwise would remain ignored, and by insti- tuting a specific treatment we can save the life of the child. Not rarely children with congenital lues suffer with eclampsia, and some are found affected with chronic hvdrocephalus. They are liable to all other morbid causes, so that they are quite often affected w T ith bronchitis and pneumonia, which may end their lives. Their skin is so easily affected by pus cocci through the abrasions or ex- coriations that quite often we find them suffering with furunculosis and deep abscesses of a specific origin. We have already seen that syphilis and tuberculosis are quite often associated together, one making the other more deleterious and malignant. There are unfortunate cases where syphilis is inherited from the father and tuberculosis from the mother. Caseous infiltra- 55 Boissard and Deve. " La Syphilis." July, 1904. Ref. Monatshefte f. prakt. Derm., Bd. 39, No. 6. TRANSMISSION OF SYPHILIS TO THE OFFSPRING 271 tions are the result of both diseases, and it is very difficult to ascertain the existence of the tuberculosis unless tubercle bacilli are present. In a general way we can state that in hereditary syphilis when caseous infiltrations are found in the lungs, it is very likely that both affections are acting together. Hereditary syphilis has a great influence on the production of diseases of the nervous system, and also has an injurious influence on the development of anomalies in the mental functions, so much so that we are compelled to treat this subject in a separate article. GENERAL TREATMENT OF CONGENITAL SYPHILIS Treatment, which so wonderfully helps and cures acquired syph- ilis, shows its power in the relief and cure of congenital syphilis. When we have under our care a syphilitic babe we must always keep in mind that it is a danger for the spreading of syphilis to others. Conse- quently a syphilitic babe must be nursed by its own mother, because if it is given to a wet nurse it will surely infect her. In the same way girls taking care of the infant must be cautioned not to kiss it on the mouth. We remember a case of syphilitic infection in a young lady caused by the syphilitic babe of her sister. In this case the initial lesion was on the right cheek of the young lady where the mouth of the babe had accidentally touched her. We had under our care an old lady with the initial lesion on the index finger of her right hand, and which was caused by the syphilitic babe of her daughter. It is, therefore, necessary to be careful with syphilitic babies on account of the danger of communication of svphilis. In case the mother should not be able to nurse her babe, then rather than run the risk of infecting another person the babe should be nursed with the bottle. In the children's ward of the City Hospital as well as in our private practice, when the babe has to be nourished by the bottle we use sterilized cow's milk, which we direct to be diluted with a barley decoction. This mixture is well borne by the stomach and affords good nutrition for the babe. The treatment of congenital syphilis, as for the acquired disease, is local and general or constitutional. Rhagades, ulcers and moist papules must be treated locally. The babe when covered with a syphilitic eruption is bathed in a solution of bichloride of mercury every day for ten or fifteen minutes. The solution is prepared by dissolving from two to four tablets of vii grains of sublimate in six gallons of warm water in the bath tub. This gives a solution of a strength of from 1 to 12,000. Although 272 THE MEDICAL ASPECTS Welander 56 denies any absorption at all of the mercurial preparation when the skin is normal, yet in this bath we find a remarkably beneficial local action. After a few baths dry papular eruptions soon fade and disappear, moist papules and ulcerated lesions soon clear up and begin to heal. Indeed, in the bath we do not see the local action alone, but also a beneficial general action due to the absorption of the mercurial preparation. It is true that the epidermis is a boundary between the internal organs and the external surroundings. It is deficient in blood vessels, yet it only limits but does not prevent absorption. Especially when the water of the bath is at a warm temperature, some is absorbed by the epidermis. Indeed, when a hand is kept for a long time in water the epidermis becomes whiter, thicker and somewhat distended from the penetration of water into its structure. When sublimate is dissolved in the water some must be absorbed. In the excoriated and ulcerated surfaces the absorption is more active. Yet from the use of the sublimate bath in acquired as well as in hereditary syphilis, we have always obtained satisfactory results. Coryza in syphilitic children is a troublesome symptom which prevents the babe from taking nourishment. An abundant secretion of muco-pus, sometimes tinged with blood, keeps discharging from the nostrils, which getting dry, forms thick crusts obstructing the passage of the air. The babe is compelled to breathe through the mouth, which becomes dry and causes great discomfort. This affection needs local attention. The nurse will be directed to remove the puru- lent secretion with a wet rag or cotton and inject by means of an ordinary glass dropper a solution of mentholated biborate of sodium. Biborat. Sodii 3 ss Menthol gr. i Aq. Camphorat. \ - • Aq. Destillat. f aa 3 1SS The nurse must be cautioned to make the injection in the nostrils while holding the babe in an erect position, in order to prevent choking. Fissures and mucous patches around the nose, on the lips, tongue, genitals, etc., have to be touched with a three per cent, solution of silver nitrate and then washed with water to remove the surplus of nitrate of silver. Ulcerated surfaces and excoriated papules are usually dusted with calomel and then covered with dry absorbent cotton to prevent con- tact with other surfaces. In case the dry dressing is not advisable on account of forming crusts, we prefer the application of a salve with white precipitate of mercury. 56 Welander, E. " Wie und wo, sollen wir hereditar syphilitische Kinder behandeln?" Bcrl. klin. Wochenschr. Sept. 12, 1904, No. yj. TRANSMISSION OF SYPHILIS TO THE OFFSPRING 273 Hydrarg. precip. alb gr. iv-vi Bismuth subcarb. ) Zinc Oxyd. f aa 3 ss Acid. Carbolic gutt. vi Vaselin. flav 3 i When we have to do with superficial ulcerated cutaneous gum- mata with ulcerations surrounded by a gummatous infiltration, we pre- fer the use of the emplastrum hydrargyri, which we spread on a cloth which is applied on the surface. From this application we have not only a local action, but also a general one on account of the ab- sorption of the mercury. In cases of ulcerated gummata, when the mercurial plaster is not longer tolerated, the application of iodoform salve will be found to give good results. It is necessary, however, to watch the use of iodoform on account of the frequent dermatitis which follows its use. CONSTITUTIONAL TREATMENT OF CONGENITAL SYPHILIS All external applications in syphilis will not be of much benefit unless fostered by the general or constitutional treatment. As for acquired syphilis, mercury is the remedy which brings about our therapeutic triumphs in congenital and hereditary syphilis. Mercury, when judiciously employed, has given in our hands wonderful results in infants wmo were already affected with syphilitic cachexia. In the same way as in the treatment of acquired syphilis, we can administer mercury to the babe by ingestion, by inunctions or by subcutaneous injections. The three methods are not chosen by acci- dent, but they are selected according to the condition of the little patient and the indications arising from the severity of the symptoms. In a case of congenital syphilis with secondary symptoms, when the affection has not too deeply affected the general nutrition, we select the administration of mercurial preparation by ingestion. Calomel has given us good results ; it brings the system more readily under the action of mercury. We give calomel to babies in a dose of 1-10 of a grain two or three times a day. The formula we use is as follows : Hydrarg. chlor. mit. . gr. iv Bicarbon. Sod gr. x Sacchr. alb gr. x M. div. in ch. aeq. No. 20 One powder twice a day. This is easily given in a teaspoonful of water or milk. In our cases the administration of these powders has regulated the bowels, and we have never seen any trouble, although continued for several weeks. 274 THE MEDICAL ASPECTS Mercury by ingestion to babies can be given in the form of gray powder, one grain four times a day ; as a solution of sublimate, one- sixtieth of a grain, well diluted ; also four times a day. In our ex- perience we prefer and advise calomel in the given formula. In case the babe should be troubled with diarrhea, then, rather than insist on the administration of the calomel, we resort to the mercurial inunctions. The ordinary mercurial ointment is diluted with the same amount of vaseline, and twenty grains of this mixture is rubbed daily into the soles, palms, back, axillae, etc., for a few minutes. The place to be rubbed must be changed, and the nurse must be cautioned not to wash the place soon after having rubbed it, in order to prevent irritation of the skin, and the • possible occurrence of eczema or mercurial erythema. After the inunction is made the surface will be covered with a piece of English lint to maintain the mercurial ointment in contact with the skin. In grave cases of congenital syphilis we have resorted to the deep injections of a mercurial preparation. Intramuscular injections with bichloride of mercury in congenital syphilis we have seen used with good results in the clinic of Dr. Ciarrocchi, in Rome. We have used injections in the g-luteal regions with five drops of gray oil, twenty per cent., once a week in the same circumstances, and we can say with more than satisfactory results. We can agree with Mon- corvo, Ferreira and Lang 57 on the decided preference for gray oil for injections in the treatment of congenital syphilis. In six of our cases of an aggravated form of congenital syphilis with papular and ulcerative cutaneous eruptions, and with symptoms of syphilitic cach- exia, four to six injections of five drops of the gray oil have rendered great benefit. As a consequence of the injections in babies, we have seen no trouble in the mouth or on the part of the bowels. Only in one instance the place of the injection became inflamed and formed a small limited abscess, but the babe had, at the same time, boils and cutaneous abscesses in different parts of its body. Consequently it was very difficult to prevent staphylococcic infection. When the symptoms begin to show signs of improvement we cease the injections and return to the internal administration of the mercurial preparation. Iodide of potassium, the other great remedy for acquired syphilis, also shows its beneficial effects in hereditary and congenital syphilis. It is indicated, alone or with mercurial treatment, in all cases of syphilitic lesions which point towards tertiary lues. When the tender- ness of the joints shows that there is a process of epiphysitis, or the condition of the bones shows periostitis, iodide of potassium must be given in sufficient doses. Likewise in the case of syphilitic dactylitis, 57 Lang, E. Twentieth Century Practice, Vol. xviii, p. 319. TRANSMISSION OF SYPHILIS TO THE OFFSPRING 275 of cutaneous gummata, iodide of potassium must be given in a dose of from ten to thirty grains daily. It is well supported by the children, and in cases of urgent symptoms the quantity can be raised to the usual dosage of sixty grains per day. Although specific treatment must be kept up for a long time, yet it has to be given with some intervals of rest. As soon as the syphilitic symptoms have improved, we cease the mercurial treatment for a while, to give place to tonic and ferruginous preparations, in order to correct the anemia and to increase the nutrition of the babe. In the case of congenital syphilis, the specific treatment must be carried on for one year and more. The remedies and their administra- tion have to be changed according to the indications, so that if. in the beginning, on account of the severity of the infection, we have used sublimate baths and deep injections with the gray oil, when the symptoms subside we may follow the treatment with calomel or with gray powders in small doses twice a day, in order to maintain a certain degree of mercurialization. The symptoms and the degree of the infection are the guide for selecting the treatment, and also for advising us when it must be stopped or resumed. It takes good, heroic and constant treatment to destroy in the babe the germs of syphilis, which have been developed in his little organism at the time of his conception. PROPHYLAXIS When a babe is born with symptoms of congenital syphilis, from parents apparently well, it is the duty of the physician to advise them both to undergo a specific treatment. The health of the woman, who has been innocently infected by her husband, has to be protected, and she must begin a good and heroic treatment for her future health and for the welfare of their coming children. In some cases we may find objections on the part of the woman, who, ignorant of the disease which she has acquired, may refuse treatment on the ground of her feeling well. In our practice we have never found any objec- tion to treatment when we have mentioned to the woman the necessity of it on account of her children. We have never spoken the name of the disease, or told to what origin it must be attributed, but we have only explained that without a good treatment she cannot have healthy children. This reason has been sufficient to persuade the woman to take her treatment without any remarks. By the treatment of the syphilitic mother we can prevent abortion and bring the pregnancy to its full term. The babe may still come forth tainted, yet he is capable of resisting the disease and of tolerating treatment, whereby he will obtain recoverv. 276 THE MEDICAL ASPECTS One also secures, by the treatment of syphilitic parents, and more especially the mother during pregnancy, the birth of a healthy babe, or at least without any syphilitic manifestation. Fournier 58 and Langle- bert 59 referred to splendid results obtained by treatment of syphilitic women during pregnancy, that clearly show its value and its efficacy. On the other hand, the results of syphilis left to itself in the mother as ignored syphilis, are absolutely frightful. O. Jersild 60 at the meeting of the Danish Dermatological Society, referred to the case of a young married woman, apparently in good health, who at her first pregnancy had a miscarriage between the second and third months. The second pregnancy reached full term, but the babe died seven weeks afterward, covered with a bullous eruption. The third pregnancy ended in abortion between the fifth and sixth months. On her fourth pregnancy she gave birth to a child, still living, but suffer- ing at present with parenchymatous keratitis. The fifth pregnancy had a full term, but the babe died when eight weeks old. The sixth pregnancy reached its full term, and the babe was born without signs of congenital syphilis. Her husband, a sailor, at this time began to suffer with brain symptoms, and died with dementia paralytica in a hospital for the insane. In her history, she could only mention the presence of a little wound in her lips some fifteen years before, and which she thought to be the result of fever blisters. She never had perceptible adenitis, nor did she ever notice any eruptions. The joints of both hands are at present affected with chronic arthritis, extremely painful, swollen and immovable. Some of the metacarpal bones have been destroyed in their epiphysis. Her daughter, born of the fourth pregnancy, was, until the eighth year of life, comparatively well, when she was affected with an eye disease which was diagnosed keratitis parenchymatosa. No alteration or deformity could be found in the conformation of her skull ; her teeth, with the exception of being somewhat wide in their implantation, showed no abnormality. There was no doubt that the husband had had an initial chancre of which the scar remained indelible on his glans, as was confirmed at the post-mortem, and that the general paralysis had been the result of the disease. The wife had been infected on her lip from the kiss of her husband, the scar being still there after twenty years. Syphilis had run a subdolous course, there being no perceptible manifestations until the disease had begun to affect the bony system. Of six 58 Fournier, A. " Syphilis et Mariage." Paris, 1890. 59 Langlebert. " La Syphilis dans ses rapports avec le mariage," p. 237. 60 Jersild, O. Ref. Derm. Zeitschr. Bd. vi., 1899, p. 763. TRANSMISSION OF SYPHILIS TO THE OFFSPRING 277 pregnancies, four resulted in abortion, or the babe was born at full term and died a few weeks after birth. The child of the fourth pregnancy, although apparently well at the age of eight, began to suffer with parenchymatous keratitis, which is an essentially late syphilitic manifestation. Jonathan Hutchinson reported that he had observed many cases of syphilitic affections of the bones in children affected with hereditary syphilis. He found especially a variety of bone affection which has a great similarity to osteitis deformans, as it is characterized by thick- ening and bending of the bones. In reference to syphilitic keratitis, it shows only late in life, so much so that at about thirty it is still liable to afflict the tainted organism. The same observations have been confirmed by v. Hippel, 61 who, in a larg-e clinic for the diseases of the eyes, has had occasion to observe a large number of children affected with hereditary syphilis, who were suffering with affections of the bones and of the joints. He places their average number at fifty-six per cent. In most of the cases the affection was double hydrarthrosis of the knee joints. The various affections of the bones have nearly constantly preceded the keratitis parenchymatosa and both remain symptoms of retarded syphilis. Many sufferings for the mother and the future child can be avoided by the application of a well-directed treatment- during pregnancy. The influence of the treatment of the syphilitic mother on the developing fetus has been in our experience very beneficial, and we consider it a true prophylactic means, capable of avoiding, or at least diminishing, the effects of congenital and hereditary syphilis. Riehl 62 expressed some doubts as to the efficacy of the specific treatment of the mother for the benefit of the offspring. He believes that the general treatment given to the mother does not reach the fetus, which remains without any influence from the remedies. Others have gone so far as to state that specific treatment of the mother in the early secondary period is not only of no benefit to the fetus, but if too much continued, will have an unfavorable influence on the course of the pregnancy. Huguier 63 and Fonberg 6i have maintained that the constitutional treatment of the mother during pregnancy 61 v. Hippel. " Ueber die Haufigkeit von Gelenke-Erkrankungen bei Heredi- tar. Syphilitischen," Munch, mediz. Wochenschr., 1903. No. 31. 62 Riehl. " Ueber den Einfluss der Behandlung syphiliskranker Mutter auf das Schicksal des Fotus." Wiener klin. Wochenschr., 1901, No. 26. Quot. by Vomer. 63 Huguier. " De la maladie syphilitique sur les femmes enceintes et les nouvelles accouchees," 1841. 64 Fonberg. " Einige statistische Daten uber Syphilis der Schwangeren mit Riicksicht auf Hereditat und Behandlung." Wien. mcd. Wochenschr., 1872, No. 22. 278 THE MEDICAL ASPECTS for the purpose of saving the child from syphilis, during the first two years of the infection, has very little beneficial action. Discouraging facts are furnished by the statistics given by Albers- Schonberg, 65 from his experience in the Frier's Maternity in Leipsig. He reported eight cases of pregnant women in the condylomatous period of syphilis, who from the third to the sixth month of pregnancy had been treated with injections of mercury and potassium iodid. One of them had been infected three or four months before concep- tion, and was treated with mercurial inunctions. Of all, not one babe was born alive, and seven were entirely macerated. The stage of the luetic disease in the mother is considered by Werner 66 as the principal factor responsible for the death of the fetus. Indeed, concerning the prognosis on the result of the preg- nancy, he asserted that the more recent the syphilis is in the mother, the more serious the prospects are for the life of the babe. On the other hand, the less the maternal lues has been treated, the more deleterious influence it has by far on the offspring, as stated by Le Grand. 67 For a conclusive result it is necessary to take under consideration two principal elements, the history of the mother and the observation of the child. The observation of the child must not be limited to the time of the birth, but must be continued during his first year, and probably until puberty. Observations have been taken by Werner amongst the infected prostitutes who are kept under police control, and when pregnant are noted and watched. From the observations of Sperk, 68 it clearly ap- pears that the first year of luetic infection is the most dangerous period for the production of an abortion. In the same way the first year of life is the most dangerous for a tainted child, for when the first year has passed the organism has gained sufficient strength to oppose the deleterious influence of the luetic germs. For this reason, in Hamburg there has been introduced the law that when a syphilitic prostitute leaves the hospital after her delivery, she has to take her babe every two weeks to the police physician for examination. When the child is found sick, it is immediately sent to 65 Albers-Schonberg. " Ueber fotale Syphilis." Munch, med. Wochenshcr., 1890. No. 19. 66 Werner, S. " Ueber die Sterblichkeit und die Haufigkeit der hereditaren Syphilis bei den Kinder der Prostitnirten." Monatshefte f. prakt. Derm., Bd. xxiv, 1897, p. 183. 67 Le Grand. " Syphilis als Ursache von Abortus." These de Paris. Ref. Wien. Med. Wochensch., 1890, No. 34. 6S Sperk. " Theorie der Morbiditats und Mortalitats Statistik und ihre Anwendung zur Untersuchung der Prostituirten und Syphilitischen." Vier- teljahreschr. f. Derm, und Syphilis, 1886. TRANSMISSION OF SYPHILIS TO THE OFFSPRING 279 the hospital. These visits have to be continued for one year, so that the babe for one year remains under medical supervision. This rule has proved to be of great advantage to the babe, which is better taken care of. Although the mother returns to her shameless life, the babe is given to a family or to an institution to be cared for. In case a low prostitute tries by maltreatments to rid herself of her offspring, the babe is taken from her by the police and cared for in a public institu- tion. In fact, when the police physician has seen the babe healthy and well, and two weeks after it comes back very emaciated and seriously sick, or the death certificate is shown, this is already suspicious and may form a subject for inquest. In general the authors who have written on the statistics of the mortality of the offspring of recently infected mothers, admit that it amounts to eighty per cent. It is, however, very difficult to state what is the fate of the twenty per cent, still remaining. It is widely con- ceded that pregnancies amongst prostitutes are not frequent. The young prostitute is soon infected with gonorrhea, which produces endometritis and salpingitis, with occlusion of the abdominal ostium. This conclusion of the prevented conception on account of affection of the tubes, is somewhat preposterous, from the fact that in our hos- pital experience quite often prostitutes from the venereal ward have to be transferred to the obstetrical. Neither is it to be maintained that all prostitutes are syphilitic. Lesser said that every prostitute will be infected with syphilis, especially in the beginning of their career. Wwedensky 69 maintains that most prostitutes are infected with syphilis in the first three years after their registration, and that after five years all are infected. Raff, however, in reference to the statistics of the tertiary syphilis, states that he has found quite a number of puellce in whom neither as far as their history nor their physical condition was concerned, could be found traces of syphilis. In consequence, he says, that the statement that all pros- titutes are syphilitic is hypothetical. They are certainly in continuous danger of infection, but according to our experience in our venereal ward quite a number escape infection, at least for some years. Werner in referring to his interesting statistics taken from the prostitutes in Hamburg, registered 185 mothers with 243 children. Of the 185 mothers, 53 were not syphilitic. Afterwards, while under surveyance, 29 acquired syphilis, and 24 were still free from infection. It must be remarked that mortality among the children of the pros- titutes, although not infected with syphilis, is always rather high, so much so that of 51 children born of non-infected mothers, 29 died. 57 69 Wwedensky. " Syphilis nnter den Prostituirten der St. Petersburger Bordelle." Arch. f. Derm. u. Syph., Bd. 36, Heft 1 und 2, Aug., 1896. 280 THE MEDICAL ASPECTS per cent. ; while of 167 children, the mothers of whom had syphilis, 106, or 63.5 per cent., died. In one set of the statistics of Fournier, of the same number of children, 167, born of syphilitic prostitutes, 145 died, giving a total of 87 per cent. Of 167 children born of mothers who had suffered with syphilis, 90 remained free from hereditary lues, 53.9 per cent., while yy, 46.1 per cent, showed symptoms of congenital syphilis. Of the first 90, 46 died, 51 per cent., while of the last yy, 60 died, 78 per cent. In reference to the influence of an early treatment on the health of the fetus, Werner 70 brings the statistics of 43 mothers, of whom 25 were suffering with syphilis acquired from one to two years before, 9 from three years, 7 had been infected for more than four years, and 4 had the infection for a still longer time. Thirty-four of these women were subjected to treatment during pregnancy. They gave birth to 21 children with symptoms of hereditary lues and 13 were healthy. Of the luetic children after the first year, only 2 were still living, and of the others, 8 still remained. This showed a mortality of 71 per cent, with a morbidity of yy per cent. Vomer 71 reported nine cases of syphilitic women, treated during pregnancy, with the result of four luetic and five healthy children. The disease, however, was not between the first and second year from infection, but in some was of more remote occurrence, which may have had a favorable influence on the health of their babies. Seitz 72 reported his observations of eleven women who had been infected during pregnancy, or in the first part of their pregnancy. Eight had been treated with mercurial inunctions, or with injections with calomel, or peptonate of mercury. Six of them had abortions with macerated fetus, two had living babies, of which one luetic died a short time after birth, the other remained healthy. In twelve more cases of pregnancies in women who had been infected from one to two years before conception, eight had received the same specific treatment ; the result was five still-births with macerated fetus, two living fetuses before full term, and one healthy babe. Taking together the sixteen cases treated, they have given only two healthy babies, showing abor- tions 81 per cent., mortality 73 per cent, and morbidity, 87.5 per cent. Vomer offers statistics of pregnant women who had been infected from one to two years before conception or in the first four months of their pregnancy. During pregnancy all have shown eruptive 70 Fournier, A. " Les families heredo-syphilitiques." Gaz. des Hop., 1892. Quoted by Werner, 1. c. 71 Vomer, H. " Ueber die Vaginale specifische Behandlung schwangerer Frauen." Derm. Zeitschr. Bd. xi, 1904, p. 162. 72 Seitz. " Einige statistische Angaben iiber den Einfluss der Lues auf der Verlauf der Schwangerschaft." Inaug. Dissert. Miinchen, 1898. TRANSMISSION OF SYPHILIS TO THE OFFSPRING 281 symptoms of more or less severity, with the prospects of congenital syphilis for the babe. Every one was subjected to general constitu- tional treatment of from four to six weeks with inunctions of unguent cinereum, or injections with bicyanate of mercury. After the general treatment, Vomer uses the vaginal treatment. The ordinary unguentum cinereum is incorporated with an equal quantity of sebum ovile, so as to give a strength of twelve per cent, and some consistency to make a suppository, which is easily introduced into the vagina and placed in contact with the cervix uteri. The vaginal treatment was used at various periods of the pregnancy, but from the results obtained, it seems that between the fifth and sixth months is the most appropriate time. Vomer produces the records of eleven syphilitic women who had been subjected to a constitutional treatment either by inunctions or by injections before conception, and after a while at the due time of pregnancy, were treated with vaginal mercurial suppositories. Of these women, one had a miscarriage at the end of the second month, another had a macerated fetus at about the end of the eighth month, a third had a babe in a good healthy condition somewhat prema- turely, which at the second month began to show signs of hereditary syphilis, coryza, papules, and four weeks later died. The others were delivered of normally healthy children, without specific signs. In the fourth week one babe showed symptoms of syphilis, and in the fifth week one became sick with pneumonia and died. Another babe, who had never shown signs of lues, died with gastro-enteritis. Two other babies towards the third month showed signs of lues ; both died, one the seventh month with gastro-enteritis, the other at the eighth month with padatrophia. Another died at ten months old with pneumonia ; the babe had never shown signs of syphilis, neither were signs of syphilis found at the autopsy. Eleven children remained alive ; a luetic one who, during the third month had suffered with mucous patches and with pustular eruption. was better, but was lost sight of. A second one, until after the fifth month, had been healthy and was seen no more. A third one showed a papulo-squamous eruption and a specific onychogryphosis. Four showed no sign of lues. The others suffered with some maculo- papular exanthema after the second and the third months. They stood the treatment and all got well. With these statistics Vomer shows that amongst 40 syphilitic women 36 had their delivery at full term, and only 4 had a miscar- riage or a still-birth, which means 10 per cent., and of the 4 two fetuses only showed signs of death from syphilis, which would cut down the rate to 5 per cent. 282 THE MEDICAL ASPECTS These statistics show very encouraging results, when compared with those of other authors. Fournier 73 from his private practice found that in 39 cases only 50 per cent, had reached the full term of pregnancy, and of children born dead, 37, 48 per cent. From his hospital practice, in 167 cases, 79 cases, 47 per cent., were delivered at the full term, and 87 cases, 52 per cent., gave birth to dead children. Mewis 74 in 63 deliveries, calculates 58.7 per cent, at full term, and 2J per cent, still-births. Neumann 75 with 52 cases, shows 62 per cent, did not reach the normal time, and 38 per cent., dead fetuses. Pick 76 and Fonberg 77 in 22 cases, show 50 per cent, premature births and 45 per cent, dead babies. Seitz 7S in 17 cases, reports 20 per cent, pre- mature births, and 67 per cent, babies born dead. This would clearly show the vaginal treatment of syphilitic preg- nant women to be of a great benefit for the babe. In fact, the statistics of Vomer for 36 babies show that in the first three months six died, 22 per cent. Of. the remaining 30, three died between the fourth and fifth month, increasing the mortality to 39 per cent. Two died between the seventh and eighth months, one in the tenth month; the mortality reaching 55 per cent, in the first nine months and 58 per cent, for the first year. It is necessary to note that in those children the cause of death was not always syphilis. In seven cases it was the result of gastro- enteritis ; in three cases syphilis caused the death of the babies as padatrophy ; the other deaths were caused, some by pneumonia and tuberculosis, while one died from furunculosis, and one from the con- sequence of prolonged labor. The time of their mortality was between the second and the fourth months. Only two babies were born dead, showing symptoms of syphilis, whereas the others at their birth were free from syphilitic manifesta- tions. One showed symptoms of lues between the second and the fourth week, while the others had syphilitic symptoms, five in the sec- ond month, eight in the third, four in the fourth, and only one in the eighth month. Most of the babies were affected between the second and the fourth months. The most common of the eruptions was the 73 Fournier, A. " Syphilis et Mariage." 74 Mewis. " Ueber Schwangerschaften, Geburt und Wochenbett Syphil- itischer, nebst Anhang iiber Syphilis congenita." Zeitsschr. f. Geb. u. Gyn., Stutt- gart, 1879. Quot. by Vomer. . 75 Neumann, I. " Klinische Studien zur Lehre von der congenitalen Syphi- lis," Me^d. Jahrb., Wien., 1885. 76 Pick, F. J. " Zur Lehre von der hereditaren Syphilis." Wiener Medicinal Halle. 1863, IV, No. 11 und 12. 77 Fonberg. " Einige statistische Daten iiber Syphilis der Schwangeren mit Riicksicht auf Hereditat und Behandlung." Wiener Med. Wochenschr., 1872, No. 22. 78 Seitz, I c. TRANSMISSION OF SYPHILIS TO THE OFFSPRING 283 papular in ten cases, maculo-papular squamous in character was found five times ; macular syphilide twice. Syphilitic coryza was present four times, three cases showed condylomata lata, and two had psoriasis palmaris and plantaris ; only once was pemphigus found, as was also the case with onychogryphosis and pustular eruption. Twelve children remained entirely free from syphilis, and of them seven died. Comparing the statistics of Fournier, Kassowitz, Werner and others, one sees that the treatment per vaginam of pregnant syphilitic women is of great help to the babe, not only diminishing the mortality, but also the morbidity. In the statistics above men- tioned, it must be considered that the cases were all from prostitutes and illegitimate children. Werner had already pointed out that their mortality is far greater than that of the legitimate babies, although born of non 7 syphilitic mothers. Indeed, the mrwelcome visit of an illegitimate babe to the prostitute is rather troublesome in their calling. In their dissipated life, frequent abuse of alcoholics, excesses in coitus, emotions, pathemata, quarrels, all these together may contribute to cause abortion. After the babe is born, on account of the trouble and of the impediment it is to their calling, it may be greatly neglected, either purposely or not, so that they may get rid of their babe. In our experience we recall with pleasure many cases of syphilitic women who hai^e been subjected to specific treatment during their pregnancy, and have given birth to healthy children. We have already referred on different occasions to several syphilitic couples. As long as they remained without treatment, their pregnancies had as a result, dead babies or babies who died a few days after birth ; while, when they were subjected to a regular treatment, they gave birth to healthy children. Some years ago a gentleman called on us to see what was the trouble from which he was suffering. We found mucous patches of the tonsils and of the lips, with general adenopathy. Our diagnosis was that of secondary syphilis. This surprised our patient a great deal, for the reason that his physician had declared him perfectly cured of syphilis, and on this assurance he got married. We requested him to let us see his wife, who, he had already stated, was not well. The lady had a mild syphilitic roseola, with a few patches of the mucous membrane of the mouth. Both were subjected to gray oil injections, and after a while to mercurial inunctions. A few months afterwards she became pregnant. Treatment was continued intermittently during the whole time of her pregnancy. She was delivered at full term of a male babe, perfectly healthy. After the second month the babe showed a mild maculo- papular eruption, with a mild coryza. The babe was treated with 284 . THE MEDICAL ASPECTS sublimate bath and calomel powders, 1-5 gr. each, twice a day. The symptoms disappeared, the babe was well, and although the mother suffered with suppurated mastitis, and he was deprived of the mother's milk, yet he continued to grow in weight. He is at present a bright boy five years old, healthy and intelligent, and has never shown any symptoms of syphilis since. One year later the mother was in the familyway again, two years and six months after syphilitic infection. When she discovered her condition, she subjected herself to specific treatment, which was intermittently continued until the eighth month of pregnancy. She was delivered at the full term of a healthy male babe, who has never shown any sign of syphilitic taint. The lady died this year with pulmonary tuberculosis. Both children so far are in excellent health. We are at present watching two pregnant ladies, one infected five years ago, who has had four miscarriages, and another infected two years since. Both have received twelve and fifteen injections with gray oil, and potassium iodid. During pregnancy both have used vaginal suppositories of twelve per cent, unguent hydrarg. The first has been a failure, on November 18 having given birth to a dead male babe, well developed, but macerated ; the epidermis was detached in large shreds. The placenta, with yellowish small foci, flabby and ir- regularly developed, showed signs of syphilitic placentitis. The sec- ond, on February, 1905, gave birth to a healthy babe, who so tar has shown no signs of lues. We can conclude this chapter with the assertion that the influence of the treatment of the syphilitic mother on the fetus is wonderful, and that treatment only is the true prophylactic measure which is capable of diminishing the ravages of the saddest inheritance which a careless syphilitic father can give to his unfortunate family. RETARDED HEREDITARY SYPHILIS From several observations mentioned above in reference to syphi- litic taint, possibly transmitted by heredity, paternal, maternal, or even both, it is plain that a babe born perfectly healthy may grow steadily and remain in good health until at a certain age it shows signs of syphilitic infection. This is what has been called syphilis hereditaria tarda, which may become manifest at any age from the fifth to the twentieth, or even thirtieth year of life. It was formerly a belief that syphilis was manifest at birth or a few weeks later, but this idea has been easily dispelled by the current observations of the manifestations of syphilis delayed not only for months, but even for years. Some authors believe that retarded syphilis, when showing TRANSMISSION OF SYPHILIS TO THE OFFSPRING 285 symptoms at a late period, is nothing else than a reproduction of mild symptoms which very likely had passed unobserved during infancy. Sturgis 79 does not believe that syphilis can remain latent for so long a period of years without showing symptoms during the earlier period of the child's life. The periods of life in which syphilis has the great- est tendency to show its presence in the tainted organism are at birth, at the time of puberty, and at the close of middle life. He believes, and it is possible, that when retarded syphilis makes its appearance at puberty, mild symptoms have existed in early infancy in the apparently healthy babe, but have escaped attention, or have been attributed to other causes. These symptoms after their disappearance leave no trace behind, and thus when the child later on in life presents indubit- able symptoms of hereditary syphilitic infection, they are considered as the first manifestations. Indeed, the long latency and the long intermission are difficult to explain, unless by admitting that the virus at the time of the nisus formativus was stored in some of the developing organs, where it has remained as a potentiality for many years, until it has found a way to show the deleterious influence in an organic system, or in some organ, or rather in some part of one. Symptoms of retarded syphilis belong to the tertiary kind ; they show a tendency to infiltration and proliferation in the affected tissues. They occur in tainted persons, and the influence of a specific treatment in the earlier period of life seems to have no special effect. It is interesting to note that there is some disproportion between the sexes in the later forms of manifestations of inherited syphilis. Hutchinson 80 collected a series of cases of late syphilis in which it appears that in 23 cases of infantile iritis, 18 were females, and in 102 cases of keratitis, 64 were in females. In the same way, of 21 cases of deafness, 15 were females. This gives a proportion of two to one, being 97 females and 47 males. Hutchinson explains these results by the fact that male infants affected with congenital syphilis are more prone to die than females, who seem better able to resist the action of the virus. It is an established fact that those who have inherited syphilis are liable to be affected with a peculiar form of inflammation of the cornea. The old ophthalmic surgeons had described a form of scrofulous corneitis which affects both eyes, which is of transitory duration and usually leaves no stains. It is a peculiar form of inter- stitial keratitis, which, according to Hutchinson, is a proof that the patient is tainted with inherited syphilis. He considers this chronic 79 Sturgis, F. R. " A System of Gen. Urin. Dis." 1893, p. 633. 80 Hutchinson, J. Twentieth Century Practice. Vol. xviii, p. 382. 286 THE MEDICAL ASPECTS affection of the cornea as a revealing symptom of the later stages of inherited syphilis. Interstitial keratitis is not a secondary affection of infancy, but occurs at the time of adolescence or even in adult life, alone or pre- ceded by troubles in the joints as a characteristic sign of inherited taint. The persons affected have enjoyed good health, have never shown any suspicious symptoms of inherited syphilis, and all at once have had their eyes become inflamed. It lasts for a few months, then disappears without any tendency to relapse. Individuals affected with this disease may show some peculiar malformation or bad implantation, especially of the upper incisor teeth ; a malformation of the teeth which has been so well described by Hutch- inson and is generally known as Hutchinson's teeth. It consists in single vertical notches at the edge of the teeth, which constitute an evidence of atrophy of the middle tentacle, and as a consequence the tooth shrinks and remains narrow and also somewhat. short. In some other cases the teeth have a normal shape, the enamel, however, at the edge of the incisors is so damaged that it has taken on a rough, chalky appearance. These conditions of the teeth are at times so pro- nounced as to leave no doubt of the existence of syphilitic taint, while at other times they give only a suspicion, which needs corroboration. Interstitial keratitis of inherited syphilis begins with an irritability of the eyes, which causes them to water, and the corneae show small whitish patches, or small cloudy points. These gradually increase in size and spread until the whole cornea has acquired a partial opacity, recalling the opacity of ground glass. Congestion of the ciliary region takes place, and the conjunctiva, which to a certain extent is involved, shows a marked contrast with the condition of the cornea. In the early stages, on the margin of the corneal surface, there may be found small crescentic patches of congestion, which recall the tint of the salmon. These may gradually spread over the whole cornea, giving it a deep brownish purple color. This condition of the cornea forms a marked contrast with the comparatively pale conjunctiva which sur- rounds it. Pronounced photophobia accompanies the disease when at its height, so much so that the patient is nearly blind. The symptoms, however, begin to subside and the inflammatory phenomena decline; this is considered the third stage of the disease, the stage of reparation. It is a splendid illustration of the power of reparation, because a cornea which was entirely opaque and which would have given very little hope of restoration, may gradually clear up and be restored to its normal transparency. This process of reabsorption of the effused elements of the cornea may be complete in a few months, or may even require years. Hutchinson has recorded only two cases of interstitial TRANSMISSION OF SYPHILIS TO THE OFFSPRING 287 keratitis where the cornea remained opaque, which he considers of rather rare occurrence. Complications on the part of the deep structure, such as the iris, choroid and retina may occur during the evolution of the keratitis, but only very rarely. The cornea alone suffers. If iritis occurs it is usually in a mild degree, and when the cornea is restored to its trans- parency, no impairment of the visual functions is left. This peculiar condition shows a great contrast with an iritis of secondary acquired syphilis, where the pupil is affected at an early period. In some cases of retarded syphilis there has been observed a con- dition of the retina closely resembling retinitis pigmentosa, and also an affection of the choroid, resembling choroiditis disseminata. Un- fortunately, these affections are rarely observed in their beginning, and when the patients ask for medical attendance, they are already beyond control. In this respect they are to be considered very in- sidious. It has been maintained by some authorities that keratitis is only a secondary affection arising from the choroidal disease. When the presence of choroidal changes can be detected, this is of valuable aid in the diagnosis. Deafness. — From the statistics of aural hospitals, it is clear that hereditary syphilis is greatly responsible for a large number of cases of deafness in young adults, which, if left to themselves, will become irremediable. Usually the affection is not limited to one ear, but both are affected. The affection does not come early like a form of a sec- ondary nature, but it makes its appearance late in life and may be compared with parenchymatous keratitis. In some cases, deafness begins with, or accompanies, or even follows an attack of keratitis. Its onset is rapid and insidious, because it is not attended by other symptoms, as no pain is present, only a slight dizziness. Loss of hearing is the dominant symptom, which so rapidly advances as to diminish considerably or even completely impair the sense of hearing. This condition is due to anatomo-pathological changes in the labyrinth, which have already been described by Toynbee, 81 Schwartze, 82 Vol- tolini, 83 Moos, 84 and Politzer. 85 In their dissections they have found results of infiltration and of a chronic inflammatory process in the delicate periosteal membrane between the bone and the nerve structure of the labyrinth. In the semi-circular canals they have also found small cell infiltration and an adhesion to the periosteum. One of the characteristic symptoms of syphilitic affection of the internal ear is the very rapid onset, which sometimes comes in one night, and the 81 Toynbee. " Toynbee's Catalogue." No. 512. S2 Schwartze. Archiv fur Ohrenheilk., iv, p. 266. 83 Voltolini. Virchow's Archiv, vol. xviii. 84 Moos. Virchow's Archiv, vol. xix. 85 Politzer. Archiv f. Ohrenheilk., xiv. 288 THE MEDICAL ASPECTS accompanying vertigo. The deafness becomes nearly complete, so that the patient cannot hear a watch, voice or tuning-fork. In the begin- ning the bone conduction is diminished on one side more than on the other, and in this case the tuning-fork placed on the forehead is better heard in the better ear. There concurs, together with the symptoms above referred to, the loss of the acoustic perception of the higher notes, which in the begin- ning are heard as false or doubled. Roosa S6 has called this condition syphilitic cochlitis, because it is in this organ that the nerve fibers receive the impression of the musical sounds. In general we can say with Green 87 that it is difficult to localize the syphilitic affection in the cochlea alone, and on the dissecting table it has been found that the alterations were not limited to the cochlea, but that they involved the membranous vestibule, and the semicircular canals, thus the affection is better expressed by the name of syphilitic labyrinthitis. Brain. — In reference to retarded syphilitic manifestations of the brain, Ashby 88 referred to Jacksonian epilepsy as one of the earliest symptoms of syphilitic brain affection in retarded hereditarv syphilis, which usually occurs during the second year of life. The convulsions begin in one hand and become general after a while, and with their recurrence, increase in severity and in frequency. The affected arm becomes paretic and remains contracted. The same occurs in the leg of the opposite side, which remains paralyzed and contracted. The child gradually loses his intelligence and may lapse into idiocy. In some cases retarded syphilis is revealed as laryngismus, or spasmus glottidis. Ashby in the post-mortem of these cases found an extended softening of the brain from a different endoarteritis ; in some cases thick gelatinous masses were found at the base and in the convexity of the brain, limited in foci, and especially in the Fissura Sylvii sclerotic patches were present. It is to be remarked that there are cases of eclamptic fits associated with partial loss of consciousness, where their relation of syphilis is somewhat obscure. Indeed, in the autopsy of children who have died in an attack of convulsions, there have been found no alterations in the brain or in other organs. This led Dornbliith to the idea that the toxin of syphilis in the first two years of life is liable to produce attacks of eclampsia and of epilepsy, as well as different forms of mania, without showing material lesions of the brain. Ashby, however, doubts a great deal whether many of these cases are to be attributed to syphilis, 86 Roosa. Trans, et Intern. Otolog. Congress. 1876. 87 Green. J. O. " Syphilis of the Ear."' " A System of Gen. Urin. Dis.," etc., 1903. 88 Ashbv, H. " Gehirnerscheinungen bei congenitaler Syphilis" Edinburgh Congress, 1898. Ref. Derm. Zeitschr., Bd. v, 1898, p. 884. TRANSMISSION OF SYPHILIS TO THE OFFSPRING 289 and he denies the relation between syphilis and the meningitis posterior simplex of the brain, either acute or chronic, and he believes with Still that it is the result of a special micro-organism. Syphilis as an hereditary taint is not always the cause of ordinary infantile hemiplegia. Osier, in 180 cases of hemiplegia, claims only in one hereditary syphilis, while Hadden in 25 cases found 2 to be positively attributable to syphilis, and 11 with great probability. It must be considered that in the moment of the convulsions, a hemor- rhage may take place, which causes hemiplegia. We do not believe that all cases of convulsions are attributable to syphilitic taint, but when there is no other cause present, and when we see that the admin- istration of potassium iodid has a beneficial effect on the recurrence of the attacks, we have good grounds to believe them to be the result of syphilis. We can repeat the same remarks in relation to chronic hydrocephalus, which in many cases may be the result of other causes, but in some cases is without doubt produced by retarded hereditary syphilis. A little girl four years old presented a hydrocephalic head, and was at the same time somewhat queer in her actions. The general health was good, and the parents thought their child to be the picture of health. The mother, a young woman, had always been in good health. The father, an old man, advanced in the sixties, strong, claim- ing to have been always in good health, came to be treated for leg ulcers, which no physician had ever been able to cure. The ulcers were multiple, round, decidedly infiltrated, one of them involved the periosteum ; they were nothing else than ulcerated gummata. The application of emplastrum hydrargyri and the administration of potassium iodid brought the leg ulcers to a speedy recovery. This was for us a clear explanation of the hydrocephalus in his daughter. At the time of puberty paresis of the upper and lower extremities may occur, which is accompanied with eclamptic or choreiform motions, gradually the intelligence is blurred and idiocy is the end. In these cases syphilis is the cause, which may have shown in a mild form in infancy, or it may have left traces, such as notchy teeth, altera- tions in the shape of the nose, choroiditis, deafness, etc. In those cases the anatomo-pathologic lesions are those of a chronic meningo- encephalitis, with atrophy of the brain. There has been found a thick- ening of the dura, and sometimes a thickening and hardening of the bones of the skull, with constant and marked signs of syphilitic endarteritis. T. Telfort-Smith 89 referred to the relation of idiocy to syphilis, 89 " Die Discussion iiber congenitale Syphilis auf dem Edinburger Kongress." Ref. Derm. Zeitschr., Bd. v, p. 887. 290 THE MEDICAL ASPECTS and he believes that congenital idiocy is to be referred to syphilis, although no history and no signs would show its presence. The altera- tions induced by syphilis in the nervous system are sufficient explana- tion for the production of idiocy, and indeed we cannot consider any other cause so powerful for the destruction of the noblest of the human organs. We agree with J. Hutchinson, Jr., in his views that we cannot always find sure signs of syphilis. Indeed, the dystrophy of the teeth, the presence of interstitial keratitis, the attacks of osteo- arthritis, etc., which show positively the presence of hereditary syphilis, are missing in fifty per cent, of all cases of hereditary lues. In the other half we must suspect syphilis, which we recognize as the chief factor of degenerative processes of all anatomical systems. In heredi- tary syphilis it happens, as in acquired, that secondary symptoms are not observed at all, or at least are so mild as to escape detection, and then tertiary symptoms set in as deep proliferating and ulcerative forms. Very likely in some cases of hereditary lues, as we have al- ready mentioned, mild secondary symptoms have escaped the attention, and then late in life have reappeared as degenerative forms of the nervous system. Skin. — In retarded hereditary syphilis it is questionable whether we will find ulcerative processes of the skin, such as those which in bygone times were classed together with lupus, and diagnosed as lupus serpiginosus. We recollect the discussions about lupus scrofulosus and lupus syphiliticus, which to-day have been thoroughly settled and the diseases have been classed in their own nosological groups. We agree with Jonathan Hutchinson 90 that ulcerated gummata represent- ing lupus are more apt to occur in late acquired syphilis, rather than in retarded hereditary lues. In a case referred to by him, where mother and daughter were suffering with syphilis, the daughter ten years old had serpiginous ulcerations on her back. Although it looked like a case of inherited syphilis, yet he was able to ascertain that the girl had been infected in her infancy. He referred to a case reported by Bulkley, of a girl twenty-three years old, with notched teeth and with a well-marked history of hereditary syphilis, affected with ulcerated gummata of one of her arms, which had always been regarded as lupus. Specific treatment brought the affection to recovery, and it stood as a case of syphilitic ulcerated gummata from retarded heredi- tary syphilis. Phagedenic ulcers of the skin which are allied somewhat to lupus, are not infrequently found in tainted individuals. Hutchinson refers to rapid and destructive forms of ulceration, which are not attended 90 Hutchinson, J. " Inherited Syphilis." Twentieth Cent. Pract., vol. xviii, p. 386. TRANSMISSION OF SYPHILIS TO THE OFFSPRING 291 by precedent infiltration or by the formation of tubercles. These phagedenic forms of ulceration occur on the face or in the throat, usually in children approaching the adolescent age. He describes these ulcers as of slow course, with ragged edges, as if they had been gnawed and undermined. The process is sufficiently rapid to destroy the soft palate and a part of the nose in a few months. When well treated and once healed up it never recurs. Hutchin- son referred to a case recorded by Percy Kidd, where a syphilitic ulceration due to inherited taint involved the larynx in a boy at the age of fourteen. He referred to another case presented by R. W. Parkes before the Pathological Society of London, in a boy of fifteen with nodes in his tibiae, who showed consequent stenosis of the bronchi and died with lung disease. To confirm his views, Hutchinson referred to another case of phagedenic ulcer from inherited syphilis, which was recorded by Harris and Simpson of Manchester. In a boy of fourteen, in whom the soft palate had been destroyed some years before, a process of phagedenic ulcer attacked his tongue in the middle, spreading towards the periphery and destroying nearly the whole of the organ. The boy showed no other indications of inherited syphilis, but his brother had the characteristic marks. In our experience we have seen phagedenic ulcers of the genitals, extending to the anus, in young prostitutes in the venereal wards of City Hospital. In some there were nodes of the tibiae, and unmistakable signs of inherited syphilis. In our case the phagedenic ulcer had affected the labia majora and minora, and had extended towards the pubis and the fossa crurogenitalis. In another case the ulcerative destruction had affected the perineum and the anus. The surface of the ulcers was covered with flabby, pale granulations which have never shown a tendency to heal up. In our cases it is difficult to say whether the phagedenic ulcer was the result of inherited syphilis mixed with tubercular diathesis, or whether it was the result of inherited syphilis with a new infection of acquired syphilis, syphilis binaria. One of our cases died with tubercular peritonitis. The peritoneum was found studded with tubercles. Another one, a colored girl, was very low with parenchymatous nephritis and the relatives took her away from the ward to their home. We have had no opportunity to see phagedenic ulcers of this kind of the face and throat from inherited syphilis. However, in our cases of phagedenic ulcers, the best results we have obtained have been from the local application of emplastrum hydrargyr. or dusting with iodoform, or bathing with bichlorid 1 per 1000 solution, and from the internal use of iodides. 292 THE MEDICAL ASPECTS Tongue. — Hutchinson referred to a case of gumma of the tongue, which had affected a woman of thirty-one, who had suffered with interstitial keratitis in her adolescence. In the family there was his- tory of syphilis. The gumma disappeared under the application of the iodides. It is about the only case of gumma of the tongue recorded as the result of inherited syphilis. We cannot add to this subject any personal observation, as we have seen gumma of the tongue only in cases of acquired syphilis. In speaking of the tongue, we find it wrong to attribute to in- herited syphilis that peculiar appearance of whitish rings on the tongues of children or boys, which was called ring-worm tongue, or better, geographic tongue. Parrot claimed this condition of the tongue to be due to specific origin. In our experience, we share the opinion of Hutchinson, that this affection is met with in other forms quite independent of syphilitic taint. We have met with cases of children and of adults showing whitish rings on the tongue, and we confess that they are rather suspicious signs of inherited syphilis. When, however, no precedents of syphilitic diathesis, or history of this disease in the family, are present, we will find this condition of the tongue to be produced by other causes. In one of our cases, a young lady of twenty-four, came to consult us for an enlargement of the sublingual glands. Our attention was called to her tongue, which showed rings covering the edges from the middle of the dorsum linguae to the apex. The rings were formed by edges somewhat elevated, whitish in color, and the mucosa comprehended in the ring was somewhat red, smooth and depressed. At first the case gave us the impression of a syphilitic tongue from inherited syphilis. Yet on studying more carefully the whole condition, we established our diagnosis of lupus erythematosus lingua. By repeated touching with pure lysol, the rings disappeared, the mucous membrane healed, and now there remain only whitish superficial scars in the center where the rings had been. The swell- ings of the sublingual glands have entirely disappeared. Bones. — We have already mentioned the frequency of late affec- tions of the bones and joints arising from hereditary syphilitic diathesis. The average of these diseases, according to Fournier and Hochsinger, would reach a total of forty per cent. It occurs in the form of periostitis with a tendency to produce roughness and hardness of the bones, especially on the tibiae. It is only rarely found on the bones forming the skull, and in the other long bones. This kind of periostitis while in progress is accompanied by much aching, but not by severe nocturnal pain. In some cases, fortunately rare, suppuration may be the result, accompanied by exfoliation of the superficial layers of the bone. TRANSMISSION OF SYPHILIS TO THE OFFSPRING 293 Hutchinson 91 refers to cases of atrophy of the long bones, as the result of chronic osteitis, which leads to great thickening of the affected bone with the production of a saber-shaped tibia, and after a while a condition of atrophy may follow. From skiagraphs taken from a syphilitic boy who had suffered fracture of the forearm, the radius showed itself to be greatly attenuated in its shaft and somewhat shorter than the ulna. There have been found affections of the bones in children with retarded hereditary syphilis which bear great resemblance to osteitis deformans on account of the thickening and distortion of the affected bones. Some of these cases of osteitis affect the epiphyses, as osteochondritis, causing immobility of the joint, a condition which was designated by Parrot as pseudoparalysis. It has nothing to do with the nervous system, but it is a local osteocondritis, which if not treated in time, may cause the destruction of the cartilages with irreparable damage of the joints. Quite often multiple affections of the joints are found as the result of hereditary syphilis in the form of an effu- sion in the serous membrane of the joints. Hydrarthrosis of both knees in adolescents is clearly a good example. Affections of the joints and bones of the spine, spondylitis, have been reported by Ridlon. Affections of bones and joints as results of retarded inherited syphilis are found in childhood and adolescence, but they are not met with after the twentieth year of life. Testes. — In acquired syphilis, gumma of the testis is a rather com- mon and well-marked form of lues, which may occur at various periods after the first onset of constitutional symptoms. In inherited syphilis, gumma of the testis may be found in the first few years of life. Henoch 92 referred to cases where the testicle was enlarged and hard, but painless. The infiltration occurs in the testis without involving the epididymus. In seven cases, four showed lesions of both testicles, and in three, only one was affected. It was found in children rang- ing in age between three months and two and one-half years. The infiltrating process commences around the arterioles of the testis, pro- ducing a cell formation and a general infiltration of the organ. The infiltration causes a pressure on the seminiferous tubules, which in con- sequence are strangulated and converted into a hard fibrous mass. When the infiltration is reabsorbed, the testicle remains in an atrophic condition. Fournier has noted several cases of atrophic condition of the testicle from inherited syphilis, some of which he referred to sclerotic atrophy, the consequence of infiltrated gumma, others to an arrest of development of the glands, which remain undeveloped as in infants. 91 Hutchinson, J., /. c, p. 389. 92 Henoch. Deutsche Zeitsch. f. prakt. Med., 1877. 294 THE MEDICAL ASPECTS Arrest in the development of the generative organs has been observed quite frequently in connection with inherited syphilis, not only in the male, but also in the female. It has been found in the post- mortem of a case of this kind that the uterus and appendages were scarcely one-half of their normal size. Lymphatics and glands. — In our experience in all cases of heredi- tary syphilis in babies and children, the superficial glands of the cer- vical region, of the axillae and of the groins are felt under the exploring fingers as hard kernels. In some cases when the child improves and gets over the luetic condition, the glands are always found to be smaller. In some other cases they remain in the same condition of hardness, although the general health is good. In a family where the father has suffered a stroke of hemiplegia, the mother has had gum- mata, and in the beginning of their married life she had several abor- tions and still-born babies ; four girls born later, although small and very delicate, have never shown signs of syphilis. The lymphatic glands, however, have always been hard and perceptible as kernels under the exploring finger. We have charge of them as family physi- cian, and we often have occasion to see those girls, and a superficial examination of the cervical region reveals the same condition of the lymphatic glands. Sturgis 93 referred to the observations of Lam- auve 94 who remarked in children affected with congenital syphilis an engorgement of the lymphatics. He quotes Bertin 95 who described inguinal lymphangitis in children affected with inherited syphilis, when no other symptoms were present. The glands, hard and swollen, resembled scrofulous engorgement. Enlargement and swelling of lymphatic glands of the bronchi in a syphilitic child were found by Hutchinson. 96 Enlargement of the mesenteric glands were found by von Barensprung. 97 Enlargement of inguinal, prevertebral and medi- astinal glands were also found and described by Casati, Campana, Lancereaux, Rivington, and others. In all these cases the hyper- trophied glands had a grayish and yellow-white appearance, and under the microscope showed a thick cell infiltration, with some hypertrophy of their connective tissues. In no case was it found that a gland under- went suppuration. To the affected condition of the lymph-glands, and to the ravages in the spleen from congenital syphilis, we attribute the relatively 93 Sturgis, F. R. " Hereditary Syphilis." " A System of Gen. Urin." etc., vol. ii. p. 645. 94 Lamauve. " Traite des Maladies Syphilitiques des femmes en couche et des nouveau nes," 1804. 95 Bertin. "Traite des Maladies Veneriennes chez les nouveau nes," 1810. 90 Hutchinson, J. Medical J~imes and Gazette, 1858. 97 Von Barensprung. " Die hereditare Syphilis," i860. TRANSMISSION OF SYPHILIS TO THE OFFSPRING 295 frequent occurrence of pseudoleukemia in heredosyphilitic children. One case came under our service in the Hospital, and we report it here on account of its interest : A boy of fourteen, whose mother died of stomach trouble, whose father was still suffering with ulcerated gummata of the legs, was brought to the institution by the police. He was complaining of pains in the legs, and was assigned by the visiting physician to Ward C as a syphilitic under our service. The boy, poorly developed, was greatly emaciated, his skin pale and of a sallow color, his mucous mem- branes nearly white. He complained of pains of both tibiae. The legs were swollen and edematous, the periosteum of the anterior portion of the tibia was infiltrated and tender to the touch. The lymph-glands of the whole body were enlarged, and those of the neck and groins could not only be felt by the exploring hand, but were visible to the eye. The spleen was enlarged and protruding under the ribs over five inches in the left hypochondrium. The urine was acid, specific gravity 1010, no albumin and no casts present. The examination of the blood gave the following result : September 16, 1903, a few days after admission, Reds 4,025,000 Whites : . . . 15400 Hemoglobin 80% Differential count of the whites, Small lymphocytes 94% Large lymphocytes 3% Polymorphonuclears 3% No eosinophiles. The reds showed nothing abnormal. Diagnosis was pseudoleukemia from congenital lues. He began his treatment with liquor VanSwieten, but after some days his condition being unchanged we gave gray oil injections, of five drops each, one every three days, and internally a saturated solu- tion of potassium iodid. The treatment was discontinued on account of stomatitis. The glands continued to increase. Then we resorted to the solution of Potass. Arsenit., which did not produce any im- provement. A second blood count gave October 10th, Reds 2,768.000 Whites 6.600 Hemoglobin 60% 296 THE MEDICAL ASPECTS Differential count of the whites, Small lymphocytes 87% Large " 6% Polymorphonuclears 7% No eosinophiles. The reds showed characteristics of secondary anemia. The patient began to have fever of a remittent type, and for better attention and comfort was transferred to the medical service. Another blood examination November 10th gave, Reds 1 ,976,000 Whites 17,800 Hemoglobin 30% Differential count, Small lymphocytes 85% Large lymphocytes 10.6% Polymorphonuclears 3-3% The patient was constantly growing worse, and the relatives took him home. The history of the case shows that the alterations of the lymph- glands wrought by congenital syphilis are of a permanent nature, which, together with an altered condition of the spleen, often are the determining cause of leukemia. A boy in a private family died with leukemia. He was attended by a colleague, who took all possible care of him. Nobody had ever suspected the possibility of syphilis in the family. Some years after the father came to consult us for ulcers of the legs. They were ulcerated gummata, which under the mixed treatment and the local mercurial applications soon healed. Then we recalled the death of his son from leukemia, and we found the clew to explain the cause of the disease. In some cases, retarded inherited syphilis may lead to arrest of growth, and the patient remains a dwarf. It is assumed that in these cases the pituitary body has been the seat of the luetic attack. In reference to the question of the persistence of syphilitic taint in individuals who have received from their parents such a bad heritage, it is difficult to state any definite limit. Hutchinson referred to a case which was recorded by Hawthorne of a syphilitic family in which the eldest born, a female, was healthy in her infancy. At the age of twenty-three she suffered with keratitis. Her teeth were notchy and characteristic of inherited lues. Three pregnancies followed of which one resulted in a miscarriage, the others in the birth of two children, TRANSMISSION OF SYPHILIS TO THE OFFSPRING 297 both of whom died of acute hydrocephalus. A fifth pregnancy pro- duced a boy who at the age of eighteen had characteristic notchy teeth, enlarged spleen and hemoglobinuria. From a sixth pregnancy a boy was born one year younger than the last one, who up to the age of seventeen remained in good health, robust and free from all evidences of taint. After this a stillborn male was produced. It is very difficult to explain how the syphilitic germ attacks one babe more than another ; respects one, and the next is killed or receives such deep lesions that it dies a short time afterwards. It is possible that the taint persisted in the mother's ovaries for the long period of seven years. It is also possible that the father received a second in- fection, which might be assumed from the saltatory way of transmission of lues in the children. From Hutchinson we take another interesting narrative in refer- ence to a syphilitic family, which was published by Dr. Routh, of Manchester. The mother had never ailed in any way, the father had shown no symptoms of syphilis since his marriage. After two still- births a child was born who in infancy showed symptoms of congenital lues, which under mercurial treatment subsided. At the age of nine the child had an enormous spleen and a nodular liver, with enlarge- ment of the glands, but no stigmata of syphilis. Specific treatment did not relieve the condition of her spleen and liver. The next child, two years younger, had infantile syphilitic manifestations, for which she was treated. At the age of seven she had the characteristic notchy teeth and rickets. A third child suffered slightly in his infancy, re- ceived no treatment, but at the age of two developed hemiplegia of the right side. Two children born somewhat later on were perfectly healthy and remained so. This is another illustration of the irregularity which we observe in the transmission of the hereditary luetic taint. More remarkable is the absolute freedom from symptoms of both parents, notwith- standing the persistence in the transmission of the taint. In all cases, however, we can clearly see the gradual dying out of the taint, although the patients have neglected treatment. LATENCY OF INHERITED SYPHILIS With all our best means for diagnostic purposes we can say that cases where syphilis has been inherited may pass entirely unob- served. We are greatly indebted to Hutchinson for calling the atten- tion of the practitioners to the malformation of the teeth and to the parenchymatous keratitis, which have revealed many cases where syph- ilis would never have been suspected. On the other side, we know that the notchy teeth and the keratitis will be found in only fifty per 298 THE MEDICAL ASPECTS cent, of the cases of inherited syphilis, while other cases with clear manifestations will not show any sign in the teeth. This leads us to believe that a certain number of persons may have received the syph- ilitic taint by inheritance, but no specific occurrences have revealed its existence. We have already mentioned the opinion of our esteemed teacher, Sigmund v. Ilanor, who used to say that if syphilitic taint exists in one individual, if it does not show in his infancy, it will show in his adolescence or in his youth or still later, but the moment will come when he will show symptoms, or the effects of the dele- terious action of the lues. We can scarcely believe it possible that, when a child is born with syphilitic taint and shows no symptoms in infancy, there is any probability he will show any in later life. Hutch- inson stated that phenomena of tertiary lues are presumably for the most part recrudescences of what occurred in the secondary stage. We have, however, seen many cases where no secondary symptoms have occurred, and yet the tainted person has suffered severe symp- toms of a tertiary nature. In the tainted individual, besides the malformation of the teeth, there are always some features which give a characteristic physiog- nomy, such as a sunken nose, prominent forehead, prominent parietal eminences, detached auriculas, etc. These conditions, however, will only suggest the transmission of syphilis by heredity, but they will not be considered as convincing proof. An infant may have circulating in his system the virus of syphilis and yet show no symptoms. This has been unfortunately proved in the cases of inoculation of syphilis by vaccination, where a skillful physician had selected the infant as vaccinifer because it exhibited all the signs of perfect and vigorous health. In 1874 Hutchinson pub- lished a series of cases of the kind. One child had been selected as vaccinifer at a station as a specially healthy child. This conveyed syphilis to sixteen other children, and yet the first child remained apparently healthy. After the most minute and careful search there was found at the anus a small doubtful condyloma as the only visible symptoms of syphilitic infection. The presence of the syphilitic virus in the system does not neces- sarily arrest the growth of the child, or show upon the skin and mucous membranes. We have remarked, in treating of acquired syph- ilis, that many times persons infected go through the primary and secondary stage while retaining the appearance of good health, so much so that syphilis may pass unobserved. The same may occur in inherited syphilis. Here, however, we have the parental history, and also the syphilitic manifestations in other brothers or sisters, which may come to our assistance and confirm our suspicions. TRANSMISSION OF SYPHILIS TO THE OFFSPRING 299 In some cases it may happen that we find amongst several brothers and sisters some showing symptoms of inherited lues, and others who have not shown and who do not show any manifestations whatever. It will be rather difficult to assume non-inheritance in those children, and we will consider them as only apparently free. The developing organism of the child tainted with lues gradually loses by its rapid metabolism the specific poison, so that a child having passed the dangerous period of infancy and entering adolescence, does not show other symptoms and regains good health. Children are usually treated w T hen showing secondary syphilitic manifestations, and as soon as they are over, treatment is dropped. Their recovery is therefore to be attributed rather to the rapidity of the metabolism, which frees the system from the syphilitic poison, than to the treatment applied. Inherited taint, however, may have some peculiar effect in the develop- ment of the anatomical systems, and especially the nervous system, which is revealed by true neuroses or by some difficulties in the edu- cation of the adolescent, or by some perverted tendencies. It is possible that no symptoms of lues will reveal its presence, that the germs will be eliminated, but its influence in the blood vessels has already produced faults or stigmata in the neuron, which will be revealed later on by moral extravagances, or by moral deformities, as we will see in the following chapters. SYPHILIS OF THE THIRD GENERATION The babe when it makes its appearance in this world must not be considered as an isolated being, but is a link of a long chain, the first link of which has been lost in the past. He carries with him all the peculiar characteristics, aptitudes, dispositions, impressions and tendencies which came to him from an atavistic influence, which he will after a while transmit to his descendants. When the offspring springs from a healthy and strong parentage, he will be strong and endowed with the characteristics of strength and health transmitted to him. But when the hereditary blemish of syphilitic infection is transmitted to him, quite often the most noble of all the systems, the nervous system, is affected in its organization, and sooner or later it will be revealed in the form of neuroses, or of some unnatural and extravagant defects of the mind, which make them belong to the class of " cranks," or degenerates. In consequence of hereditary syphilis we find some anomalies of development, or some peculiar marks, which in many cases can scarcely be considered as true pathological conditions, and are called dystrophias, which in most of the cases produce alterations of the 300 THE MEDICAL ASPECTS organs with impairment in their function. Whether certain defects shall prove injurious or not to the organism is determined: in some cases at the time of birth ; in others, during the development ; and in others, late in life. Under the influence of hereditary syphilis, on account of the defects produced in the vascular sphere, an organ, structure or function may be lacking or excessive. Embryonic poten- tialities are easily influenced by the developing syphilitic germ which affects organs and tissues, sometimes with a deviation of formation of essential elements resulting in monstrosities. The anomalies of development may be revealed in the affection of the different organs, as in the delicate structure of the brain. These variations may be found affecting the nervous system in its anatomical structure, and produce a true disease or a regress of the individual in the direction of degeneracy. In these cases the development of the neuron takes on successive changes, analogous to those found in adult fish, frogs, birds, etc. There is an increasing complexity of the cell but no formation of rudimentary parts, in consequence there is an arrest in the development of the neuron. The imperfect development of the neuron implies an imperfect power of association, and as a conse- quence an impaired facility for education. The peculiar anatomo-pathological alterations produced by syphilis in the tunics of the young, newly forming blood vessels, are sufficient to explain, at the period of formative stress, on account of the lack of nutrition the imperfect development of the delicate neuron. In the transmission of syphilis it may happen that the recently known spirochaetae, the cause of this disease, may attack the cerebral organs and act as factors of epilepsy in the sense maintained by Weisman. 98 In other cases, the malformation of the cells of the brain will be the cause of idiocy, or of other serious psycoses. At times it is revealed in the somatic development of different organs, and we find defective development of the urogenital system, deformities of the face, skull, irregular growth of the teeth, misshapen ears and limbs. These anomalies are sometimes associated with perversions of the mind, and in many cases the affected persons show unmistakable signs of syphilis. It is easy to understand that the nervous system has its part in the disorders of general development, since individuals who present deformities have also decided disorders of the nervous system. The inebriety in the father may have some influence in the de- veloping offspring, who may have neuroses of different kinds, but we have also histories of healthy children in spite of the drinking habits of the father. According to our observations, inherited syphilis must 98 Weisman. " Essays on Heredity." Oxford, 1889. TRANSMISSION OF SYPHILIS TO THE OFFSPRING 301 be held accountable as the cause of the malformations and of the neuroses of the descendants. J. Hutchinson " in his wide experience with syphilitic families, is somewhat reticent in the matter of affirming that inherited syphilitic taint may be transmitted to the offspring. He finds that this point may have some support if we keep in mind the long persistence of the possibility of transmission by mothers. Another difficulty is that one or the other parent of the third generation infant may have had syphilis in acquired form. It is rather a complicated question and practically it is very difficult to follow the history of three generations, when it is a hard matter to find out the history of a single patient. Furthermore, the individual of the third generation must be followed, because some dystrophias are apparent at the time of the birth, but other conditions like the azoospermia, the rudimentary uterus, the hystero-epilepsia, the sexual perversions, cannot be found out other than at the time of puberty. In the preceding chapter we have seen that in children born of syphilitic parents there is found a certain immunity, which, however, is only limited to the first period of life. We have referred to some cases of our own practice tending to show that individuals with un- mistakable signs of hereditary syphilis are again infected with the disease, forming that which Tarnowski calls syphilis binaria, a sort of double syphilis, one inherited and the other acquired. This double infection has indeed a deteriorating influence on the whole system, which is revealed in the infected person and in his descendants, causing degeneration of the race. The double combination of syphilis causes deviation from the ordinary type of the evolution of the disease, which produces atypic forms, and as a double contamination will have a deteriorating influence on the descendants. Tarnowski refers to some very interesting statistics taken from twenty-five families, which have been constantly under his observation. Following the first, sec- ond and third generation, he finds that syphilis in the second genera- tion is already much milder, and causes less trouble than when recently acquired, and in the third generation is still much milder and less injurious than in the second. Amongst eighty-one indi- viduals of the third generation of syphilitic families, in two only were found signs of hereditary syphilis and in fourteen dystrophies. Tarnowski comes to the conclusion that when individuals in the third generation show symptoms of hereditary syphilis, this is mostly due to a new infection on the part of the party of the second genera- tion, or as he calls it syphilis binaria. Vice versa, an individual of 09 Congres de Medicine, Paris, 1900. Section dc Dermatologie et de Syphilog, 302 THE MEDICAL ASPECTS the second generation affected by hereditary syphilis, if he does not acquire syphilis again, will not transmit hereditary syphilis to his descendants of the third generation. Consequently acquired syphilis in the first generation does not reach the third generation in the ordinary way, nor in the saltatory way. It will never produce the ordinary symptoms of the syphilitic hereditary infection in the third generation, but the infection remains as a taint in the family. So far we are lacking in observations and in facts in order to establish what this syphilitic taint is capable of producing in the development of the offspring. Tarnowski refers to some statistical data, which are able to throw some light on so obscure a subject. In 25 syphilitic families he noted 155 pregnancies, which re- sulted in Living children, 98 ) Still births, 57 \ second generation. Of the 98 born living children, 40 got married, and they produced 131 pregnancies, resulting in Stillbirths, 41 Living children, 91 I third generation. These results have a tendency to show that syphilis has much more deleterious effects on the second generation, and as hereditary syphilis, is less pernicious on the third generation. In fact, of the 98 children of the second generation, Tarnowski could account for 91, of whom 49 per cent, showed symptoms of hereditary lues, also different dystrophies. While of the 81 living children belonging to the third generation, only 19.7 per cent, showed symptoms or dystrophies accountable to lues. The symptoms and dystrophies consisted in 91 cases of the second generation, 12 in manifestations of hereditary lues, and 33 dystrophies. In the 81 cases belonging to the third generation, only twice could he find symptoms of hereditary syphilis, and 14 times cases of dystrophies. In regard to the third generation, Tarnowski maintains that hereditary luetic symptoms are to be attributed rather to syphilis binaria, than to the transmission of syphilis from the first generation. When a party of the second generation has remained exempt from another infection, although he has shown symptoms of hereditary syphilis, he will not transmit syphilis to his descendants of the third generation. These observations, however, are not in accordance with those TRANSMISSION OF SYPHILIS TO THE OFFSPRING 303 reported by De Amicis 10 ° who in five syphilitic families found heredi- tary syphilis to be just as virulent in the third generation as in the second. In fact, in the first case of the second generation, one boy lived with symptoms of hereditary syphilis, and a girl died in the first year with meningitis. The boy of the second generation during his life suffered gonar- tritis and at the age of twenty had parenchymatous keratitis. At the age of twenty-six he married a healthy girl, and the result of their marriage was : First pregnancy, male child, stillborn. Second pregnancy, male, living-, affected with hydrocephalus. Third pregnancy, female, died ten months old from meningitis. Fourth pregnancy, male, living, showing microcephalism. Second family : First generation. Man affected with syphilis married a healthy woman, and four children were the result of this marriage. Of the four children of the second generation, three males died in infancy, the last one, a female, was subjected to mercurial treatment and lived, though remaining very delicate. She married a healthy man, and as result in the third generation : First pregnancy, a female, who soon began to lose in nutrition, but was saved by mercurial treatment. Second pregnancy, female, living, died with intestinal affection in the twenty-sixth month of life. Third pregnancy, male, living now, eleven months old, now under specific treatment. Third family : Man affected with syphilis married a healthy woman. Result in second generation: First pregnancy, female, at the age of thirteen suffered with parenchymatous keratitis and cervical adenopathy. In consequence of mercurial treatment recovered. She married a young man free from syphilis, with the result in the third generation of: First pregnancy, abortion in fifth month. Fourth family: Man affected with syphilis after good treatment married a healthy woman. Second generation : First pregnancy, living child. Second pregnancy, living child. Third pregnancy, abortion. Fourth pregnancy, abortion. 100 De Amicis, T. "La discendenza degli eredosifilitici." Giont. Intern. delle Scienze Mediche. Anno xxiii. 304 THE MEDICAL ASPECTS Fifth pregnancy, abortion. Third generation : The first son, who never showed syphilitic manifestations, at the age of twenty-two married a healthy woman with the following results : First pregnancy, male, died thirteen months old. Second pregnancy, male, died fifteen months old with spasms. Third pregnancy, male, died two months old. Fourth pregnancy, female, living, when two years old pronounced only Papa and Mamma. She had whooping-cough, and after it she did not pronounce a word. Now, at the age of seven she is deaf, she has microcephalism and has a tendency to idiocy. Fifth family:- First generation has some obscure history. Second generation : Son shows multiple scars on the chest and on the limbs, from lesions suffered in his infancy. He has kyphosis, and a sister died from hydrocephalus. No history of tuberculosis in the family, and the cutaneous lesions cannot find any other explanation than that of congenital syphilis. He is the third of the family. His brother died at the age of two. He married a healthy woman, with the following results in the third generation : First pregnancy, abortion at the seventh month. Second pregnancy, abortion at the seventh month. Third pregnancy, abortion at the seventh month. Fourth pregnancy, \ Fifth pregnancy, v premature delivery, babies died after a few days. Sixth pregnancy, ) Seventh pregnancy, living babe, died five minutes after birth. Eighth pregnancy, abortion third month. We have purposely referred to the statistics of De Amicis, be- cause they show that syphilis in the third generation has maintained its virulent and fatal effect on the developing offspring. His observa- tions recall those of Jullien, who reported cases of syphilitic mani- festations with virulent symptoms as the results of syphilitic heredity in the third generation, and also those of Barthelemy and Pospelow, who found true gummatous productions, which are manifestations of genuine late syphilis. These virulent forms of syphilis transmitted, to the third genera- tion are those which Tarnowski explains as the result of syphilis binaria. It is interesting to recollect his observations, which give a different color to the dark background which syphilis gives when transmitted to the third generation. In the observations of the authors referred to and in those of De Amicis it seems that no reinfection had TRANSMISSION OF SYPHILIS TO THE OFFSPRING 305 taken place and that the lesions which were found in the third genera- tion were to be attributed directly to syphilis of the first generation. In these cases the lesions could be referred to inflammatory luetic processes, to gummatous infiltrations of the skin, bones and different organs, together with abortions and stillborn babies. Indeed, it seems that syphilis coming from the first generation has lost very little of its virulence, so far as it concerns the third generation. Edmund Fournier has referred to the statistics of 46 married couples of heredo-syphilitics, who produced 146 pregnancies, with the results of 43 abortions, 37 babies born dead or died soon after birth, while 65 children were still living. Of the 65 living chil- dren many were affected with deformities, anomalies of development, dystrophies, such as to make them a class of unhappy invalids. In the statistics of Jullien on 256 pregnancies, there were 77 between abortions and stillbirths, which is 30 per cent. The reason of so great a mortality of these children is easily found in their weak constitution, which causes their life to be severely menaced, especially in the first months of their existence. When growing adolescents, they, on account of the weak systemic condition, are liable to show neuroses, meningitis, eclampsia, and are more easily affected by the other ordinary morbific causes. When adults, they often suffer from epilepsy, neurotic conditions, idiotism. Sometimes they have affections of the bones. They have something peculiar about their faces; the frontal eminences are quite accentuated, the features are asymetric, the nose saddle-shaped. The alterations of their physiognomy are often accompanied by deficient cerebral functions, so that they are unable to study, to work, some- times they have trouble in their speech, and they are often deaf and dumb. The dystrophic conditions of the teeth which are found as the result of hereditary syphilis in the second generation, are found in the third also. In the heredo-syphilitics there have been found peculiar stigmata in the fundus oculi, which according to Galezowski and to Albert Antonelli 101 bear witness to hereditary syphilis. The principal troubles are found in disturbances of the pigment of the fundus oculi, oftener of the choroides, which are not different from those which are seen in acquired syphilis after the recovery from a syphilitic choroiditis. The parents of the patient in question had no signs of acquired syphilis, and had only shown traces of syphilitic taint. According to the same Antonelli, syphilis in the third generation 101 Antonelli, A. Quoted by De Amicis, 1. c. 306 THE MEDICAL ASPECTS is the cause of optic neuritis, or neuro-retinitis, and chorio-retimtis, a process which occurs during fetal life or in the beginning of the extra-uterine life, and only rarely during infancy. These processes of the fundus oculi from heredo-syphilitic taint are usually mild, especially when the intensity of the virus has been so greatly attenu- ated as to produce only an hereditary syphilis without any apparent symptoms. They may, however, leave abnormal pigmentations and superficial scars, which are visible with the ophthalmoscope, and re- main as characteristic stigmata of an hereditary taint. The same condition, however, is found in heredo-syphilitic patients of the second generation, and the difference between the second and third generation consists only in a milder form for the third genera- tion, showing the attenuation of the syphilitic taint. This pigmented condition of the fundus oculi and the difference of intensity between tainted individuals of the second and third genera- tion is a witness of the influence of the first heredity on the second and can be considered together with other important alterations and dystrophies. The comparative study of the dystrophies of the second and third generation in the same families confirms the observations of Tarnowski of the gradual diminution of the intensity of syphilis from one to the other generation. In the second and third generation dystrophies are frequently found in the teeth, and also in the shape of the auriculae. Often in the second generation, the teeth appear notchy, teeth of Hutchinson, or in the form of microdentism, or by congenital 'absence of the superior lateral incisors ; while in the third generation they will appear only as erosions of the teeth or as an anomalous implantation, or as premature decay of the teeth. The auriculae of the second generation are often badly shaped as in the form described by Morel, or show absolute deformity. In the third generation these deformities are not reproduced unless in the direction of the auriculae. Dystrophies of a severe type in the second generation, such as infantilism, microcephaly, persistence of the foramen Botalli, lack of development ' of some parts, are usually not reproduced in the third generation. In the same way, congenital obesity, epilepsy, morbus Basedowi, are only very seldom found in the third generation. In reference to the generative organs, Tarnowski was able to find seven persons of the second generation out of seventy-four showing sexual dystrophies, which in the females consisted in rudimentary development of the uterus, and in men in azoospermia, impotency, and in two cases in sexual perversion. Plate XIV DlATROPHY OF THE FlNGERS IN A HeREDOSYPHILIDE Ulcerated Gum mat a in a Heredo-syphilide TRANSMISSION OF SYPHILIS TO THE OFFSPRING 307 We give an illustration that shows a deformity of both hands, consisting in an anomaly of development of the fingers, giving an ugly appearance to the hands. It was in a patient nineteen years old in our service in the City Hospital, suffering with syphilitic periostitis of the tibiae from hereditary syphilis. In fact, all these dystrophies are accompanied by some symptoms which undoubtedly show syphilitic antecedents, such as notchy teeth, sinking of the base of the nose, natiform skull. These are such characteristic stigmata that they testify to the presence of syphilis in both, or at least in one, of the parents. But fortunately, as the genera- tions progress, the stigmata gradually disappear, so that if no new infection takes place in the second generation, signs of syphilis are nearly lost in the third generation, and in the fourth generation any taint of syphilis has been completely extinguished. We can see that syphilis has a great influence on the generations : in the second it is transmitted, producing death of the fetus as in miscarriages, or as infants born dead, or causing the babe to die during the first year of life ; it causes in some cases sterility of the individuals, and in many circumstances malformations, dystrophies of different degrees. Following the statistics given by Tarnowski we find that in the second generation only twenty-two per cent, have been entirely free from syphilitic symptoms, and have shown no signs of anatomical or functional dystrophies. In the third generation syphilis loses its morbid influence and fifty-five per cent, of the babies are born well without taint of the morbid inheritance from their parents. If no other un- favorable heredity takes place, the fourth generation returns to normal. The attenuation of the morbid influence of syphilis from genera- tion to generation is greatly influenced by a new infection, especially if this takes place in the second generation, and then as cases of syphilis binaria. In these cases in a family where one member already having hereditary syphilis acquires a new infection, the influence on the third generation is indeed very pernicious. From this double syphilis the number of miscarriages is greatly increased, as is also that of the children born dead or dying in the first year of life. The symptoms of hereditary syphilis in the third generation are then much more frequent, and the malformations and dystrophies likewise occur quite often, showing a much more powerful virulence than in the ordinary cases of hereditary syphilis. Fortunately, cases of syphilis binaria are rarely found, and the degeneration of syphilitic families is not often met with. Further- more, the marriage of members descending from syphilitic families to parties of healthy families exercises a curative effect on the health 308 THE MEDICAL ASPECTS of the generations, so that in the fourth or fifth generation the families return to a normal healthy condition. This is the only explanation which can be given in regard to the existence of syphilis for so many centuries without causing diminution or degeneration in the population. In consequence we have all reason to maintain that the remedy against syphilis amongst the population will be easily found. The proper laws for regulating prostitution, the isolation of the infected parties, preventing them from spreading the infection, and laws regulating marriages, will give us the certainty of succeeding in stamping out this scourge of humanity. In the question of hereditary syphilis in the third generation, although many observations have been referred to, yet a great deal of doubt is found in the generality of the cases. It is, however, neces- sary to note a great difference in the origin of the heredity, whether from the mother or from the father. The infection from the mother is much more sure than from the father. In many cases in which we had treated the father for syphilis before his marriage, we have seen result a family of healthy children. We have also seen the father, affected with extensive patches of syphilis tuberculo-ulcerosa on his legs, have children with splendid health. But we always return to the assertion of Sigmund, when you have to do with a party born from a syphilitic parent, you must not consider him or her in his first youth, but you must follow him in all periods of life. When the mother has the infection then the transmission of syphilis to the off- spring is a certainty. Indeed, we find in our daily practice, and other practitioners, clinicians and specialists refer to having often met with cases where the morbid phenomena could not be explained in any other way than by the admission of a second hereditary transmission. Jullien 102 in this regard has collected a large number of observations, which have much enriched the doctrine of syphilitic heredity, and to which we must refer the reader for a complete knowledge on the subject. From all his observations it results that syphilis hereditaria, al- though in the third generation, is often the cause of abortion or of the death of the infant at the time of birth. Syphilitic heredity is not a cause of sterility, it has no influence on the phenomenon of conception, on the contrary, in syphilitic families we often find a number of children. Someone would attribute to a syphilitic taint the birth of two or three children at the same pregnancy, but so far there are only contradictory arguments on this point. Syphilitic lesions are referred to by different observers, some 102 Jullien. " Descendance des heredo-syphilitiques." XIII Congres Intern, de Medicine, Paris, 1900. TRANSMISSION OF SYPHILIS TO THE OFFSPRING 309 belonging to the secondary period, some to the tertiary. In conse- quence there have been found in some cases superficial eruptions of the skin, in others a deep destructive process of the same in the form of ulcerated gummata. The bones and joints often show lesions which represent other affections and yet yield only to antisyphilitic treatment. The nervous system is the part of the body which is quite fre- quently preferred by this abominable disease. The brain is often affected, many children die with meningitis, and the cause cannot be easily found unless the syphilitic taint is traced from their parents. Infantile paralysis is often found in children with a hereditary syphil- itic taint, and chorea nutans is by Comby considered as a nervous disease from syphilitic heredity. This sad heritage is the cause of idiocy, of epilepsy, of impaired intellectual development, of sexual perversion, of criminality, etc., which we will study in separate chapters. Ricord has asserted that nobody receives syphilis from his grand- father, and this assertion was accepted as a law for the very reason that in the third generation, clear infectious symptoms are not present. The question, however, began to be studied in a more general way, by ascertaining the presence of other possible alterations, which, if not directly of a syphilitic nature are yet induced in the system by the action of the syphilitic virus. In these cases syphilis has so affected the vascular system and has so influenced the general nutrition of the organism, as to render it liable to the attacks of other infectious elements and make it a good culture medium for their development. These manifestations have nothing characteristic of the syphilitic type, but have nevertheless some peculiar aspect, and are accompanied by some peculiar abnormalities, that an eye used to seeing syphilitic patients easily suspects to be originated from a syphilitic taint. These affections have been called parasyphilitic manifestations; they are not directly influenced by antisyphilitic treatment, because they are only different affections which find a good ground in a syphilitic organism. In this regard Jullien mentions the general debility of the infants, which is only the result of hereditary syphilis in the third generation. In his statistical notes it appears that twenty-nine infants from syphi- litic parentage have died from a few minutes after birth to a few months. In our service in the City Hospital we have had a large number of babies taken into the institution in an extreme degree of emaciation, who have died of marasmus in the first months of life. Unfortunately, these poor creatures are taken to the Hospital by others than their parents, and we can scarcely learn their names, let alone 3IO THE MEDICAL ASPECTS obtaining any idea of their history. In these cases we believe it is more the effect of syphilis in the second generation than in the third. Returning to the cases of Jullien, he refers to an infant who suddenly died without any definite symptoms, and which Fournier said died without malady, showing the liability of these infants to do so. This vulnerability of their system is also manifested by the affec- tions which they often show, as obstinate cases of impetigo, otitis media purulenta, adenopathies, caries of the bones, and frequently their life ends with tuberculosis, which finds a good ground for its development. It will not be out of place to mention children affected with rachitismus. Every physician is certainly acquainted with the studies of Parrot, who thought he was able to refer the rachitismus to symp- toms of inherited lues. He was perfectly right in his views, but the acceptance of rachitismus as a symptom of hereditary syphilis was strenuously opposed. His opinion and his studies were taken up again by many syphilographers, and to-day Moncorvo, Callari, Moreira, Gibert and Jullien are inclined to consider rachitismus as a disease found in individuals of syphilitic parentage. In families where some of the children are affected with rachitismus, we find that frequent abortions have taken place. Rachitis is frequently associated with chronic coryza, with malformed and early decaying teeth, all pointing to the specific heredity of the sufferers. Many affections have been found in heredo-syphilitic children, which, however, have nothing in common with syphilis. It seems that the syphilitic taint has a tendency to favor the development of diseases of the respiratory organs, beginning with the nose in. the form of a chronic inflammatory process of the mucous membrane, and of adenoid vegetations in the posterior naso-pharyngeal cavity, and ending in the broncho-pulmonary apparatus as chronic bronchitis, leading to the development of tuberculosis. Monstrosities. — Syphilis as a hereditary taint from the parents at times displays a teratogenic influence on the descendants, with re- sulting monstrosities. Gley and Charrin have shown in their inter- esting works the production of monstrosities to be in a great many instances the result of syphilis hereditaria. In our practice we have observed two cases of acephalia, which occurred in two Italian families, in which both parents were syphilitic. Of the two monsters one was born already dead, and the second was born alive but died a few hours after its birth. They were well developed and well nourished, without a sign of syphilitic affection. Jullien refers to several observations, one from Le Pileur, of a TRANSMISSION OF SYPHILIS TO THE OFFSPRING 311 case of hemophilia in a little girl, four cases of nevi communicated by Troisfontaines, Caubet, Torok; one case of malformation of the iris reported by Fournier, one case from Hamonic of cryptorchidismus and polydactylism, two cases of hare-lips, one case of monstrosity and one of a congenital amputation. When we recall the important alterations of the blood and lym- phatic vessels caused by syphilis, we will see that these affections peculiar to the vascular system as the hemophilia and the naevi are quite frequently the result of hereditary lues in the third generation. In the case of the hare-lip, which was communicated by Hamonic, it w r as found in a child well developed and apparently in good health. His father had a hare-lip, with a cleft palate, and he was the son of a syphilitic, who had a perforation of the palate from an ulcerated gumma. Dystrophia;. — The children born of syphilitic parents often show some abnormal development of their body. In some cases they are small, thin, and of a meager appearance, with a small waist, in other cases they are not proportionately developed. Moreira referred to a boy four years old only 55 centimeters high, and to a girl of eight years, who measured 92 centimeters. Lannelongue referred to a child born of syphilitic parentage, who showed abnormal disproportion be- tween the right and the left side. Barthelemy found a marked dis- proportion between the length of the femurs and that of the body, while Moncorvo pointed out an enormous length of both legs. We had already had occasion to report a case of a babe, the fifth offspring of a syphilitic father, born with only three fingers of the right hand, and a short humerus of the left side, ankylosed at right angles with the bones of the forearm, as is shown in the illustration. 103 In a general way we can see that the development of the heredo-syphilitic children is not regular, it is usually slow and somewhat tardy. It is often found that in those children, the appearance of the teeth is greatly retarded, so that in the second year of life they still have no teeth. Sometimes one of these children at the age of three years cannot speak, some cannot walk, a girl at the age of fourteen years does not show any development of the breast, has no menstruation, and all her acts and words tend to infantility. Often the skull shows some peculiar malformations, disproportions and deformities, which give an idea of the specific heredity. In some cases the fontanellse are ossified too early, in other cases they remain opened for a much longer time. In some cases there is microcephaly, in others macrocephaly ; in one the frontal eminences are greatly exag- 103 Ravogli. " Considerations on Inherited Syphilis, with special reference to paternal inheritance." Lancet-Clinic. 312 THE MEDICAL ASPECTS gerated, in another the parietal eminences are too pronounced. In consequence, there is a lack of harmony in the proportions of the skull which is revealed by the irregularity and asymmetry of the features of the face. The nose is often sunken in the middle ; the teeth often missing, deformed, badly disposed; all gives a peculiar specific appear- ance entirely characteristic of these beings. If such is the result of the syphilitic taint on the external appear- ance of the heredo-syphilitic individual, not less must be the deleterious influence on the development of the nervous system and of their mental faculties. In fact, we find these children rather tardy in learning; they are unable to study and they follow a conversation with difficulty. They are half idiots, sometimes with permanent defects of speech. Others are of rather an irritable nature, easily excitable, impulsive, passionate, some are inclined to erotic ideas, some are perverted. The teeth, as already said, are retarded in their growth, irregular in their implantation. They are small and separated, notchy, round, they show erosions, are easily broken, and subject to decay. The eyes are liable to show anomalies in heredo-syphilitic subjects, in the form of flecks, irregular or asymmetric pigmentation of the iris, pigmentary retinitis, strabismus, congenital or precocious cataract, the etiology of which has been attributed to syphilitic heredity. Deaf-mutism is in a great many instances due to congenital, rather than to acquired conditions. It is the result of osteitis or periostitis of the temporal bone, which affects the cavity of the middle ear, causing anchylosis of the ossicles, but more frequently of absence of the internal ear or any of its parts. It is also produced by colloid degeneration of the labyrinth, with atrophy of the auditory nerve, or from some lesion of the brain. Every one of these conditions finds syphilitic heredity as its principal cause. The skin of these individuals may also impress a diligent observer with its yellow parchment-like aspect ; in some cases the hair is scanty and limited in length, dry, easily falling out. Cyanosis has been found in one case by Moncorvo, and in another by Barthelemy. In in- dividuals descending from syphilitic parentage in the third generation, syphilis is not more transmitted as such, but only as alterations result- ing from its deleterious influence on the vascular system. It is there- fore revealed in the form of anomalies, arrest of development of organs or systems and for which the syphilitic process alone is responsible. Treatment. — In our experience with individuals affected with syphilis have undergone a long and regular treatment, and when the wife has remained exempt from infection, the children are usually spared. But when insufficient treatment has been used, and especially when the wife has been infected, the children are then sure to be in- TRANSMISSION OF SYPHILIS TO THE OFFSPRING 3 J 3 fected. If the infection has not been so virulent as to kill them in utero 3 they will show symptoms of congenital lues. They need treat- ment, which must be long and continued in order to save their lives. Some will get well after persistent and relapsing symptoms. The germs of syphilis when transmitted by heredity seem to be more tenacious and to have a better grasp on these poor creatures than they show in the cases of acquired lues. Hereditary syphilis is anomalous in its manifestations, so that a child born with multiple syphilitic dactylitis, after a few months has been known to show an eruption of ulcerated patches on the scrotum, while in acquired syphilis the evolution of the disease maintains a cer- tain rule in the progress of the symptoms. And thus was originated the distinction between the secondary and tertiary periods, which is still useful and of practical interest. The treatment of the individuals acquiring syphilis, or as we have called them, those of the first generation, is the only hope of safety, and the treatment must be a long continued one and repeated at in- tervals. When the parents of the first generation have neglected treat- ment and the syphilitic virus has been allowed to develop and saturate their organisms, then the influence on the family will be disastrous, and it will visit the third generation. Cases of so-called mild or latent syphilis are more dangerous for the reason that the patient thinks he is well, and is unwilling to undergo further treatment, and the physi- cian, deceived by the lack of symptoms, has not the determination to insist on the continuance of a treatment which seems apparently unnecessary. In the generality of cases, when a regular treatment has been em- ployed and the offspring has escaped the danger of death in utero, if it shows symptoms of lues it must be treated as we have above ex- plained. Under a regular treatment syphilis is attenuated and in the majority of cases it does not show further manifestations. In some families where both syphilitic parents had been under our treatment, we have found that the children, although not the picture of health, are bright and intelligent. The syphilitic virus with time and treat- ment keeps growing weaker, and is no longer transmitted to the children of the third generation as syphilis with virulent syphilitic manifestations, but it does exercise a deleterious action in the develop- ment of the fetus, inducing malformations or dystrophies, which at times are single and at times are associated. In many cases, malforma- tions do not occur in a visible way, but vices of conformation may affect the internal organs and especially the nervous system. The health of one of the parties contracting marriage has a great correcting influence on the health of the offspring. The symptoms 314 THE MEDICAL ASPECTS found in the descendants are sometimes shown in an unequal and saltatory manner. For instance, a man who has suffered with syphilis marries a healthy woman, but is still taking treatment out of precau- tion. His wife will give birth to a healthy child, who during life will never show signs of hereditary lues. While ceasing from treatment a second child is born, and although apparently healthy, at some period of life will show some of the characteristic signs of retarded syphilis. We have so far no explanation for this saltatory transmission of syphilis by heredity and much less for that which concerns lues of the third generation. The explanation given by Jullien, 104 based on the alterations of the vitality of the cells caused by the toxins, may give an idea of the permanent or of the transitory character of the resulting lesion. The syphilitic virus is rather diffusible, but it is of a durable nature. It lasts and persists for years concealed in the latebrae of the organism. It is susceptible of attenuation from the biological changes produced by the metabolism of the cells, and it may also be eliminated spon- taneously through the natural cytophagic activity of the cells, and so taken to the natural excretory organs, from where it is eliminated. In many patients the elimination of the syphilitic virus is com- plete and recovery takes place, which has been proved by a large number of reinfections. This class of individuals can be considered as a favored one by so resistant a constitution that their tissues and cells will not retain the deleterious germs. They will have children, who will show no signs of the sad inheritance. On the other hand, there is another class of patients of a weak and unresistant constitu- tion, whose cells and tissues remain so persistently imbibed with syphilitic virus, that it seems nearly impossible to rid them of its pernicious influence. In this class of patients, if their system is not corrected, and its toxic condition not neutralized, it is an impossibility for their descendants to be free from syphilitic taint. This virus, only recently known in its entity, known better by its effects, affects blood and lymph vessels, and is carried to the remotest and most deep-seated cells of every organ and apparatus. If it is not transmitted as such it is yet capable at the moment of the formative stress to produce arrest of these organs so that imperfect development and anomalies of dif- ferent degree may result in the final product. 104 Jullien, L. " Descendance des heredo-syphilitiques." Paris, 1900. PART II THE MEDICO-LEGAL AND SOCIOLOG- ICAL ASPECTS SYPHILIS AND MARRIAGE After all that we have considered in reference to the deleterious action of syphilis in families, we have reached a point at which we may propose to society some means to prevent young men infected with syphilis from contracting marriage after a short time and an insuffi- cient treatment. We do not consider syphilis as an absolute permanent obstacle to marriage, but it is only a temporary impediment, which is removed by a good and well-directed treatment. Only the physician who has pursued special studies in syphilology is able to decide the question of the admissibility of marriage for a man who has suffered with lues. SYPHILIS AN IMPEDIMENT TO MARRIAGE Every measure, as Burr x said, which is wise in its provisions, should have the hearty support of the medical profession. It is only through our profession that a knowledge of the extent and ravages of these diseases can be imparted, and means for their prevention pointed out. We can imagine but one prophylactic measure which is capable of preventing injury and death to innocent wives and children, and this is stringent laws regulating matrimony. Not all the applicants for marriage have received a good education and are capable of understanding the seriousness of their step when contracting' marriage still under the influence of the luetic infection. Nor are all applicants aware of the gravity of the disease and of the danger that their wife and family may take the disease, and conse- quently they fail to consult a physician in this regard. On the other hand, an innocent girl entering the bonds of marriage has a right to know that her own body shall not be contaminated through this rela- tion by an existing contagious disease or by a taint. The parents or relatives have a right to know that their offspring shall not be victims of hereditary afflictions. Every child has the inalienable right to be born well and not tainted with disease which later on will make him unhappy. The state alone can safeguard these rights by means of wise and stringent legislation. The same views were maintained by the mem- 1 Burr, A. H. " State Regulation of Marriage for the Prevention of Com- municable and Hereditary Disease." Journ. A. M. A., Dec. 3, 1898. 317 318 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS bers of the Second International Conference of Brussels, which in the eleventh project of law, pointed out to governments and to the public the practical utility of a compulsory medical examination before marriage, in the form of an examination for life insurance. With these laws the state is able to prevent the diseased from contaminating the healthy and innocent through the license to marry. These rules ought to subject at least the groom to a sanitary visit before obtaining the license for marriage. In our country it is easily feasible on account of the necessity of the license from the Probate Court for the celebration of the ceremony. The license would no longer be a mere formality, but would be obtained when the indi- vidual is found in a condition to support a wife and family, and free from any disease which might infect his wife and make his family a burden to society. The examination for venereal diseases would have for its principal scope the protection of an innocent girl from undergoing all the tortures we have enumerated. Indeed, as taught by Ricord, stated by Noeggerath, repeated by all syphilologists and venerologists, the majority of males contract gonorrheal infection before matrimony. In a great many cases it remains latent for indefinite periods and is easily communicated to the wife, exposing her to all pelvic diseases. It is often a cause of sterility, and in the children is often the cause of blindness. In reference to syphilis, we have already pointed it out to be the principal cause of abortion and of stillborn children, and that tainted children usually die in the first year of life, enfeebled and lowered in their vital resistance. They are subject to many forms of nervous diseases, as idiocy, epilepsy, and also to some forms of insanity. At the same time, if the intended groom should be found to be suffering with pulmonary tuberculosis, it should be the duty of the physician to stop and impede so unfortunate a match. Consumption is the great white plague, which cuts down from one-ninth to one-seventh of the human race, and it is often com- municated through marriage, and the children are born with a weak constitution and have a tendency to tubercular affections. We have already seen that syphilis has a tendency to increase mental and nervous derangements, and the tainted person by marrying is liable to beget offspring belonging to the class of physical and moral degenerates. This class of people give the largest contingent for the diseased, for the defectives, and for the criminals, which largely fill asylums, poorhouses and jails, and remain for the state to care for. For this reason the state has a right not only to protect the individual, but also to protect society, by diminishing the number of those who might remain as a burden to the public welfare. In this way the appointment of a physician by the Probate Court SYPHILIS AND MARRIAGE 319 for the examination of the man applying for the marriage license would be the most desirable solution of this sociological problem. French authorities have proposed that the candidate for marriage should exhibit a certificate from a physician, which would be the sanction or the prohibition of his marriage. This procedure is greatly praised by Jullien, who finds that the father of the bride would be relieved of much anxiety in reference to the health of his intended son-in-law. We find a serious objection to this manner of certificate, for the reason that it will give opportunity for a great many mystifications, which can easily be avoided, when the physician is appointed by the Court and is selected from among the most reputed specialists in this line of science. We do not agree with the opinion of Morrow, who alleges great hostility of public sentiment in this country against such a restrictive measure. Here is the necessity of obtaining a license, and in order to obtain this valuable document an examination has to be made to determine the fitness of the applicant. In so grave a question, where the happiness of a family is at stake, theories and poetry count for nothing. The visit has to be made in order to ascertain whether Mr. X., who applies for a marriage license, actually has syphilis or a gonorrheal infection, which will without doubt infect his wife. When no symptoms are present, when the man, if he has been infected, has undergone a regular treatment for the period of three to four years, when no gonococci are present in the gleety discharge from an old stricture, nobody will refuse to this man the requested license. At this moment in several States in the Union a movement in this direction is gaining ground, and before long it will be a law. In this case the license will be a clean patent that the man contracting mar- riage is not in a condition to infect his wife with venereal diseases. The idea that such a law will promote celibacy, as Morrow states, because self-respecting persons would rather forego marriage than be subjected to such a humiliating condition, is nothing more than a bugaboo. No self-respecting person foregoes life insurance because of the sanitary examination. Very likely a man infected with syphilis will refuse to show his condition to the examining physician, and will become so self-respecting as to forego marriage on account of evading a sanitary visit, which would place him in a humiliating position. The other objection, that many aspiring to marriage will go to another State where such a law is not in force, may be true, but we do not care. Anyone who has done anything wrong and wants 320 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECT to evade the law may do so if he chooses ; he will suffer the conse- quences. Jullien related that the Minister of Justice of Spain was so greatly wrought up over the sanitary conditions, especially relating to venereal diseases, that he wished to have a physician intervene in every request of inscription for marriage. In our short stay in Spain we have seen in the streets of several cities children affected with grave manifesta- tions of inherited syphilis carried around by sickly mothers to arouse sympathy among the passers-by and obtain alms. The Probate Court ought to require from every applicant for a marriage license the production of a certificate from a doctor specially appointed by the same court, stating that the applicant is free from contagious diseases. This certificate will make the license a document of great value and not a simple formality ; it will prove a blessing to a great many families and to future generations. The physician should be a man thoroughly familiar with derma- tology and syphilology, and should consider the matter only from the actual sanitary standpoint. The visit for a life insurance is a different question from that for a marriage license. The insurance companies are interested in the future consequences of syphilis in reference to the longevity of the applicant, in the visit for a marriage license the question rests on the inoculability and transmissibility of the disease. The physician therefore has to consider the proposed marriage only as a sanitary problem. The solution of this problem is that a man must not be permitted to marry as long as he is in a condition to infect his wife, or to transmit syphilis to his children. We hope that in the near future a case of syphilis will find in the microscopical examination, data which can be of valuable help in the determination of this question ; so far at present the judgment of the physician must rest in the knowledge of the alterations of the disease, and on the clinical observations. The point is that there are no signs of syphilitic manifestations, which are of an infectious nature, and that the appli- cant for the marriage license has no signs of recently acquired syphilis. Moreover, if the applicant should still have signs of an old, extinct lues, or he should admit having had lues, it would be the duty of this examining physician to determine the time elapsed from the first in- oculation and the quality of treatment undergone. Indeed, it is impossible to establish with certainty the time when a man who has been infected with syphilis will be out of quarantine and will not be dangerous for spreading infection. We have already seen that the disease may have different degrees of gravity on account of the quan- tity of virus, of the association of other infectious germs, and also on account of the constitution and of the healthy condition of the general SYPHILIS AND MARRIAGE 321 svstem of the patients. The method of treatment which has been employed, the time for which it has been continued, the easy yielding of the syphilitic manifestations, are all data which should exert a great influence in the consent for a license for marriage. When the infection dates from several years, and for years no manifestations have appeared again, when the patient has taken a regular treatment continued for a number of vears and no more symptoms have shown, he can be safely considered out of any danger of transmission of the disease. The assertion that after three or four years, and worse still that after two years syphilis is extinct and the syphilitic man can safely marry without fear of inoculation or of the transmission of lues to the offspring, is absolutely erroneous. It is possible that in a certain number of cases after the second or the third year no more symptoms appear and the disease loses its contagiosity and its transmissibility ; but we also see cases where after the fifth, the sixth, and even the eighth year, mucous patches still return and the disease is still capable of being inoculated. We have already seen that the transmissibility of lues from the father to the offspring persists longer, and that although all symptoms have practically disappeared, yet the children may become tainted with inherited lues. In general we can assert that when a man infected with syphilis has undergone a regular treatment, for a period of four years, and for over a year no specific symptoms have reappeared, he can be released from quarantine and can safely be permitted to marry. With a well-regulated office of this kind for the sanitary inspection of the aspirants to marriage, there would be obtained a prevention of the spreading of syphilis and its introduction into the families with the sad and fatal consequences which we have already considered. The objection that the couple will elope and have their marriage celebrated in another State does not diminish the good and the benefit of the institution of such an office of public hygiene. The possible benefit will be appreciated by the different States and very likely the law will be adopted by many, so many that it would not be easy to find a place to avoid the law. Furthermore, we are trying to diminish the evil by preventing the introduction of infectious diseases into the family, and if they do not understand the importance of the health of the family, the responsibility rests entirely with them. SYPHILIS AS A CAUSE FOR DIVORCE Syphilis, or better, venereal diseases, have not had a very extensive consideration in courts of justice. The only recognition for judicial determination has come in cases for divorce, and as these are usually 322 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS final in the lower trial courts, few cases reach the highest tribunals where the laws are established and become precedents in the archives of the legal profession. In but one State of the Union is there a direct law touching the subject in question. Judge Otto Pfleger kindly stated to us that the Kentucky legisla- ture in 1897 passed a law granting a wife a divorce on the ground that the husband had contracted a loathsome disease, and in one adjudicated case (41 Southwestern Reporter, p. 26) gonorrhea has been classified as such a disease. Almost every State has " cruelty," or " extreme cruelty " as a ground for divorce. This is not confined to personal violence. The weight of English, Scotch and American authorities is to the effect that any misconduct which tends to impair the health or which creates an apprehension of bodily injury is cruelty (see Vol. 9, " English and American Encyclopedia of Law," p. 788.) Therefore to willfully communicate a venereal disease is clearly cruelty, for it is misconduct tending to impair the health and to render cohabitation unsafe. This has been so held in the Supreme Courts of England, Connecticut, Maine, Michigan, New Jersey, North Carolina and Tennessee ("American and English Encyclopedia of Law," Vol. ix, p. 792.) This ground is not, however, available to the wife if she continued to cohabit with the husband after knowledge of such a disease, unless she was unaware of the dangerous nature of it. It must, of course, be made clear that the wife contracted the disease from the husband. In a late case in California (94 California Reports p. 225) it was determined that communicating gonorrhea to the wife is cruelty as defined under the statute. In the law books we find great lack of knowledge in reference to syphilis. All that is spoken of is venereal disease ; gonorrhea and syphilis being confused as one. Under the head of adultery as a ground of divorce we find some adjudications regarding venereal diseases. In the American courts not much is thought of their presence, because of the uncertainty of establishing adultery. In New York and Massachusetts adultery may be inferred, where the husband had contracted a venereal disease long after marriage, although it was said that such a fact is not always incompatible with innocence. Adultery, therefore, will not be inferred from the presence of the disease shortly after marriage, as it may have been contracted before marriage, or be due to a return of symptoms of secondary syphilis. Proof that the wife had syphilis will not bear the inference that SYPHILIS AND MARRIAGE 323 the husband committed adultery inasmuch as she may have contracted the disease by her own adultery, by contagion or by accidental means. All of this goes to prove that the courts have found difficulty in fixing the blame on the guilty party by the mere presence of venereal troubles. Bishop 2 too, considers one of the principal causes proper for divorce, extreme cruelty, which renders cohabitation physically unsafe. For a husband knowingly to communicate venereal disease to his wife is adequate legal cruelty and in aid of the necessary proofs of knowl- edge, the presumption will be that he was aware of his own diseased condition and of the danger of infection. But it has been deemed that for a man to marry while this disease is on him, and thereby endanger his wife, is not legal cruelty, if in fact it is not taken by her. But in reason, this favorable construction of the act would arise simply from the presumption that he had used precautions to prevent infection. A husband's attempt, while he has venereal disease, to force his wife to his bed, is regarded as of a mixed nature, partly cruelty and partly evidence of adultery. Venereal disease is presumed to come from sexual commerce and prima facie proof of a husband's adultery has been deduced from his having it long after the marriage. Its appearance soon after mar- riage, as above stated, does not lead to this conclusion, because ante- nuptial misconduct may have produced it. But even in the former case, if we look rather to the legal reason than to specific authority, we shall find it necessary for some evidence to appear that he was not infected by the wife, for in so intimate a relation, where the disease of one party must almost of necessity extend to the other, how can the court in the absence of proof charge the guilt specifically upon either? Looking again to adjudication, where there was an attempt to establish adultery against the husband by showing the wife to be suffering from recent infection, Dr. Lushington 3 considered this fact not alone sufficient, since she might have contracted the disease from another. He claims that it is impossible to lay down any general inflexible rule, for each case must depend upon its own circumstances, and these must assist the court in coming to a conclusion. By a judicial committee the doctrine was stated to be that the adultery of the husband cannot be inferred from the mere fact of the wife's being tainted with venereal disease, although she herself is not even suspected of adultery ; that its existence in her is consistent with the adultery of the husband, with her own adultery, and with accidental 2 Bishop, J. P. " Commentaries 011 the Law of Marriage and Divorce," 1881. vol. i, p. 736. 3 Lushington, quoted by Bishop, 1. c, vol. ii, p. 633. 324 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS communication of it, and that where there is no proof of the husband having been himself diseased at the time specified in the libel, it will not be ascribed by preference to the first of these causes, even though it appears that at a former time he had infected his wife. In principle, if we reject the somewhat prevalent idea that acci- dent may bring this disease where the usual cause does not, and if in a particular case it is found to have originated long after the mar- riage, then the conclusion is plain, that one or the other of the parties, or both, must haye offended. Now how shall we determine at whose door the guilt lies? Often we cannot; but in a case of this kind, con- sulting reason rather than specific authority, evidence should be re- ceived of the entire course of life, and the associations and temptations of the parties respectively, the result of which would be, that some- times the judge might become fully satisfied and sometimes not. and the divorce would be granted only when he was satisfied. DAMAGES IN CASES OF SYPHILIS The question of damages in case of syphilis alleged as an impedi- ment to marriage has been fully ventilated, and we can state that this matter has been nearly settled by the courts. In some cases syphilis could have been alleged as a pretext to break a contract of marriage, although the condition of one of the parties would have been not such as to require the nullification of the contract. And by this means the responsibility of damages or of an indemnity which is asked in cases of breach of promise would be escaped. It is better for us to look into some practical cases in the judicial courts, in reference to syphilis as an impediment to marriage and as a cause of divorce. From these cases we will learn a great deal about what the jurists think in this matter. For this reason we will refer to the case of Shackleford vs. Hamilton, which has gained so much notoriety, and the decision rendered by Judge Prior in this case has been adopted by all the jurists. 4 It is implied as a part of every agreement to marry, that any subsequent change in the mental or physical condition of either party without fault, so as to render it impossible in the nature of things to accomplish the objects of the marriage relation, will release the parties from the agreement. Where a man who had contracted syphilis entered into an agree- ment to marry, believing in good faith that he had been cured of the disease, the reappearance of the disease without fault on his part, so as to render him unfit to marry, released him from his obligation, and 4 " Reports of Civil and Criminal Cases Decided by the Court of Appeals of Kentucky," vol. xi, Frankfort, Ky. 1894, p. 80. SYPHILIS AND MARRIAGE 325 constitutes a good defense to an action against him to recover damages for breach of the contract. The attorney for the appellant produced the following legal points : I. Matrimonial intercourse is the principal end of marriage, and where by reason of supervening disease or impotency this end cannot be answered, either party to a contract of marriage may refuse per- formance without incurring any liability ; provided, the changed con- dition was not brought about by his fault. 5 We shall not enter into the legal technicalities of the case in reference to the tenability of the contract, and to the circumstances which justify a verdict for exemplary damages, but we will dwell strictly on our subject, syphilis as a ground for the release of a party from the contract of marriage. Indeed, there is no implied term or proviso in an ordinary contract to marry that syphilis, whether contracted before or after the en- gagement, should release the syphilitic party from performing his contract or paying damages for its breach. In the case in question the defendant admitted that he made the contract of marriage when he believed himself to be in good and sound health. Before any con- tract of marriage he had contracted syphilis, for which he was treated, and after steady and good treatment he had been pronounced cured and free from the malady. He stated that he had consulted another physician, who after a thorough examination of his person, assured him that there was not the slightest evidence of the existence of the disease, and his regular physician who had treated him during the time of the disease had told him that he was cured and in a fit state to marry, which he could safely do. After this time, with the belief that the disease no longer existed, he made the contract of marriage. He stated that after the engage- ment to marry and without fault on his part, symptoms of the disease again appeared, and so he was advised by his physician not to marry. In the case, the judge took under consideration the possibility that the reply could have been prompted by the view of escaping the re- sponsibility in the way of damages, rather than by an honest conviction of his physical condition. The judge, however, based his judgment on the testimony of the physician, who gave satisfactory evidence on the alleged facts. The court below had sustained that as the man had entered into a contract of marriage, he was bound for its breach, that the contract was unconditional and the man being able at the time the promise was made to perform the contract, he must either execute it or become 5 Quoted from Bishop " On Marriage and Divorce," vol. i. Sees. 321, 322. P- 657^ 326 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS responsible in damages for the breach. The judge in this case remarked that a contract of marriage is not a mere bargain, to be viewed as an exchange of chattels between the parties competent to contract. But marriage is an agreement to create a status that forms the basis of our social system, and in which society has more interest in preserving its purity than the parties concerned. When the marriage contract is consummated, the parties taking each other for better, for worse, for richer, for poorer, and agreeing to cherish each other in sickness and in health ; the fact of the social standing of the one party or the other, or their pecuniary condition was not as represented, will afford no ground for relief. Still, when there is only a mere agreement to marry, there may be such a condi- tion of the one party or the other as to health or other bodily infirmity arising subsequent to the agreement, as would authorize either party in declining to enter into the marriage relation. Bishop 6 maintains that, " after marriage one cannot complain of an impediment known to him before ; but if he were ignorant of the existence of the defect, or of its incurable nature, though in himself, he may take advantage of it by suit of nullity. The marriage was a mistake ; the ends intended by it cannot be answered." Without sexual intercourse the ends of marriage, the procreation of children and the pleasures and enjoyments of matrimony, cannot be attained. According to Ayliffe, the first cause and reason of matri- mony ought to be the design of having offspring, the second the avoiding of fornication. The law recognizes these two as its principal ends. If the disease is merely temporary and the change in the physical condition of a party to a marriage contract, without his fault, is such as to render him less capable to discharge duties in the marital relations, it would be sufficient to justify its breach. But when the party is afflicted with a disease which is dangerous to the health of the party who comes in contact with him, as it would be necessarily communicated by sexual intercourse, and through her to affect their offspring with the poison, when it is connected with the fact that he was ignorant of the disease being upon him at the time he contracts to marry, he will be excused for the non-performance of his undertaking. While the contract to marry is silent as to any condition, it must be implied that any subsequent change in the physical or mental con- dition of either party, without fault, so as to render it impossible in the nature of things to accomplish the objects of the marriage relation, will release the parties from agreement. Impotency, insanity, or such a diseased condition of the body as would affect the offspring and endanger the life of the mother if the contract were carried out, would certainly be within this rule. 6 Bishop. " Marriage and Divorce," 6th Edition, p. 582. SYPHILIS AND MARRIAGE 3 2 7 Another case of the kind is reported as Allen vs. Baker, in which the opinion was delivered by Justice Ruffin. The defendant refused to comply with his contract because he was affected with syphilis. The disease was contracted before entering into the contract, but he had been advised, and firmly believed that he could be cured in time, and so be enabled to fulfill his engagement. The judge said that acting in good faith, and from a conscientious conviction that his disease was incurable, he refused to comply with his agreement. The court in that case said, 7 " We cannot understand how one can be liable for not fulfilling a contract when the very performance of it would in itself amount to a great crime, not only against the individual, but against society itself." In this case the judge found that if the defendant would be compelled to marry and avail himself of his con- jugal rights, he would necessarily communicate syphilis to his wife and to his offspring, and that to inflict upon him punishment by way of damages for not executing the contract, would be compelling him to do that which is against law, human and divine. The disease renders him incapable of marriage without actual damage to the life of the woman by communicating to her and through her to their offspring a disease which is now gradually destroying this man. No greater crime in law or morals could have been com- mitted than the performance of his agreement. The purity of our social system, the interest of the public in preserving sacred the marital relation, the protection of those whose existence may spring from such an unholy alliance, as well as the future welfare and happiness of the parties themselves, require that such a construction should be given to this class of contracts. He maintained that the answer of the de- fendant presented a valid defense and in consequence he reversed the judgment. In the Court of Common Pleas of Hamilton County, Ohio, Judge Frederick Spiegel decided a case of application for divorce of a man perfectly healthy, who had married a syphilitic woman. The reason for which divorce was asked was on account of infected children. The man, before marrying, knew that the woman had been syphilitic, but she assured him that she had been perfectly cured. After a few months of marriage the wife conceived, and at the end of the fifth month she had a miscarriage. After this she became pregnant again and a stillborn child was the result. The third babe was born alive, but two weeks after was covered with papular syphilide. Treatment was instituted and the babe grew better of the eruption, but after a while it began to suffer with eclampsia and was affected with hemiplegia. After such terrible consequences the husband began to brood * 86. N. C, 91. 328 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS over his condition and look to his wife as the cause of his misfortune, and he applied for a divorce from her. The court appointed two ex- perts to investigate the condition of the health of both parties and report. We examined first the husband, a man thirty-two years old, a fine specimen of manhood ; he did not remember of ever having been sick in his life. The most careful examination failed to reveal any syphilitic sign. In consequence he was declared perfectly healthy. The examination of his wife was as follows : A small and sickly woman, anemic, exceedingly nervous, admitted to have been acci- dentally infected with syphilis for over nine years. In fact, on the internal surface of the mucous membrane of the inferior lip she showed a well-marked cicatrix where the initial lesion took place. The tongue and the mucous membrane of the cheeks still showed opaline patches, and the arch of the palate was red with dilated blood vessels. Cer- vical, subaxillary, epitrochlear and inguinal glands were still hard and perceptibly bore witness of the syphilitic adenopathy. On one of the shoulders a whitish scar, round in shape, showed that she had been affected with cutaneous gummata. The report was favorable to the husband. The judge, starting from the object of marriage, which is propagation and continuation of the species, found a healthy man bound to a sick woman. The result of such a marriage had been abortions, stillbirths, and one sick and paralyzed babe. This man with another woman could be happy and have a healthy family. The judge on this ground declared there was sufficient reason to dissolve the marital vows and have both free. He therefore granted divorce. However, as the husband had known that the woman he was going to marry had been syphilitic he accorded an alimony to the wife of $1700 and that the husband should pay the cost of the trial. This he cheerfully did so as to be free from a woman who on account of the syphilitic infection had become a disagreeable object to her husband. In our courts syphilis is considered a cause for divorce as a form of extreme cruelty. Indeed, a man who knows he has been infected, who has been warned by his physician not to marry on account of the danger of infecting his wife, commits, if he marries in spite of all, an act of extreme cruelty, and that woman who has been infected has a right to redress in the courts of justice. Honor must be attributed to the legislators of the State of Michi- gan, who in their session in 1899 enacted that: " Any person who has been afflicted with syphilis or gonorrhea, and has not been cured of the same, who shall marry, shall be deemed guilty of felony, and upon conviction thereof in any court of competent jurisdiction, shall be SYPHILIS AND MARRIAGE 329 punished by a fine of not less than five hundred dollars, or more than one thousand dollars, or by imprisonment in the State's prison at Jackson not more than five years, or both such fine and imprisonment in the discretion of the court." The fact remains, as Valentine 8 says, that Michigan stands in the front of the world in recognizing the dangers of uncured syphilis and gonorrhea. Syphilis, as one of the most repulsive of diseases, which con- taminates the healthy wife, which infects the offspring, which brings death or disease to the children, offers a good ground among acts of extreme cruelty for obtaining a divorce. THE MEDICAL SECRET Before leaving this part concerning the individual infected with syphilis, we wish to examine briefly two important questions which have reference to the physician in his relation to his syphilitic patient. The first is whether the physician is bound to maintain the medical secret in reference to syphilis and to what extent. This interesting subject was masterfully treated by Morrow 9 at the meeting of the American Dermatological Association in Washington, under the title of " Syphilis and the Medical Secret." The physician, no matter what theories or what dogmas he may follow, no matter to what school or sect he may belong, finds himself always under the obligation of secrecy in reference to any information of a patient's condition which he has obtained in the exercise of the profession. This is the Hippo- cratic oath, accepted and respected by the best medical men of any time, and considered as the duty of the physician towards his patients. It has always formed the code of duty, and a just and discreet pro- fessional secrecy is the base on which rests the principle of the con- fidential relations between physician and patient. If the patient expects so much from his physician in general, he expects much more of him in reference to venereal diseases, which on account of their shameful character would injure him in his social standing. On this tacit contract the patient goes to the physician and confides to him his secret trouble, relying on his discretion that his secret will never be divulged. The State, however, under the consideration of the necessity of preventing the spreading of contagious diseases, has made the social welfare- much superior to the interests of the individual, and has com- 8 Valentine, F. C. "The Irrigation Treatment of Gonorrhoea," p. 212. 9 Morrow, Prince A. " Syphilis and the Medical Secret." The Journal of Cutaneous Diseases, June, 1903. 330 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS pelled by law the physicians to report all cases of contagious diseases dangerous to the public health. In this way the authorities, notified of the existence of a disease of a contagious character, are enabled to isolate the case and protect the public from its spreading. Although syphilis and the venereal affections are of a contagious nature, in most of the countries they have not yet been included among those to be reported. In Norway and in Denmark, however, the ven- ereal diseases must by law be reported by the physician just as any other contagious affection. With this measure they claim a great gain in the diminution of the venereal diseases, for the reason that the authorities are able to locate the dangerous sources of contagium and keep them under surveillance, and compel the infected individuals to undergo a thorough treatment. We, however, do not agree with their opinion, and we believe that the obligatory denunciation by the physi- cians of all venereal affections to be dangerous and injurious to the community. The reported diminution of venereal affections is rather ephemeral, and according to our opinion finds its cause in the conceal- ment of the venereal afflictions. When a man is infected, instead of going to consult a good physician or a specialist, he will avoid him as a spy, because he knows that he will report his case to the sanitary bureau. He will conceal his sufferings, and will rather consult a drug- gist or an herboiist, but will never go to a respectable physician. As a consequence, this measure will tend to increase the chances for quacks and charlatans, who, being unscrupulous, will avoid the law and extort money from the unfortunate victims. As long as the infected indi- vidual remains by himself and follows the rules given him by his physician, there is no trouble in maintaining his secret. But there are a great many circumstances where the health of others is con r cerned, and the physician finds himself in the dilemma of revealing, or at least of making known, his secret, or exposing the health and the welfare of others. In the case of marriage, for instance, it is the duty of the physi- cian to explain to his patient the danger of syphilitic infection for the wife, and of the hereditary transmission of syphilis to his children. The patient, therefore, has to subject himself to a long and thorough treatment for a period of years, before he can venture married life. Most of the patients readily accept the advice of the physician, and on their part there is no trouble. In some circumstances, however, it will happen that a patient, fully aware of the importance of the disease with the resulting dangers, will still insist on the necessity of his marriage. In some cases the marriage has already been announced, and it would be an impossibility to postpone or break off the engage- ment. In other cases, for other reasons he will insist on g-ettinq- mar- SYPHILIS AND MARRIAGE 331 ried, exposing in this way an innocent girl to the ravages of syphilis. In cases of this kind the idea of keeping the secret would be nothing else than abetting a crime, and we do not see any duty on the part of the physician of sticking to his obligation of secrecy. In this case it is the question of saving a young woman from the ravages of syphilis. Only the physician knows that the intended groom is infected and will surely infect her, and he is the only man who can save her from the sufferings and the torture of syphilis. The Hippocratic oath enjoins, 10 " My tongue shall be silent as to the secrets which are confided to me, and I will not use my profession to corrupt manners or aid crime." AVhen we are persuaded that the marriage of such a man is nothing more than a contemplated crime, which he wants to commit on account of selfishness and even of sordid motives, then it is our duty as men of honor to stop such an iniquitous wrong. This code cannot be made to protect a man who seeks to make unhappy an innocent woman in her married life, and in this case a hint given to her family physician would be a blessing for that family. We cannot refrain from reproducing the following case referred to by Langlebert, and quoted by Morrow : " The father of a young woman asks information relative to the health of a young man (your patient) w T ho is engaged to his daughter. ' I wish to ask under the seal of secrecy certain details as to his malady. I beg you to say whether I can or cannot accept him as a son-in-law. I hope that you will take into consideration the embarrassment of a father placed between the desire to give his daughter the husband of her choice, and the fear of the results the marriage may have if the hints that have been given me are unfortunately true.' " " In the case given above," says Langlebert, " should the physician, entrenching himself behind the Hippocratic oath and the prescriptions of the law, keep absolute silence, or only interrogating his conscience, should he make it the judge of the secret confided to him, to divulge it or be silent, according to the circumstances ? " We do not differ from the opinion of Dr. Goide, who in com- menting upon this case said : " If a client affected with constitutional syphilis, which resists all treatment, does not fear to solicit the hand of a pure young woman, who is the joy of her family ; if the father of this young woman comes to demand of me in confidence if he can in all security give her to this man who would soil her by his first contact and leave her as her only consolation children affected by his malady, shall we respond by a silence which may be misunderstood, and thus render ourselves accomplices of a marriage, the fruits of which will be so deplorable? Never would I have the courage to 10 Morrow. L. c. 332 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS obey the law under such circumstances. My conscience would speak higher than it and without hesitation I should say, ' No, do not give your daughter to this man,' and I would not add another word." Langlebert indicates the physician's role as follows: "I regret that I cannot give the information you ask. The least you can do, if you intend to carry out this project of marriage, is to inform the young man of the warnings you have received, or have him come with you or send me a note by which he authorizes me without restriction to say whether he can or cannot espouse your daughter. " The physician ought to interdict all kinds of information as to the health of a patient on the occasion of marriage ; as a professional principle, an invariable rule of conduct, he should take refuge behind the proscription of the law. " The alternative is cruel ; it requires a certain courage in such cases for the physician to remain master of himself and faithful to his duty. " If it be a misfortune to society, it would be a much greater damage to permit the enfeeblement of the tutelary principle of the medical secret, which is one of the necessities even of the social order." Much ado about nothing ! In our estimation this medical secret in the circumstances referred to is greatly overrated. We do not be- lieve that we serve as detectives, no, but when a father of an intended bride comes to us and asks if he can marry his daughter to Mr. X, our patient, and we know that he is affected with syphilis in full blast, we believe that it would be cruel not to reply frankly, " No," or at least, " Not at present." That no will save that poor woman from so many sufferings, will save her from having dead or sickly children, will save a family from many troubles. Indeed, we must approve the frank and decided way of Juhel Renoy, who claims it not only lawful, but compulsory, for a doctor to oppose and even denounce any criminal project which his patient may entertain in reference to marriage. So decisive an action is greatly disapproved by Jullien, who goes so far as to call the action of his colleague a treason, for the reason that his patient confided to him the secret of his disease, as a secret, fully persuaded that it would not be divulged. Of the same opinion is Thibierge, who is also firmly convinced of the necessity of maintaining the medical secret. He claims that although the physician is troubled in his conscience on keeping the secret, regarding himself almost as an accomplice in an action which he condemns, yet he must never forget that " no one is sufficiently sure of his conscience to put it above the law." He states that the enforcement of the obligation of the medical secret is an indispensable condition for the public prophylaxis. When the patient could not rely SYPHILIS AND MARRIAGE 333 on the silence of his physician, he would rather go to a quack from whom he can buy secrecy. Timorous patients, under the wrong im- pression of having had syphilis when they had only a slight venereal accident, laboring under the idea that a syphilitic man must not marry, may remain celibates. Others who had a very mild case of syphilis, for the fear of confiding their secret to a physician, would remain without treatment and then marry and so infect their wives. While others, having had syphilis many years previously, under the impres- sion that it was not safe for them to marry, would remain single. He concludes that from the relaxation from the obligation of the medical secret there would result grave disadvantages for individuals and for society. We do not deny that in all his arguments there is some truth, we know well that the syphilitic patient wants to conceal his trouble, and is therefore constantly on his guard against anything which might raise suspicion as to his condition. We maintain the secret of our patients and we consider it as sacred as our word. In the ordinary cases, when our patient has been warned not to marry for two or three years, he accepts the word of the doctor as final and will not speak of marriage until he has his physician's assent. If a man infected with syphilis and warned of the danger of infecting his wife if he should marry, still persists in his intended marriage, he does not tell us who his intended bride is nor where she is. Neither has it ever happened to us that a patient has insistently replied, " I want to get married in spite of your warning " ; but they remain silent, or they say, " we'll see about putting it off," or " I will take my time." In this way the physician has no idea that his patient will get married in the condition in which he is, and although he should have the suspicion that his patient will carry out his purposes, yet it is im- possible for him to do anything to prevent the consummation of marriage. If as an exception there should present itself to us a repetition of the case of Langlebert, then without saying what is the disease for which the intended son-in-law is under our treatment, we should advise the gentleman to postpone the marriage of his daughter in- definitely, as his intended son-in-law is too sick to get married. We believe that a reply in this sense will not be against the obligation "of the medical secret, and at the same time will put on their guard the family of the intended bride and postpone the nuptials. If it should happen that a patient with a recent attack of syphilis were such a brute as to insist on his intended marriage with the certainty of infecting his wife, then we will say with Morrow, that the physician must be guided by his own conscience and light in the 334 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS matter. In such a case a monster who has no feelings, no heart and no conscience would not deserve to be protected by the professional secret, and the physician who would remain indifferent to the perpe- tration of such a criminal act, disclaiming all responsibility on account of the law of medical secrecy, would deserve all the blame. We have had other cases where the medical secret could not be maintained. A young man after his graduation from a literary college, finding himself free from its yoke, trying to sip the pleasures of the world, contracted syphilis. A mild roseolar eruption followed and he came under our treatment. His father, who was already aware that his son was no more in good health, found some bottles with our name on them. He called, and with exquisite kindness requested to know the ailment of his son. In this case it was the father who wanted to know from what his son was suffering; it was not a case of making the secret known to anybody else for any purpose, but was for the protection of the family. The reply was that his son was affected with syphilis. It was a case where the question could not be answered in any other way. The secret remained buried in the family for the protection of the others. It has happened, although very rarely, that we have been called before the court to testify for what disease our patient was under treatment, in cases of divorce, or in criminal actions. We have asked the opinion of Hon. Otto Pfleger, Judge of the Court of Common Pleas in Cincinnati, concerning the privilege of the medical secret be- tween physician and patient before the court. His reply is as follows : That the relationship between the physician and patient is a sacred one and should under all circumstances be protected in law, more so than that existing between the lawyer and his client or the priest and his confessor, we would all say is axiomatic. It may be necessary for a patient to inform his physician of some secret occurrence in order to enlighten him and save his life. This, however, is not always true of a client to his attorney, and not of a communicant to his priest. The common law, which is based on the decisions of the courts of England, and of the United States as contradistinguished from laws passed by legislative enactment, made communications between an attorney and client privileged, but this is not so of communications between a physician and a patient. The latter are privileged where the legislatures in consideration of public policy have passed special laws on that subject forbidding the disclosure in evidence against the will of the patient of informations acquired by the physician in his pro- fessional capacity. The following States have such a law, — California. Colorado, Indiana, Iowa, Kansas, Michigan, Missouri, Montana, Xew York, Pennsylvania and Wisconsin. SYPHILIS AND MARRIAGE 335 The State of Ohio, standing alone in this respect, has the following law upon its statute book: Sec. 5241. The following persons shall not testify in certain respects. 1. An attorney concerning a communication made to him by his client in that relation, or his advice to his client, or a physician con- cerning a communication made to him by his patient in that relation, or his advice to his patient ; but the attorney or physician may testify by express consent of the client or patient ; and if the client or patient voluntarily testify, the attorney or physician may be compelled to testify on the same subject. This law so far as the relation of attorney and client is concerned, was construed by the highest courts of the State in i860 to mean that this secrecy is a privilege of the client, and that where the client voluntarily took the witness stand and gave evidence generally (al- though not specifically regarding the confidential communication) he lost his privilege, and thereby consented to the examination of his attorney and of himself touching any admission made by him. (See King vs. Barrett, 11 Ohio State Reports, p. 261.) In 1877 the law was again under review in the forgery case of Duttenhofer against the State (34 Ohio State Rep. p. 91.) This time the court decided that this law did not apply to criminal cases, and the common law, making such communications between an attorney and client absolutely privileged, unless consented to by the client, would be followed. The principle decided in the first case is applicable to the relationship of physician and patient. If the patient is a mere witness and not a party to the case, the communication is privileged, but inasmuch as a physician is seldom called except in cases where his patient is one of the parties litigant, and as such patient invariably takes the witness stand in his own behalf, it seems there is practically no protection in Ohio, for either the patient or his physician in a civil proceeding. To give this matter a practical test in the courts would require much courage on the part of a physician, because his refusal to answer would amount to a contempt of court in interfering with the adminis- tration of justice, and would result in a fine and possible imprison- ment. Perhaps a martyr to the cause may some day be found. There is at least room for proper legislation on this subject. In divorce cases, for instance, no expedient has any value ; before the court we must answer yes or no, or be sent to jail. In these cases the defendant is placed on the stand and testifies himself on his condition, and he has to open his secret himself, so that it would be of no benefit in the case for the physician to remain obstinate in his silence. 336 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS We thoroughly understand the importance of the medical secret, we respect it and maintain it as the highest duty, but we find that in particular circumstances, when the health of others is involved, and in cases where the administration of justice shall require, this medical secret is bound to be revealed. PROFESSIONAL ETHICS WITH SYPHILITIC PATIEXTS Another question arises in reference to the ethics of the physician towards his patient. All questions of this kind are difficult to trace and their solution rests rather with the personal tact of the physician than with his professional knowledge. When we make the diagnosis of syphilis, and we tell the gentleman or lady that he or she is affected with the dreaded disease, this creates an embarrassing position, which is connected not only with the present, but also with the future of the patient. In the hospital service and in the public clinics we do not care much for ethical rules ; we dictate the diagnosis to the assistant physi- cian and we limit ourselves to telling the patient, " you have syphilis, you must be careful because you may infect anyone who comes into contact with you or with objects which you have used, such as pipes, glasses, spoons, etc." In private practice the condition is very different and the question may still arise, " Shall the patient be informed that he or she has syphilis?" (Klotz.) X1 Under ordinary circumstances it is our strict duty to inform the patient of his disease, so as to place him on guard against the con- tagiousness of the affection, especially in the early stages. Further- more, we need the co-operation of the patient for the continuance of the treatment, and also for the abandonment of some habits, such as the use of tobacco and intoxicants, which when retained usually have a disastrous influence on his future. Truth is necessary to inspire confidence in our patient, and if truth is withheld even for a reasonable purpose, the idea of deception may shake the reliance of the patient in the word of the physician. In some cases, however, taking into consideration the nervous sensibility of the patient, the circumstances in which he is placed, we may deem it wiser to withhold our diagnosis for a time until the patient is better prepared for the real situation. Many have a horror of the disease and the idea of the possibility of causing or of having caused infection in others may lead them to some rash act. Fournier has already referred to a long list of suicides as a consequence of syphilis. 11 Klotz. " A System of Genito-urinary Diseases," etc. " Syphilology," 1893, p. 683. SYPHILIS AND MARRIAGE 337 In the case of a nervous patient, where the idea of syphilis would cause a deep and sad impression, we believe with Klotz, that it is better to give to the patient the benefit of the doubt. We can point to the possibility of an infection, and later on, when the patient is better prepared, he will be informed of the real condition. As long as the patient is responsible only to himself for his acquired trouble, our position towards the patient is not so difficult ; but when the party is married, then our position is more delicate and difficult. It must always be remembered that there is the possibility of an accidental infection, and we must regard our patient just as if he had been infected without culpability. The most important point for the physician is to instruct the patient as to the contagious nature of the disease, so as to save others from being infected. In the case of a wife who has been infected by her husband, when the plain truth would bring trouble into the family, we prefer to leave her in ignorance of her condition, not for the purpose of shielding the guilty party, but for the sake of peace. When infection has taken place we believe it will be of no advantage to a woman to know that her disease has been communicated to her by her husband, and cause quarrels and lawsuits in the family. Quite often we have pointed out the infectious nature of the disease, and the pos- sibility of transmission, but we have withheld the name of the disease, to keep things quiet. In case of hereditary syphilis we believe much more in withhold- ing the name of the disease, rather than in destroying the confidence and the love of the children towards their parents. The physician has no right to constitute himself a judge of the morality of his patient, and although the patient has acquired syphilis as a result of his own indiscretion, it is not right for the physician to consider him as a criminal. The man infected with syphilis, although through culpable exposure, is a sick man and he is entitled to the same care and to the same attention as patients affected with other diseases. It is inhuman and cruel of some religious people who are striving to deny admittance into the hospitals to patients affected with syphilis, on the plea that the disease is the result of indiscretion. This is the result of their ignorance, because they will admit into the hospital a . patient paralyzed on account of cerebral syphilis, and deny treatment to a patient with syphilis in the secondary period. A few weeks' treat- ment in the secondary stage of syphilis would have prevented cerebral syphilis and that patient would never have had to occupy that bed in the hospital for a long time under medical service. Diseases which are the result of indiscretions are many, and if these are admitted into the hospitals, syphilitic patients must enjoy the 338 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS same rights. One of the most powerful means of checking the spread- ing of syphilis is the isolation of the patients, and when we can have a syphilitic patient in the hospital, it is a great gain in this direction. A well-directed treatment for a syphilitic patient, administered in the hospital at the beginning of the secondary period, will, we are certain, save many months of treatment later on when tertiary symptoms will develop. A ward in the hospital for syphilitic patients is a necessity, and will be of great benefit for the prevention of the spreading of the infection, and for diminishing the ravages of tertiary syphilis. SYPHILIS IN REFERENCE TO MARRIAGE AND TO FAMILY The fact that syphilis is transmitted from the parents as a sad heredity to their children has been universally accepted only in recent times. Many have denied the transmission of syphilis by heredity, and Kluge 12 admitted that syphilis from the mother passes to the child only when the genitals are affected with chancres or ulcerations, and the babe became in this way inoculated. Hunter maintained that syphilitic infection of the offspring in utero was possible only when the mother was affected with syphilis, and he denied the transmission of syphilis by heredity when the fathei was suffering with secondary syphilis, and the mother remained still healthy. Hunter, however, believed that only the pus of the initial chancre was capable of transmitting the disease, which through the blood vessels of the placenta was carried to the fetus. While Hunter admitted the possibility of the infection of the fetus from the mother, and denied the transmission of syphilis from the father, Swediaur 13 maintained that syphilis could be transmitted from the father to the fetus through the semen, but did not mention the fact 'of the transmission of syphilis from the mother. Ricord and his followers, although they denied the inoculability of syphilis through the blood and purulent secretions from a syphilitic patient, yet they admitted the transmission of syphilis to the offspring from both sides, either from the father or from the infected mother. In most of the cases of the children carrying with them this sad heritage from the uterus, the affection must be recognized as coming from the father. Montanier maintained that some men affected with latent syphilis communicate the disease to the wife, without finding in the woman traces where the virus has found its entrance into the 12 Behrend. Archiv fur Syphilis und Hautkrank. Berlin, 1846, 1st B. 1st Heft. 13 Swediaur. " Traite complet des maladies syphilitiques," par Swediaar. Paris, 1801. SYPHILIS AND MARRIAGE 339 system. The same opinion was expressed by Cullerier, Simonet and Oewre, that syphilis from the father is transmitted to the offspring through the mother. Drysdale, however, found that this assertion did not correspond to his experience, but agrees with the fact that when the mother is affected with syphilis the children are more certain to be affected with congenital syphilis. Zeissl is of the opinion that men affected with syphilis can generate syphilitic children while the mother remains apparently healthy. He has found that this immunity is only apparent, as he had often occasion to observe those ladies married to men still suffering with so-called latent syphilis to lose their former fresh and healthy color, and although they have no children, they assume a chloro-anemic appearance, their glands become swollen, they complain of sternal neuralgia, in a word, they have symptoms of syphilis and only a well-directed antisyphilitic treatment can help them. The fear of the transmission of the syphilitic infection to wife and family has to-day spread in all classes of men, so that everyone who has been infected is interested to know what the chances are of trans- mitting syphilis in case of marriage. Henrick Ibsen had the courage to show in his magnificent drama, " The Ghosts," young Oswald ill and suffering, who has learned from his physician the sad truth that he has syphilis of the brain as sad inheritance from his dissipated father. If a man affected with syphilis in its early stage, with secondary eruption, should get married, he is a criminal and ought to be punished for his offense. There is no doubt that his wife will be affected with syphilis in the same way as this disease is ordinarily acquired. A poor woman affected with syphilis and a gonorrheal endome- tritis, contracted from her husband, was innocently asking the following question : " Doctor, can you tell me how it is that a girl soon after she is married has to suffer so much with her womb, and with her general health? I can say that since the first days of my married life I have never had a day when I have felt well. This experience is not mine alone, but other girls, my schoolmates, healthy and strong as I was, after marrying have suffered and are suffering just as I am." The reader will understand that the answer which we could give in that case was such a one as would have only a palliative effect. We found it much better to conceal the cruel truth from her, because it was too hard to tell her plainly that her husband, infected with loath- some diseases, the result of his dissipation, had infected her, and she was suffering on his account. To have taken her from her innocent ignorance would have aroused ill feeling and quarrels in the family. 340 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS We thought it better to evade the question and let her be happy in her ignorance, advising her to continue her treatment. Our interest is directed to those persons who have once been af- fected with syphilis and have undergone a good and sufficient treat- ment. They have seen no more symptoms of active syphilis, they wish to enter married life, and they want to know if they can get married, not only without any fear of infecting the wife, but also without fear of having children affected with hereditary syphilis. Indeed, the relations of syphilis to marriage are of the greatest importance, as they involve pathological consequences which not only affect the interest of the family, but also society at large. The spread- ing of syphilis happens not only by the act of intersexual relation, but it can be introduced in a subdolous way, as happens through conception. Syphilis makes marriage unhappy. The idea of easily getting sick, the recurrence of rheumatoid affections, of ulcerated gummata, al- though of a superficial type, make life tiresome and gloomy. When infection has been communicated to the wife any symptom which may occur is a cause of regret and of grief. It destroys the mutual love and esteem between husband and wife which is the necessary founda- tion of marriage. Syphilis is not only capable of destroying the fetus in utero, or of showing up in the offspring in all its forms, but transmits a defective organization ; the infant comes into this life lacking in development, stamped with inferiority. So that Morrow 14 wisely remarks that syph- ilis is not only a factor of depopulation, but a cause of degeneration of the race. We will not be accused of pessimism if we say that syphilis increases a great deal the egotism, which is a sign of decay. This unnatural selfishness is a consequence of the exhaustion of the vitality of the species as well as of the individual, hence the family instinct dies out. The question is a very vital one, as there is nothing more im- portant than the perpetuation of the race, and syphilis kills the product of love, or stains it with its filthy poison in order to make the offspring sickly and hideous. The wish for the companionship of a person of the other sex, which naturally arises from the impulse of procreation, is dulled and decreased by the idea of being infected with svphilis. When a married man has been affected with syphilis, he is often sad and gloomy in his thoughts and cannot be a pleasant and congenial companion. In highly cultured classes of society, where instruction and education have attained a great development, the sexual impulse becomes exclusive and discriminating, which is the reason why the offspring come full of vitality and energy. It is thus that marriage, 14 Morrow, P. A. " Social Diseases and Marriage." 1904, p. 182. SYPHILIS AND MARRIAGE 341 as Nordau 15 says, the only relationship between man and woman coun- tenanced by society in which offspring are produced, should be the result of love. Love is the great regulator of the life of the race, the impelling force which promotes the perfecting of the species and pre- vents its physical decay. When the thought of the possible infection of the wife or of the offspring is weighing on the conscience of a man, the mutual attraction cannot be sincere and cordial. There is a mental flaw, which will be revealed in the future of the offspring. The chil- dren, if they escape infection, will inherit the faults of the parents, probably increased, and their good qualities will be modified or probably lacking. When infection takes place, although in a very mild form, the children sickly and tainted, show signs of a poor and miserable generation. This will produce children belonging to that class known as not only degenerates, but also as perverted. The idea of syphilis in the family which has been introduced by the father will always remain as a tormenting thought, which on occasion of any little indisposition of the children or of the wife is renewed, and it will mar the family life with a sorrowful unrest. It is impossible for a woman to forget that one of the first presents she received from her husband was a disease, and no matter what social rank he may have given to her, no matter what dresses and ornaments, she cannot have any esteem, much less love, for such a companion. The woman is in every way the victim, who is infected either directly or indirectly through conception. The man, when destitute of the courage to assume the responsi- bility of having a family, fearing that the disease may manifest itself in his children, concludes to remain unmarried. He will remain a confirmed old bachelor. In all these cases the physician plays an interesting role. He has to deal with vital problems which reflect on society from a physical and moral standpoint. It is his task to stop a marriage by his veto, or it falls to him to allow the marriage. A great responsibility weig-hs upon him, for from the solution of these problems depends the happi- ness and the future of a family. The idea that syphilis cannot be cured is a great mistake, and equally wrong is that idea that as a consequence the man who has been once infected must never get married. We have seen that syphilis is curable and it is permanently cured. In our rather long practice we have had occasion to treat many young men infected with syphilis. who after a period of some years have married, and neither they nor their wives have shown signs of the disease, and their families are healthy and happy. In this regard A. Fournier 16 is right when he 15 Nordau, Max. " Conventional Lies of our Civilization," p. 277. 16 Fournier, A. " Syphilis et manage." Paris, 1890, p. 20. 342 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS reproaches his colleagues, who have entertained such gloomy ideas in reference to the marriage of syphilitic persons, as absolutely to forbid them to marry, under the assertion that " when a man has unfortunately contracted syphilis, he must keep it for himself, and never expose his wife and children to the danger of this disease." Such an assertion we find without foundation and without a scientific basis, and we accept that of Fournier, which agrees with our expe- rience, that " when a man has syphilis, he must strive to get well, and when through a continuous treatment the disease has been rendered harmless for himself and for others, then he can re-enter the ordinary conditions of life and he can aspire to marriage." Indeed, syphilis does not constitute a permanent impediment to marriage, but it entails only a temporary interdiction. After a certain period of treatment the disease gradually dies out, the man returns to his normal condition of health, and he can without fear have a wife and children. Fournier refers to the observation of eighty-seven young men who had been infected with syphilis and who after a rational treatment of regular duration have married and have never communicated any suspicious symptom to their wives, and in a total of 156 children no traces of syphilis could be found. Consequently a man who has once been infected with syphilis can get married, but he has many conditions to comply with, and only after the fulfillment of them can he obtain a clean patent and enter married life. It is necessary, therefore, to exactly establish these conditions, which when neglected will expose to danger of infection the wife and the family. As we have seen in other chapters, it is not the question of time alone, but it is a question of undergoing a strong and heroic treatment. Without these two essentials of a certain period of time having elapsed from the infection, and of a regular specific treatment, the .man who has had syphilis, on entering married life becomes a danger for his wife, for his children, and for the community. II SYPHILIS IN RELATION TO DEGENERACY Syphilis is capable of producing malformations and anatomical deviations from the normal development and of degrading the un- fortunate descendants. We have already seen stigmata consisting in facial asymmetry, deformities of the palate, anomalies of the teeth, hare-lip, peculiar shape of the nose, all to be connected with a syphilitic parentage. It is now of vital interest to study the part which syphilis takes in anomalies and in disturbed or retarded development of the functions of the nervous system. These anomalies and any arrest of development must not be considered as direct syphilitic manifestations, but they are rather the result of the effect of the syphilitic taint on the blood and also on the lymph vessels causing these affections. In other chapters we have already mentioned the important anatomo- pathological alterations produced in the blood vessels from the be- ginning of the hard chancre to the formation of gummatous produc- tions. These alterations in the adventitia and much more in the intima of the vessels are so characteristic, that from the condition of their tunics the anatomo-pathological diagnosis of syphilis can be easily established. In many cases of children affected with hereditary syphilis we have found the same hyperplastic condition of the tunics of the blood vessels in different organs which did not show macroscopic pathological lesions. In order to gradually enter into the discussion of so important a subject we will refer to a case which has greatly impressed us in our practice. In 1886 we were treating a patient for ulcers of both legs. He was a young man, twenty-two years old, of rather delicate physique, had never acquired syphilis and had enjoyed rather good health. The ulcers of the legs, multiple, circumscribed, in a kidney-shaped disposi- tion, suggested a possible specific origin. Applications of mercurial plaster and large doses of potassium iodid cured the ulcers. While under treatment we had occasion to see the father of our patient for some trouble and we found that he showed unmistakable symptoms of acquired syphilis. For several years we lost sight of the patient, when he came to consult us in regard to his daughter, a little girl of eight, who was suffering with convulsions, which had been diagnosed by every physician as epileptic, and for which nobody had been able to do anything. 343 344 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS The little girl was of a rather weak constitution, but of a bright intelligence. Her skin was dry and of a yellowish hue. Connecting the links of the history of her grandfather, and of the ulcers of the legs of her father, it was not difficult to find the indication of a specific treatment. Under this treatment the epileptic attacks have disappeared and the girl is enjoying good health. We have already had occasion to mention a case of a family where the father was healthy, but the mother had been affected with syphilis when a young girl. She had nine pregnancies in succession which resulted in abortions and dead children. Finally after undergoing severe antisyphilitic treatment during pregnancy, she gave birth to a healthy child. It was a boy who remained well until the age of five, when he was taken with spasms. It was a clear case of Jacksonian epilepsy, the attacks beginning from the left leg. The boy was treated with inunctions with mercurial ointment, and internally with large doses of iodide of potassium. The attacks have disappeared and since then the boy has always been well, is attending school and shows him- self to be rather intelligent. Epilepsy is not a syphilitic affection, it is rather a symptom of cerebral disturbance, although many neurologists are inclined to con- sider it as a pure neurosis without recognizable lesion. Chaslin stated that he had found in true epilepsy sclerosis of the neuroglia of the convolutions, an alteration which he called gliosis, and which would prove to be a congenital malformation of the external layer of the blastoderm, and could be connected with a heredo-syphilitic parentage. Partial epilepsy described so well by Hughlings Jackson forms a portion of the symptomatic syndrome of an acute or chronic form of meningitis. Syphilis is one of the most important etiological factors, and it is universally admitted that the presence of gummatous forma- tions in the meninges or in the brain produce this peculiar form of partial epilepsy. It is, however, a parasyphilitic affection, because it is produced in the same way by traumatism, fractures with depression on the cerebral cortex, and is a valuable sign in the case of surgical interference. It has been found in persons who had been previously attacked with hemiplegia or partial paralysis, which must be considered as the result of cerebral lesion from alteration of the blood vessels. These alterations in most of the cases result from the condition of the tunics, and of the interior of the blood vessels induced by syphilis. The at- tack is exactly the same, if produced by syphilis or if resulting from any other cause, but on many occasions the antisyphilitic treatment has been of great benefit to the sufferers. In partial epilepsy the attack is often preceded by some sensation SYPHILIS IN RELATION TO DEGENERACY 345 of pain, cold, or numbness in the limb where the initial spasm takes place. These alterations of sensation are to be considered like the aura epileptica. In partial epilepsy in some cases the patient does not lose consciousness and the attack remains strictly partial. It may begin from the face, the spasms starting from an eye or from the mouth and then spreading to the rest of the face with contractions of the eyelids, of the lips, of the muscle levator alae nasi, gnashing of the teeth, ex- tending at times to the muscles of the neck. When the attack commences from the extremities, it is the thumb and the index finger, or the great toe, which are flexed convulsively, and from them the spasms extend to the arm or to the leg. The greater or less spreading of the spasm causes great difference in the clinical appearance of the attack, so that in some cases, although it begins as partial in one extremity, it spreads to the whole body with loss of con- sciousness. In some cases after the attack of partial epilepsy there remains a weakness in the affected muscles, which at times may reach the degree of transitory paralysis, and even disturbances of speech, stammering, paraphasia and true aphasia. These conditions are more liable to appear after the attacks of partial epilepsy than after general epilepsy. Usually in this affection the attacks begin on the same side and in the same group of muscles. In this connection we find it of some interest to refer to a case of ophthalmic migraine, which was greatly benefited by an antisyphilitic treatment. The patient was a man of forty, of rather dull perception, but well educated. He showed a strange conformation of the skull, cranium nati forme, and his right hand and arm were weak and poorly developed on account of infantile paralysis, which he remembered in his early youth, associated with recurrent spasms. He was afflicted with attacks of violent pains in the left half of his head and face, accompanied with scintillating scotoma, which lasted for some time, then a period of exhaustion followed and he fell into a somnolence which lasted for a few hours. There was no doubt that the affection was one of ophthalmic migraine. The most persisent and dreaded symptoms were : the flash of light which he used to see at the beginning of each attack ; the violent headache, hemianopsia, and vertigo, which was followed by nausea and vomiting. The gentleman could not even raise his head from the pillow for fear of vertigo and of the flash of light, which he dreaded. We had never had occasion to see his parents or relatives ; his father was living in Italy, as were also two brothers, but nothing could be found to enlighten as to the history of the family. From the anatomical conformation of the skull, from the appearance and faulty 346 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS implantation of the teeth, from the history of spasms and hemiplegia in his infancy, the diagnosis of syphilis in the second or third genera- tion was justifiable. Our diagnosis, after a while, found good support in the result which we obtained when he was subjected to severe specific treatment. At present he has fully recovered, is attending to his occupations, and has never been troubled since. There is no doubt that his affection consisted in a partial epilepsy, produced by the condition of the blood vessels, induced by an inherited syphilitic taint. Like convulsive partial epilepsy, ophthalmic migraine at times occurs in a serial form, recurring several days in succession. In some cases the attacks are of an intermittent type and terminate in a period of stupor. In another patient, who had been luetic for years, there occurred attacks of ophthalmic migraine, which were followed by ptosis of the right eyelid. He gradually improved as far as the migraine was con- cerned, and began to raise the eyelid, which remained somewhat lower than the other. At the time of the attack of migraine he complained, not only of the flash of light in his right eye, but also of a loud noise in the ear of the same side. He was after a while seized with an apoplectic stroke, from which he recovered, leaving paralysis of the left arm associated with partial asphyxia of the fingers and hand, showing that the vasomotor nerves had been involved in the same process. In some cases one of the sterno-cleido-mastoid muscles has re- mained contracted, drawing the head away from the painful side. Ophthalmic migraine, although it has been considered as an accident of not much gravity, is nevertheless an ominous sign, which when con- nected with arterio-sclerosis may produce permanent paralysis, which will persist as monoplegias or hemiplegias, and even as diplegias, some- times with a fatal termination. We agree with the opinions expressed by Jullien, Tommasoli, Fere and others, that hereditary syphilis is an important factor in the causa- tion of epilepsy in children. A long list of different causes of epilepsy has been given, and Esquirol, Morel and Lucas have maintained that the influence of drunkenness at the moment of conception has a great influence in the production of epilepsy. Others have enumerated as its causes the use of the forceps at the moment of delivery, the long retention of the head in the pelvic cavity, the placing of the infant always on the same side, etc. Brown-Sequard 1 and Fere 2 have attached a great deal of im- 1 Brown-Sequard. Archiv. de Physiologie, 189 1. 2 Fere, Chas. " Les epilepsies et les epileptiques." 1890. SYPHILIS IN RELATION TO DEGENERACY 347 portance to a neuropathic taint transmitted from the parents to their children in the form of convulsions. Fere referred to the case of a man who in consequence of a trauma became epileptic, and had a daughter who at the age of five was affected with epilepsy. These observations, however, do not exclude the fact that syphilis is one of the most powerful factors in the production of epilepsy. Syphilis may cause convulsive attacks as poison in the secondary stage, without causing any anatomical lesion. We remember in our practice a girl of a Syrian family who contracted syphilis. At the first eruptive period she was seized with epileptic fits. As the syphilitic symptoms diminished in their intensity, the frequency and the severity of the convulsions gradually diminished. It is also possible that pre-existing epilepsy may be aggravated by acquiring syphilitic infection, and in this case antisyphilitic treatment will be of great advantage in cases of epilepsy. Fournier has estab- lished a para-syphilitic epilepsy, to which he could not assign any char- acteristic feature, nor any special type. During the tertiary stage of syphilis, epilepsy shows itself with some frequency. In these cases there is no doubt that epilepsy is the result of syphilitic lesions on the nervous tissue, such as the formation of a gumma, erosions of the cranial bones, specific inflammation of the meninges, alterations of the blood vessels. In our service in the City Hospital we remember a patient who was affected with an ulcerated gumma of the left knee, who had never before suffered with epilepsy, and in the ward he was attacked with several epileptic fits. Under an antisyphilitic treatment the ulcer of the knee was brought to recovery. By means of a prolonged antisyphilitic medication we obtained gratifying results in an Italian who had been epileptic for many years. He was a man with a peculiar conformation of the skull, with an asymmetric appearance of the parietal eminences and a pronounced protrusion of the frontal bone. His nose was somewhat sunken under the glabella, his teeth were irregular and decayed. Although he showed no signs to certify the presence of syphilis, yet from the malformations referred to we had every reason to suspect an hereditary syphilitic taint to be at the bottom of his sufferings. He suffered with minor attacks, petit mal, usually at night time, he was aware of the coming attack, as he woke up just before being affected. The attacks were so frequent as to recur twice in the same night. The man had no rest, he felt tired and despondent, as he felt himself unfit in the day time to attend to his occupation. ' With an active antisyphilitic treatment, consisting of subcutaneous injections of gray oil fifty per cent., and of iodipin, the attacks began to 348 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS diminish, so that for a while they were limited to one a week. Gradu- ally he improved so much that the last time he was seen he had not had any attack for over six weeks, he slept soundly, attended cheerfully to his occupation, and had gained considerably in weight. The case cannot be considered as an absolute cure, but we find the results to be very gratifying. Inherited syphilis, although in some cases it may produce epilepsy by anatomo-pathological alterations induced on the tissues, yet in most of them it only prepares the ground for the development of the dis- ease. According to Gowers 3 the affection which excites the convul- sions is most frequently at the cortex, and when an organic disease causes convulsions beginning at a certain locality, the disease is in- variably at the cortex. For this reason epilepsy is produced by any morbid affection of the gray matter of the cortex, and in some cases, as referred to by Fere and Chaslin, it is produced by a diffuse sclerosis of the neuroglia. We have dwelt somewhat on epilepsy for the reason that, in many cases, syphilis is the cause of the disease, or if not the direct one, one of the predisposing factors. There is no doubt that epilepsy produces a degeneration of the mind, and an epileptic has a psychical condition of his own. There are incomplete or aborted manifestations of epilepsy, which have been described as mental vacuity, which is a momentary sus- pension of the psychical functions, without convulsions. Besides this mental vacuity with inactivity of the intellectual faculty a dullness is associated with impulses, which makes the epileptic sometimes danger- ous to his family and to society. These mental disturbances may precede or follow a convulsive attack, but in some cases a kind of vertigo constitutes of itself the paroxysm equivalent to a psychical attack, which Maudsley compares to a mental convulsion. Under the influence of this attack, the patient is capable of exhibiting rude behavior, of damaging objects and even striking or killing people. Other patients may commit indecent acts, of which they do not retain any recollection, falling after a while into a state of prostration or into an epileptic fit. This state of vacuity of mind associated with impulses is usually of short duration, but at times may last for several hours, and Charcot has found it to last to the extent of one week. In this case the epileptic is capable of committing crimes necessitating a complexity of acts, such as theft, arson, etc. In their acts, the epileptics in this state of psychical condition, do not show anything to attract attention, on the contrary their actions appear reasonable and justified. The danger 3 Gowers. " Diseases of the Nervous System." SYPHILIS IN RELATION TO DEGENERACY 349 usually comes from the hallucinations of a terrifying nature, to which the patient is subject and under which he receives the dreaded im- pulses. Of course, in the whole act committed by an epileptic under the mental attack, there is something characteristic which makes it distin- guished from a criminal act feloniously committed. The impulsive act of an epileptic is sudden and independent of the ordinary circum- stances ; it is preceded by an irregular state of mind, restlessness, irri- tability. The act is constantly of the same kind, and always done in a like manner. Furthermore, in case of violence, there is a larger amount of force displayed than is necessary ; for instance, in a case of murder, the victim will be found with the head entirely severed from the body, or covered with wounds from head to foot, as the epileptic throws himself fiercely against the cadaver. The paroxysm ceases suddenly and it is followed by depression, the same debility which succeeds a convulsive crisis. The epileptic does not recollect anything of the act committed during the impulsion and unconsciousness is the characteristic of the delirium of the epileptic. The recurrence of the attacks causes nervous exhaustion, and it requires some days for the epileptic to regain the lost hemoglobin and to repair his mental activity. In consequence, often-recurring attacks cause deterioration of the whole system, the intellect perishes com- pletely, and the post-epileptic exhaustion is the cause of the dementia which is the end of some of these unfortunates. We can say that the moral and intellectual faculties in the epileptics usually are not so very well balanced. There is always something extravagant in the acting and in the talking of epileptics, at times they are easily excitable, at times they are sad and depressed. In a moment, from the sentiments of generosity and of jovial expansion, they fall to the opposite extreme of gloominess, jealousy and despondency. Under this depression and despondency, with the consciousness of inferiority and of impotence, the suicidal impulse sometimes arises. Their fre- quent hallucinations and terrifying dreams, to which they are subject, make them timorous and suspicious. Their mental oscillations are often the cause of remittent or circular insanity. In the epileptic, as a rule, the memory is often weak, perception is rather difficult, and conception is somewhat slow. In some epileptics occurs a sudden lighting up of the intelligence in the form of hyper- amnesia or hyperideation, which may last several hours or even some days preceding the paroxysm, but it is always followed by mental depression. Gradually the epileptic, with the repeated attacks, falls into 350 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS epileptic dementia. It has been stated that epilepsy is frequently associated with idiocy in such proportions that one-third of all idiots are epileptics. On the other hand, we find also a fair number of epileptics who do not show any sign of degeneracy. On the contrary, we know of great men who have suffered with epileptic attacks, and yet they have distinguished themselves in literary works. Anomalies in the epileptics may be found when epilepsy has begun at a very early period of life, and in these cases morphological or functional abnormalities may be present to show the intensity of the predisposition. Dumas de Montpellier 4 noted as an abnormality in epileptics the inferiority of the facial angle, Solbrig the narrowness and deformity of the vertebral canal. Lasegue laid great stress on the cranial, asymmetry, which he considered a constant abnormality in true epilep- tics. He considered epilepsy to be the result of malformations of the cranial bones which had taken place at the period of the ossification. Although this statement is entirely exaggerated, yet we cannot deny that cranio-facial asymmetry is often found associated with epilepsy. According to Fere the asymmetry affects the cranium and the face at the same time. It may be found that the frontal eminence is less marked on one side, or the parietal eminence is too prominent, the orbit less wide. In some cases, deviation of the nose gives a peculiar appearance to the lines of the face, while in other cases the inferior maxilla is shorter and the teeth are badly placed. Quite often the vault of the palate has been found highly arched. Among the cranial deformities we find at times a relative increase of one of the diameters, the vertical, forming sugar-loaf head, or an increase or diminution of the other diameters in the form of macrocephaly or microcephaly. Malformations have been found not only on the face and cranium, but also on other parts of the skeleton, as asymmetries of the thorax, of the pelvis, unequal length of the extremities, abnormal length of the fingers, polydactylism, syndactylism, etc. In the same way anomalies have been found in the eyes, as different colors of the irides, asymmetry of the pupils, deformity of the auricles, anomaly of the genital organs. It seems that the general nutrition in the epileptic is often im- paired. Bean remarked that epileptic girls menstruated later, and often showed signs of general disturbances and weariness. These stigmata are not found in all epileptics, but they are quite developed in hereditary epilepsy. The reader has already noted that these stigmata which have been found in epileptics, are just the same as we have found in heredo- syphilitic subjects. The organic deterioration of the epileptic can, 4 Quoted by Fere. " Twentieth Century Practice," Vol. x. SYPHILIS IN RELATION TO. DEGENERACY 351 therefore, be attributed without doubt to syphilis in the parents. Of this opinion we find Jacobi, who stated that many cases of epilepsy can be traced to inherited syphilis, and Holt, 5 who stated that syphilis may be the cause of epilepsy even when there is no local disease of the brain. In fact, persistent malnutrition of the infant, in spite of proper food and hygiene, is very suggestive of congenital syphilis. Hanson 6 said that he had no doubt that epilepsy may have its origin in the mal- nutrition of the second stage of acquired syphilis, while local endo- cranial diseases come later in the luetic history and are usually due to chronic inflammation or meningeal growths. Cases of epilepsy origi- nating from hereditary syphilis, according to Hanson, would develop later than those due to alcoholism. In the same way cases due to cranial asymmetry rarely begin after the eighteenth year. Epilepsy is often related to other defective mental conditions of pupils, which are unfortunately often brought to the attention of the sufferers by their teachers and by their companions with taunts and even with rebukes. .These conditions of association do not improve the capabili- ties, which could otherwise be developed, and they grow more reserved and timid, and sometimes spiteful and suspicious. Feeble-minded children are divided by Noyes into: 1. Those in whom the faculty of perception is deficient, as the deaf and blind. 2. Those having the special senses, but lacking the power of attention. 3. Those showing defects or diseases of will. 4. Those showing defects of reasoning power. 5. Those who are morally defective. We must not believe that syphilis is a general cause of epilepsy, but in a great many cases hereditary syphilis may be, if not the cause proxima, at least the predisposing cause of epilepsy. In many cases syphilis may act as a toxic element, like alcohol and lead poisoning, which in a neuropathic individual are capable of causing epileptic attacks. In other cases it may produce an irritative condition of the nervous cells on account of the condition of the lymph and blood vessels, which are so much changed on account of syphilis. In these conditions it is possible, as Esquirol, Morel, Lucas and others have maintained, that drunkenness of the parents in the moment of concep- tion may be of an injurious result on the nervous system of the off- spring, and epilepsy be the consequence. But when the condition of the blood and lymph vessels are such as to impair the development and 5 Holt. " The Diseases of Infancy and Childhood." L. Emmett Holt. New York, 1897. 6 Hanson. " Etiology and Propylaxis of Epilepsy." D. S. Hanson, Pedi- atrics, vol. xiv, No. s, 1902. 352 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS the nutrition of the neuron, we will find that syphilis will act as a primary predisposing cause, and drunkenness of the parents as the exciting cause of the epilepsy in the child. DEGENERACY It is not rare in our experience to meet and become acquainted, or even to enter into ties of friendship, with scientific men, with writers, poets, painters, etc., who gradually, under a keen study will reveal in their actions or talk some kind of abnormality in their reasoning, or some mental faults, which make us consider them in the group of " the cranks," as we call them in our American slang. They represent a class of people who show the greatest intellectual activity, and are able to command the respect and admiration of anyone who comes into contact with them. But when associating with them, it is easy to find out in their ordinary life, moments of extravagance which reveal something wrong or defective in their mental faculties. This class of people has been well defined by Nordau with the term, " fin de siecle " men, and have been grouped with the dusk of the nations. They show some limping point in their ideas and in their expressions. One will show some silliness in his conceptions and in his judgment, another will show some incoherence in his ideas. One will have some intermittance of excitement and depression of his mental faculties, while another will show depravity in his tastes and tend- encies. One will show himself passionate, irascible over matters of no importance, while another will show no emotion in the presence of serious events. In all their perceptions and conceptions, they are not exactly natural, and in the range of their mental manifestation is a kind of disharmony between their intellect and their emotions. A man who is not a plrysician finds a sufficient explanation in the terms caprice, eccentricity, affectation of novelty, instinct, but a physician recognizes in them hysteria, neurasthenia or degeneracy. They are degenerate in the sense of Morel, 7 who defined degeneracy as a morbid deviation from an original type, which has been accepted by Nordau. According to Morel, " this deviation, even if at the outset it was ever so slight, contained transmissible elements of such a nature that anyone bearing in him the germs, becomes more and more incapable of fulfilling his functions in the world " ; and mental progress already checked in his own person, finds itself menaced also in his descendants. When we inquire into the origin of this debilitation of the human race, we must see a pernicious morbid cause, which is capable of under- 7 Morel. " Traite des degenerescences physiques, intellectuelles et morales de l'espece humaine et de causes qui produisent ces varieties maladives." Par le Dr. B. A. Morel, Paris, 1857. SYPHILIS IN RELATION TO DEGENERACY 353 mining the constitution, the strength, the health, and the intellectual faculties of the affected people. Syphilis, the disease with the poetical name, has a great deal to do in the debilitation of the human race, and to such an extent that we do not hesitate to say that it is one of the most effective causes of degeneracy. We have already seen the peculiar deformities and dystrophies to which the descendants from syphilitic parents are subject, so characteristic, indeed, that they have been denominated stigmata or brand-marks. It is really an unfortunate termj as Nordau has remarked, including a false idea of degeneracy as if it were the consequence of a fault or the indication of a punish- ment. Such stigmata we have already seen consisting in asymmetry, or unequal development of the halves of the face and cranium ; imper- fection and malformation of the auriculae, which sometimes protrude from the head like handles, squint eyes, hare lips, irregularities in the form and in the position of the teeth, flat palates, supernumerary fingers. All these malformations cannot be explained in other ways than by a cause, which acts upon the vascular system, cutting off the nutrition with the arrest of development. We can study as much as we want, but we will always find syphilis in the developing embryo to be the only cause of the vascular alterations producing the referred dystrophies. If the originators of the fin de siecle movement have in themselves some characteristics which make them belong to the class of de- generates, very likely a physical examination of their organism will reveal a syphilitic hereditary taint. Stigmata, however, are not only of a physical nature, but there are some of a mental order, which, as we have already mentioned above, give a peculiar idea or some peculiar psychical mark to make them recognized as belonging to the degener- ates. These persons have already been designated as " borderland dwellers," by Maudsley and Ball, as being on the line between reason and madness. Magnau called them higher degenerates, and Lom- broso, " mattoids," from the Italian word matto, insane. The asymmetry which we have found in the face and cranium of those individuals is repeated in their mental faculties, of which some are nearly stunted, others greatly excited. The degenerate, accord- ing to Nordau, has a flaw in the sense of morality and of right and wrong. For them there is no law, no decency, no modesty. Some of them are capable of committing crimes for the purpose of satisfying their impulse or caprice, and without any regret or even notice of their offense. These persons, according to Maudsley, are affected with moral insanity. But there are others in a lower stage, who do not commit any crime, but yet they boast of the theoretical legitimacy of the crime. Thev have their own ideas about eood and evil, virtue 354 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS and vice, which they consider only simple distinctions. They admire and speak of the greatness of evil-doers as of heroes, they try to find beauty in hideousness, and call attention to every bestiality. In con- sequence the psychological stigmata of moral insanity in all its degrees are referred to Egoism and Impulsiveness. The person in this condi- tion of moral weakness is unable to resist a sudden impulse and com- mits any deed for his egoism. The emotions in the degenerate are greatly exaggerated, so that he will laugh or shed tears for entirely inadequate reasons. He thinks his excitability a mark of superiority, and believes himself above the others, whom he considers vulgar and narrow-minded. In others, a condition of mental weakness and despondency is the prevalent sign of degeneracy, they have a vague fear of everybody, they commiserate themselves and feel tired of themselves. The sufferer is a melancholic one, who is downcast, despairing of himself and of the world, fears the unknown, and believes himself menaced by dangers. He touches the landmark of the paranoiac. This dejection of the degenerate is combined with a disinclination to action due to a lack of will power. He, however, has no idea of his incapacity for action, he takes it to be a consequence of his own determination and not of a deficiency of his brain. He has his own philosophy of renunciation of the world and men, he wants quietism and praises the high ideal of the mind. He is incapable of concentrating his attention on any subject, and his ideas are semi-lucid and blurred, conveyed by defective senses to a dis- tracted consciousness. It is impossible for him to have a civil position, where steady attention is required, but he ascribes it to his idealism - and to his esthetic tendencies. A degenerate has also doubts of everything, he studies chimerical enterprises, thinks himself a discoverer of the most difficult problems. Lombroso refers to these intellectual peculiarities of the degenerates, the acts and the writings of revolutionists and anarchists. They find themselves unable to live under the existing circumstances, they want a morbid variation, as they cannot bear social conditions which impose upon them self-control, of which they are incapable on account of their lack of will power. In consequence they believe themselves reformers of society, they want change of government, and under an idea of misunderstood philanthropy they boast or commit absurd and monstrous deeds against people, property and community. Some of them, as I have stated in the beginning, appear to be highly gifted men, and of them Lombroso 8 makes a group which he calls superior degenerates, which he considers as an active force in the progress of society. This idea, however, is strongly opposed by Nor- 8 Lombroso. Nouvelle Revue, July 15, 1891. SYPHILIS IN RELATION TO DEGENERACY 355 dau, 9 who follows the opinion of Tarabaut 10 that cranks, wrong- headed, unbalanced, incapable creatures, they belong to the class of whom it may be said that they have no mind, or whose minds produce nothing. They have a characteristic in common, weakness of judg- ment associated with an unequal power of intellectual faculties. In consequence their ideas are fantastic, dream-like, lacking of subject and through the power of a disordinate imagination, are without a substantial conception. This forms the principal reason of decadence ; in fact, when we take painters, poets and writers of such an age, we find brilliant colors wrongly associated, verses rich in rhymes, lacking in thoughts, and novels full of hysterical recitals, without aim. and with- out conclusion. Such qualities we find in those persons who, al- though greatly admired, commanding respect and attention above others, yet show some flaw in their mental faculties or in their expres- sions, which makes them rank among the mattoids. Another set of persons are amazed at their perverted doctrine, admire them in all their expressions and doings, and follow them in their extravagances. They belong to the same class. The unnatural emotionalism which we find in hysterical women must also be regarded as a sign of degeneracy, and their psychical im- pressionability makes them dangerous to society. The morbid mobility of their mind and the excitability of their imagination conveys to their mind all sorts of fantastic and senseless ideas, which on account of a peculiar suggestive faculty assume the appearance of perceptions, and consequently they believe all that foolishness as truth. The in- clination to lie, which is so characteristic of hysterical women, does not come from their will, but from their excitability and from the false- ness of their perceptions. They lie, entirely persuaded of the truth of their illusions and hallucinations ; people who are feeble-minded admire that kind of fantastic and excitable creatures, they are amazed by their vivid and wondrous tales, they are enthused by their fallacious and ridiculous doctrines, they become their followers, profess the same fantastic ideas, because they are unable to think with their own brains and are incapable of sound judgment. They lack good sense, are weak-minded people, and find just what they want in those hysterical people, forming what Charcot has called, la folie a deux, in which a deranged person forces his insane ideas on a companion. Lombroso has well remarked that malefactors associate together, forming bands, one connected with the other in their misdeeds and in their crimes. In the study of the etiological factors of degeneracy we find a 9 L. c, p. 24. 10 Tarabaut. " Des Rapports de la Degenerescence mentale e de l'Hysterie." Paris, 1888. 356 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS long list of morbid causes alleged as capable of weakening the system of persons and make them susceptible to degeneration. Morel traces degeneracy to poisons, and find that alcoholic excesses, tobacco, opium, badly preserved food, are all capable of producing degeneration in the race. Fere attributes the cause of hysteria and neurasthenia, and consequently of degeneracy, to the fatigue of the present generation. He has very wisely remarked that a normal individual can be easily changed into a hysterical one by tiring him; in consequence all these forms are to be considered as the result of the depression of vitality. Many observers assign an important part in the production of degeneracy to the great progress of our era, to the railroads, the travel, the vibrations, the accidents, and they even say that all these have made a railway spine, a railway brain. To this excitement, when we add the enormous increase of the consumption of tobacco and alcohol, we will surely agree with the French scholar, Fere, that these conditions have. a great relation to the fatigue. The individual who has stood a great deal of fatigue or excitement feels exhausted, and that feeling of ex- haustion prompts the use of stimulants. The ephemerous euphoria which is produced by a drink of whisky is an artificial invigoration of only a short duration, in consequence their exhaustion increases the weakness of the will and a craving for more whisky which they are unable to resist. That the tumultuous life, the rush of business, the modern way of living, may have some influence in depressing the bodily vitality and preparing a new generation having many degenerates, neurasthenic and hysterical subjects, nobody can deny; but this we consider only as an occasional cause. It is a cause which is found very plausible by the generality of the people. Business cares have disturbed this mind, failure of success has driven that man crazy. But an observer of human nature, a physician, will see that the alleged cause is only an occasional one, and he will look for a cause which we call causa proxima, the true cause, which has produced histological and patho- logical changes of the nerve cells, which in consequence of any other occasional cause have manifested their diseased condition. The gray surface of the brain is made up of innumerable nerve cells, which by their activity constitute intuition. The nerve cell is an anatomical unit, as it exists by itself independent of all other tissues. It has only contiguity of structure, but no continuity as proved by Golgi. A pyramidal cell has two integral parts, the body and the process of the cell, which together form the anatomical unit, which is now called the neuron. The body of the neuron is the seat of the nucleus in which is again found the nucleolus. The nucleus is very large, and apparently has a SYPHILIS IN RELATION TO DEGENERACY 357 nutritive function only. Indeed, if any part of the neuron is cut off from the portion containing the nucleus, the remaining portion of the neuron will degenerate and die. It seems impossible to unravel the complex network into which the cells and fibers are interlaced together ; and we can say that the function of each single element is really beyond our reach. But we will easily understand that any pathological altera- tion or any malformation affecting the connective tissues of the nervous system or of its blood vessels must produce great and important changes in the functions of those delicate nerve cells. The connec- tive tissue binds together the delicate nerve elements, and also supports the blood vessels, which perforate the membranes to carry the nutrition to the nerve fibers. In order that we may explain the different alterations of the functions, and the morbid manifestations which result from the pathological changes induced by syphilis in the connective tissues and in the lymph and blood vessels of the nervous system, it will be useful to recall the functions of the nerve cells in their psychical activity. The circulation of the blood in the skull is so protected that it is not sub- ject to differences of pressure or of resistance from the external world. The quantity of blood enclosed in the cranium is independent of any pressure, having peculiar functions to perform according to the places where cerebral activity is called for. Donders, 11 Kussmaul and Tenner have trephined the skull of animals and have inserted in the holes watch glasses to cover exactly the exposed brain. In this way the variations of the circulatory system of the brain could be plainly seen, in some districts greatly increased, in others diminished. Furthermore, they could also prove the great interest which the cere- brospinal fluid has in the circulation of the brain. The cerebrospinal fluid, which is contained in a strong membrane running from the brain to the end of the spinal cord, is the regulator of the circulation, and it is supplied by the perivascular lymph vessels, which have an interest- ing part to perform. The way the veins are disposed is a protection to prevent venous congestion of the brain in the bodily efforts, and also for the arteries in the thyroid gland, which pressing against the branches of the carotids prevents an extraordinary flow of blood to rush towards the brain, leaving its circulation entirely independent. When a stimulus acts upon the receptive portion of the nerves, like a ray of light upon the retina, or a rough body upon the skin, etc., the effect of the stimulus is conveyed by the nerve to the nerve cell in the cerebral cortex. The cell is immediately affected by the impression received and propagates it to the neighboring cells of the same kind. 11 Donders. " Ziemssen's Pathologie und Therapie Nervenkrankheiten " Band I. 358 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS The effect of the stimulus spreads like the wave circles produced in a pool of stagnant water by a falling object, which run in proportion to the intensity of its force. According to Mosso's experiments, it seems that when the effect of a stimulus reaches the cell in the cortex, the blood rushes to that area, increasing its nutrition. In this way the impression in the cells is changed into perception, and from their energy and activity it is transmitted in ideas or impulses. The cells, furthermore, have also the faculty of preserving not only an image, but also the strength and the character of the stimulus. In consequence the cells are able to remember the impressions. When a new stimulus reaches this cell, it rouses in it an image of a kind similar to that previously had, and this memory-image strengthens the new stimulus, consequently it produces a more distinct impression on consciousness. If the cell were unable to receive the impression from the second stimulus without remembering the first, it would be impaired in its interpretations. The stimuli then would be perceived, only with- out connection one with the other, and lacking the assistance of earlier impressions no knowledge could be obtained. This is the memory which is the most important faculty of a normal brain. To this must be referred the association of ideas, which is capable of giving us the complete image of the whole phenomenon. The senses are affected contemporaneously by the parts of the phenomenon, as in thunder we have light and sound affecting our senses. As a conse- quence, the sound by itself will be capable of recalling the light, and all together the whole phenomenon. In the same way the sound of falling water will recall a waterfall, the sea, etc. Wundt formulated the law that for the association of the ideas, four conditions are neces- sary: simultaneity, similarity, contrast and occurrence in the same place. In the organisms of the higher animals, the brain and the nervous system acquire knowledge of the external world, and this is used for the benefit of the individual. Memory makes this possible only by the association of the ideas. It is easily understood that a brain which is susceptible to a perception, and through the association of ideas to recall numerous representations, is far more able to recognize, con- ceive and judge, than another without association of ideas capable only of concepts derived from sense perceptions and of representations originated accidentally by contiguity. Although the association of ideas forms the most interesting part for the memory, yet there is no rule and no order in the representations without another mental faculty, attention. Attention brings the repre- sentations together in due order, as produced by the association of SYPHILIS IN RELATION TO DEGENERACY 359 ideas, so that they may be used for knowledge and judgment. Atten- tion is the act of concentrating the mind on any object of sense, or on any mental conception. Ribot 12 defined it as a spontaneous or arti- ficial adaptation of the individual to a predominating thought. Hardly any faculty is more important for the intellectual progress of man than the power of attention, as maintained by Darwin. 13 It is a faculty which suppresses part of the images which have arisen from other excitations, and maintains the vividness of the others which are related to the causes exciting or to the object perceived. To obtain so important a result, we cannot fail to see that the blood vessels have an interesting part in the production of this psychical function. Nordau and Lehman 14 attribute this action to the interfer- ence of the will, which produces motor impulses to the muscles of the cerebral arteries. The arterioles are, therefore, contracted or dilated, and the supply of the blood is diminished or increased. The cells which receive a larger quantity of blood operate more powerfully, while the others, which have no supply, must suspend their action. The will only determines the attention, by the emergency, degree of clearness and duration of presentations. A strong will will much better adapt the organism for obtaining complete sense impressions, and induce memory images, capable of rectifying or completing a pres- entation. There is the adaptation of the whole organism to a pre- dominant idea, so as to give an exact knowledge of the different objects. This adaptation lasts as long as the cells acting in the pres- entation are capable of maintaining the attention, but when fatigued must cede the ground to other cells, and in consequence the adaptation is directed towards other purposes. In these intellectual functions the will is a very important factor, so much so that the stronger the will is, the better the organism is adapted to receive impressions, to connect them with memory-images so as to complete the presentation, and to suppress all other presentations which are outside of the subject. Attention is the result of culture capable of directing the powers of the organism, while a defective attention leads to errors and super- stitions. In order to obtain attention, a will power is required, which is only an attribute of a well-constituted and well-nourished brain. In individuals with malformed or exhausted brain will power is lacking, and as a consequence they are unable to give attention to any subject. An individual who is sick or weakened by disease is incapable of attention. The cerebral cortex receives the impressions not only from the nerves which are in relation with the external world, but also from 12 Th. Ribot. "Psychologie de 1' Attention." Paris, 1889. 13 " Descent of Man." 14 Quoted by Nordau. L. c. p. 84. 360 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS the interior of the organism, from the nerves of the different organs and from the nerve centers of the spine and of the sympathetic system. Every stimulus is referred to the brain cells, where it causes a distinct presentation, which is related with the nerve centers from which it proceeds. So it happens that we feel the sensation of hunger and of thirst, which is aroused by the necessity of food or water in the organ- ism, and by the association of ideas, it recalls to us different articles of food or of drink. The nerve centers in some of the subjects under our consideration are morbidly affected on account of the circulation, or on account of morbid irritations, consequently they react in quite a different way from the normal ones. In some of the degenerates we find that every stimulus awakens sensual activity. Every presentation brings to them erotic thoughts, and they feel emotions of erotic nature at sights, words, odors, which they refer to unknown qualities. Indeed, syphilitic individuals are the most sensual class of people, and as already stated in syphilitic families we find remarkably numer- ous conceptions. In a syphilitic family we have found in seven years of marriage, first, one miscarriage in the fifth month of pregnancy. Four months after the lady was pregnant again and gave birth to a well child, which is living in good health. After this child, the lady had four miscarriages in succession, at intervals of a few months one from the other. Then she had twins, which were brought forth at maturity. Both were males, weak and sickly, and died in the fifth month of life, from inanition and eclampsia. After this she became pregnant again and has given birth to a male child, who is now seven months old, very pale and weak, suffering with colds (coryze) and so many troubles that the physicians are not able to understand the case. The lady now thinks she is pregnant again. In all syphilitic families which we have carefully followed, where the treatment has been neglected or been insufficient, we have remarked a large number of conceptions, of which some have resulted in abor- tions and others have brought to the world a syphilis-tainted child. We do not hesitate for a moment to refer the sexual supersensitiveness, the erotic perverted sensuality to syphilis or to syphilitic taint. Zola in his " Rugon Macquart," has well described Madame Gervaise and her daughter Nana, where he has shown that licentiousness and lewd- ness passes a miserable inheritance from the mother to the daughter. It is a constant law of nature that all living creatures resemble those who have produced them, and that from one generation to another, good and bad qualities of the body and of the mind are constantly transmitted. Syphilis is never mentioned, but a great deal of the psychical abnormalities are due to its poison or to its effects on the SYPHILIS IN RELATION TO DEGENERACY 361 blood vessels. The inherited syphilitic poison is capable of exciting the nervous centers connected with the sexual activity, so as to make those affected belong to the class of degenerates or of the perverted. It is true that vice and crime are coeval with the human race, and that before the infection and propagation of syphilis there existed " good men," " bad men," " thieves," " murderers and prostitutes." The responsibility for vice and crime is usually thrown on the will of the individuals, without any consideration of the anatomo-patho- logical conditions of his nervous system. After the study of the alterations of the blood and lymph vessels induced by syphilis on the neurons, either preventing their development or diminishing their nutrition, it is apparent that it must have a great influence on the psychical functions of the tainted individual. Indeed, Lydston 15 is right when speaking of the fruitless results in the reform of delinquents by the penal system and by moral suasion, he finds the faults of both methods chiefly in the fact that their bodies have been forgotten. Man feels, thinks, wills and acts according to his anatomical conditions and the physiological development of his brain. This has always remained a conviction of the thinker, but on account of the scanty knowledge of the anatomo-physiological condi- tion of the brain, for centuries it has been only in the conscience of the scholars. After the institution of cranioscopy by Blumenbach, and after the anatomical studies supported by the philosophical ideas of Gall, the anatomy and physiology of the brain progressed to the highest point, through the works of Lauret, Gratiolet, Broca, Huscke, Virchow, Bischoff, Hown, Huxley, Lombroso, etc. The thesis, as already enunciated, was whether the remarkable class of men delinquents by nature do not exhibit facts to support and maintain that their criminal acts are the result of abnormalities in their brain. This class of delinquents already furnishes moral signs of their abnormal mental condition by the insufficiency of all means to prevent crime, and while they recognize the prepotence of society on them, yet they have no idea of injustice and follow their impulse to commit crime. Benedickt 16 in the examination of the brains and skulls of nineteen habitual delinquents, who died in the Croatian prisons, found defects of the whole cerebral mass consisting in a lack of development of the bridges of the gray matter, increased anfractuosities, a defect of early organic development. Betz, of Kieff, and Zernoff, of Moscow, who have made so many studies on the brains of the Slavs, have also recognized the 15 Lydston, F. " The Diseases of Society." Philadelphia. 1004. p. 17. 16 Benedickt, M. " Ueber den Gehirne der Verbrechern." Wien. 1879. 362 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS atypical condition of the brains of the criminals. The atypical devia- tions of the brain of the delinquents places them in a special anthropo- logical variety. He must be in reference to his crime, as it were, a near relative of the epileptic or of the insane. Proclivity to commit crime is not the disease, but only the predisposition. Indeed, crimes are not to be compared with monomaniacs, but, in the case of an abnormal physical construction of the brain, are greatly the result of abnormal psychical conditions. This forms the predisposing cause ; social cir- cumstances, however, are the occasional factors. It is of great interest to establish whether the atypical conditions of the skull have any influence in the production of the anomalies of the brain. The superior portion of the skull is of the greatest impor- tance, as it contains the frontal lobes, which are the seat of the inhibi- tory or controlling faculties, which enable the man in the normal condition to exercise his will and resist animal impulses proceeding from other organs. The posterior lobe, abundantly covering the cere- bellum, is also very interesting for the intellectual development of the race. Consequently the highly developed occipital prominence cor- responding to the occipital convolution would be a sign of intelligence. The exaggerated curve of the parietal bones would very likely show a defective development of the central cerebral lobe, and this anomaly has been found in several delinquents and in epileptics. We cannot say anything definite in reference to the asymmetry and malformation of the cranial bones, but they may show a malde- velopment of certain portions of the brain, with perturbation of the functions originating in that area of the brain cells. We know a great deal about the relation of the affections of the special sensory and motor areas to the impairment or abolition of special senses or of the muscular groups, but we do not yet know the results of the affections of some areas of the brain cells in relation to certain psychoses. Nobody denies that moral perverts have an anomalous develop- ment or a disease of the sensory organs, but this is only recognized by faulty material development or dystrophies which can be seen ex- ternally. When in a man there are found signs of idiocy, micro- cephaly, hydrocephaly or some peculiar asymmetries in the construction of the head or of the face, it is immediately referred to a fault of brain development and his perverted moral condition finds easy explanation. There are, however, conditions of perverted functions of the brain which are occult and are not revealed by any external malformation. It is generally admitted that the form of the skull corresponds to the form of the brain which is adapted in it, as an organ of protection. It has also been established that the skull is moulded upon the brain. SYPHILIS IN RELATION TO DEGENERACY 363 The regular closure of the sutures and of the f organelles in fetal life and after birth are of great importance in the development of the brain. Their regularity can be taken as a criterion to ascertain the degree of development and the integrity of the brain. The influence of syphilis on premature ossification of the fonta- nelles and on the union of the sutures is easily apparent. The skull of a healthy newborn infant shows a great predominance of the cranial over the facial portion. This is due to the undeveloped con- dition of the maxillary antrum and of the maxillae, and to the small size of the nasal fossae. The parietal and frontal eminence are large and conspicuous, the frontal sinuses and superciliary ridges are want- ing. The bones of the vault are without diploe, consisting of a single layer. The sutures are absent, each angle of the parietal bones being undeveloped is connected with fibrous tissues leaving a space called fontanelles. The anterior fontanelle is large, lozenge-shaped ; the pos- terior, small and triangular ; while the lateral ones are irregular in shape. This precarious union of the bones forming the skull of the infant lasts after birth for a certain period, then they become ossified, and the union of the bones is perfectly solid. The frontal fontanelle can still be felt open in the second year of life. It was called foks pulsatilis vertex palpitans, because the old physicians believed they were able to feel and to see the movements of the brain, from which the spirit of life was going through the nerves. The posterior fonta- nelle at the time of birth is already filled and after birth is soon obliterated. The same is true of the lateral fontanelles. This loose- ness of the bones forming the skull of the infant is to leave ample space for the development of the brain. Syphilis is the disease which directly influences a hasty ossification, and it is well known that before the third month of life the frontal fontanelle in a syphilitic child is solidly closed. This premature ossification and reunion of the bones must surely have an influence on the developing brain, which, com- pressed in its structure and not receiving the full quantity of blood, is somewhat impaired in its nutrition and therefore suffers in its evolution. We can see as active factors two different conditions influencing the developing brain of a tainted individual. One is the result of the toxic elements arising from the syphilitic germs, which produce an irritation in the nervous cells and are able to cause convulsions and spasms. Another lies in the anatomical changes in the blood vessels and in the bones. The bone canals, narrowed and distorted by an increased and too hasty an ossification, produce a pressure on the blood vessels whereby the circulation is impaired and the nutrition of 364 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS the nervous cells becomes insufficient and the development of the organ imperfect and irregular. In many cases the premature closure of the fontanelles is the cause of microcephaly, which is accompanied by idiocy. Savage, Burr, Berkeley 17 and others do not lay much stress on syphilis as a producing agent of idiocy, for the reason that, in many cases of low grade idiocy there were not present the characteristic stigmata of the disease. In two years, however, he has seen only four cases in which there was an indubitable history of syphilis. The luetic poison, nevertheless, shows itself in many forms of nervous disease and is more frequently an indirect than a direct factor in the causation of idiocy, since it may not be until the third and fourth generation that the mental disability becomes prominent. With the respect due the opinion of so eminent a scientist as Berkeley, we must recall the fact that we have seen cases of idiocy in boys and girls who had inherited syphilis from their parents. The organs which are principally affected by the syphilitic process are the blood vessels, and as they nourish the nerve cells, their altera- tions are certainly responsible for an intellectual deficiency. An in- flammatory process affects the walls of the arteries, resulting in a diminution of their lumen which reduces the supply of nutrient fluid to a minimum. At the same time the same process affects the lymph vessels, narrows their channels and causes a hindrance to the lymph flow. This causes a partial edema of the brain substance, which results in epileptiform attacks. Syphilitic disease of the large vessels of the brain is so character- istic that it is easily distinguished from common arteriosclerosis and other degenerations. They show macroscopically loss of their trans- parency, become opaque and assume a grayish tint. Their lumen is found narrowed and hardened and in some cases it may be obliterated by the formation of a thrombus. 18 Hiibner 19 microscopically demonstrated that the syphilitic proc- ess of the brain arteries consisted in a true specific inflammation. It may be considered a true endoarteritis, which is revealed by the pro- liferation of the endothelial cells, which on increasing forms, together with round cells from the nutrient vessels, a tissue of granulation similar to that of a gummatous production. According to the men- tioned author, this granulation tissue would run in the interior and alongside of the arteries, narrowing their caliber and completely in- 17 Berkley, H. J. " A Treatise on Mental Diseases." 1900, p. 493. 18 Ravogli, A. " On the Histo-Pathological Alterations of the Lymph and Blood Vessels in Syphilis." Cincinnati Lancet-Clinic, Oct. 17, 1903. 19 Hiibner, O. " Die Luetische Erkrankungen der Hirn- Arterien." Leip- zig, 1874. SYPHILIS IN RELATION TO DEGENERACY 365 volving the vessels. The process may stop after a permanent nar- rowing of the lumen or may continue till a complete obliteration is effected, leading the artery through degeneration to the condition of a fibrous cord, incapable of performing its functions. In some cases the adventitia as well as the intima show such a proliferation of cells as to be equivalent to a gummatous formation, reducing the lumen of the artery to a minimum. Indeed, Baumgarten 20 pointed out the condition of the adventitia in the affected arteries as the starting point of the process. He claims that, in the arteries of the cortex, the most frequent affection caused by syphilitic poison is a diffused periarteritis. The rapid multiplica- tion of the small cells among the fibrillar elements of the adventitia fill up the extravascular space, causing a heavy pressure. The media also infiltrated with the new cellular elements, suffers mostly from a process of necrosis, which causes the muscular elements to disappear and be replaced with a round-cell mass. This is also gradually reab- sorbed, leaving a mass of caseous degeneration with crystals of hema- toidin and debris. The intima is not indifferent to the syphilitic process. Cellular proliferation affects its layers and the lumen of the vessels is reduced in its caliber. Both processes described are clinically found as having disastrous effects on the cerebral substance. Berkeley refers to nine cases of dementia paralytica of specific origin, which at the autopsy showed the blood vessels affected with the described periangioitis. The proliferation, invading the adventitia, extends to the sur- rounding lymph space, which becomes filled with cellular and fibrous elements, which, on one side, enter into the media, and on the other permeate the surrounding nerve tissue causing degeneration of their connective structures. Alterations of the kind have been found, not only in specific troubles of the brain, but also in cases of interstitial degeneration, as in the disease of the pyramidal tracts, tabes dorsalis. After the brief description of the pathological alterations produced by syphilis on the vessels of the nervous system, it is easily understood that this is one of the most effective factors of diseases of those organs. Syphilis transmitted in a hereditary way to the fetus will have the same influence on the developing vessels and will consequently be the cause of congenital faults, or of deficiency. Anatomical abnormalities have been found in the construction of the basilar arteries, which are significant of a defective formation of the whole body. In some cases there has been found an absence of the large basal arteries or an un- usual caliber in them. The noted absence of the right or left posterior communicating artery must have great influence on the development of 20 Baumgarten. Vir chow's Archiv, 1878- 1879. 366 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS the brain ; and when the entire system of the basal vessels is too small, it will fail to bring a sufficient blood supply to the encephalon. The cerebellar arteries arising from the basilar artery have in many cases been found too small. So far statistics on this subject are lacking and as a result we cannot give any definite data. The alterations already mentioned are sufficient to show that syphilis is one of the most important causes in the production of psychoses. In syphilis, therefore, we find an element of causation capable of leading to physical and moral degeneracy. Its poison, subtle and dif- fusive, reaches the most remote cells of the body, producing irritation or impairing their nutrition. This will prepare on the one hand a quantity of idiots, of epileptics, of imbeciles, and on the other a class of persons mentally deficient or of extravagant tendencies, of de- generates. In our views we do not oppose the therapeutics used by the penologists to try to reform their man, to elevate him, and in case of failure to put him in jail or administer capital punishment. We do not argue against the efforts to make of a criminal a man with a healthy and sound brain. We find, however, that one of the most important remedies rests with society in general ; to try to diminish every possible cause capable of deteriorating the nervous system and the mental faculties of the individual. PHYSICAL SIGNS OF DEGENERACY The deformities, dystrophies, abnormal types, which we have noted as results of syphilis in the third generation, in the so-called heredo-syphilitics, are those which constitute the stigmata of degenera- tion. For this reason we have grouped them together to show the influence of hereditary syphilis in the production of degeneration. Degeneration which is the result of syphilis in the third generation is not of a permanent character in the succession of generations. In the lowest grade of degenerates the abnormal development remains in the individual and dies with him. In these cases there is no reproduc- tion. In the highest class of degenerates the promiscuity of the races in the marriage, is a great correcting element in the health of the generations. The abnormal development is lost and children are born without marks which were visible in the father. Micro cephalus. — Smallness of the cranium is the result of an imperfect development of the brain, as porencephalus, cerebral hemor- rhage in infancy, rudimentary evolution of the cortex and corpus callosum, are from the too early closure of the principal sutures. The microcephalic skull may represent either the brachicephalic or the dolichocephalic type, but it is remarkably small. I" a case SYPHILIS IN RELATION TO DEGENERACY 367 referred to by Berkeley, 21 a man six feet and two inches in height had a skull circumference of forty-four centimeters, and the brain weighed only 400 grammes. The bones and muscles were fairly developed, but the intellect had never progressed beyond the capacity of using coherently a few words. In cases of microcephalus below forty-four centimeters, there is a stunted growth, and an arrest of the higher cerebral functions. The crania of microcephalics may present deformities, but they usually are symmetrical, but always showing the tendency to inferior mental capacity. Macrocephalus is usually due to hydrocephalus in early life, rarely to hyperplasy of the cerebral substance, or to the thickening of the bones. The skull is more symmetrical than that of the microcephalic, as the overgrowth has been equal in all directions. The facial bones, in contrast with the overdeveloped cranium, seem too small and dis- proportionate to the size of the head. The inferior and superior maxilla are smaller than in the normal size. The individuals of this unfortunate class are nearly all dwarfs, show signs of having suffered rickets, distortion of the long bones. Their skull is usually of the brachycephalic type. The too early closure of the cranial sutures is responsible for the deformities and asymmetries of different types. The synostosis of the coronal suture and of the posterior portion of the interparietal suture will cause an upward projection of the skull forming the so- called tower head or pointed head. Amongst idiots and imbeciles there is to be noted the great height of the head disproportionate to the other measurements. The unusual shortening of the anterior re- gions causes the protrusion of the eyes, giving them a flat appearance. The premature closure of the frontal suture is the cause of a narrow forehead, with a compensatory broadening of the posterior regions of the skull, which gives to the head a kind of triangular appearance. This type of skull is called trigonocephalic, represents closely the fetal skull, and is peculiar to all classes of imbeciles. It belongs to the dolichocephalic type. The early unilateral synostosis of one frontal with the corre- sponding parietal bone is the cause of the projection of one-half of the head, inducing obliquity of the cranium, which is called plagiocephalus. On account of impaired development of the parietal bones the cranium remains flat, platycephalus, an anomaly which is often found among epileptics and hereditary degenerates. A compensatory devel- opment of the basal regions takes place causing the broadening of all diameters in the horizontal measurements. 21 Berkeley. L. c, p. 536. 368 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS When the interparietal suture is closed too early the head takes on a peculiar elongated shape like two craniums ; it is an exaggeration of the dolichocephalic type, and it is called scaphocephalus. The frontal region may be pushed forward, with a projection of the brows and an increased depth of the eye-sockets. The occiput, however, may be projecting without deformity of the forehead as the result of an early closure of the posterior half of the sagittal suture. In this case the deformity consists in an attempted compensation from the lambdoidal suture, producing an abnormally protuberant occipital bone. This gives an accentuated dolichocephalic appearance to the skull. When at an early age synostosis occurs between the occipital and temporo-sphenoidal sutures, it induces abnormality of the sphenoidal bones, as it is found in many cases of cretinism. Other minor anomalies in the shape of the skull, consisting of peculiar asymmetries, are found according to Peli, 22 to the extent of only 12.50 per cent, in normal individuals, and 42.7 per cent, in the insane. While in hereditarily burdened persons of both sexes, ab- normalities of the skull are found at the rate of 64.3 per cent., and in men alone belonging to this class the proportion reaches as high as 88.5 per cent. The auricula present innumerable variations from the normal type. The fusion of the lobulus together with the skin of the neck is so often found in sane individuals, that it can scarcely be considered as a stigma of degeneracy. Vicious implantations of the ears, ears projecting too far, or too closely implanted on the head, ears inserted at abnormal angles, or implanted too high or too low upon the neck may be considered as brands of degeneracy. The form of the ear shows anomalies and deformities which make them rank with the other marks of degeneracy. In some cases the ear has no lobules, or there is unusual prominence of the antihelix, or an excessive length of the organ with distortion of the helix, antihelix and anti- tragus. To this class belong the Darwinian ear, w T hich has the helix interrupted by a tubercle where its transverse passes into the descend- ing portion ; the ear of Morel, in which the normal folds are obliterated and the whole auricula appears much larger, projecting outward from the sides of the head like the handles of a pot. The nose shows a peculiar shape, as that of a saddle ; the root of the organ is deep underneath the glabella, and has a nearly hori- zontal direction. The nostrils are larger than in the normal. The septum is often deformed. The broadness of the nasal bones is usually found in cretinismus. 22 Peli. " Cefalometria in 670 alienati." Arch. Hal. per le mal. nervose, etc. SYPHILIS IN RELATION TO DEGENERACY 369 In treating of syphilis in the third generation we have already pointed out some irregular pigmentations of the iris, which are the result of specific taint. We can add in this connection congenital strabismus, coloboma, cloudy cornea, pigmentary retinitis, total con- genital blindness and congenital ptosis. Nobody would doubt for a moment the luetic origin of these deformities. In cases of idiocy and imbecility the long bones are found of an abnormal development, and tending to dwarfism. The bones are ab- normally broad in cretinism. Quite often there is found congenital club-foot, club-hand, distorted and supernumerary digits, or only two or three fingers, as shown in one of our cases. These are considered stigmata of degeneration, but we should rather say stigmata of in- herited syphilis. The mouth shows decided marks of degeneration. The orifice may be too large or too small ; in some cases it shows hare-lip or cleft palate, signs of inherited syphilis in the third generation. The soft palate shows some anomalies, being too long, or irregular, with an abnormal uvula. The most important abnormalities are found in refer- ence to the alveolar processes, which at times are too narrow, at times too broad, retaining teeth of the first dentition. The hard palate shows signs of malformations, which according to Berkeley are found in nearly forty per cent, of all degenerates, with peculiar types of deformity. A normal palate shows a segment of a low arch with its highest point on the palatine apophysis of the superior maxillary bone, and its pillars in the alveolar processes. This normal type finds a great many variations ; in some the palate is flat, in others normal with a V-shaped incision in the line of the central suture. In some others the arch is very small and elevated on its upper segment. Recently at- tention has been called to a ridged and rough formation of the central suture, which in some give the sensation of bony elevations, which form the abnormality known as torus palatinus. Ferrari, in 1121 skulls of insane persons, found it present in fifty-two per cent. Nacke found it in 32.9 per cent, of insane women. It is also found in sound persons, but not so frequently as amongst the insane. We must mention that Prof. Baccelli in his lectures taught and maintained that one of the unmistakable signs of old acquired syphilis, and mostly of inherited syphilis, was this condition of exostoses along the side of the central suture of the palate. In our experience we have often had occasion to use this sign to establish the presence of an old latent, or at least of an old extinct lues, or of an inherited taint. The deformities of the palate referred to are in no way dependent on cranial construction. Berkeley would scarcely comprehend this 370 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS condition of ridged suture of the palate among the deformities which are present in insane and in degenerate individuals. It is not our aim to treat profoundly this question which interests so much the phrenolo- gist, we only want to point out the fact that the so-called stigmata of degeneracy consist in malformations or deformities, which in many instances are to be attributed to inherited lues. We have already mentioned the defectively developed and the supernumerary teeth, their irregular implantation, the imperfect de- velopment of the alveolar process, and the irregular shape called notchy teeth. The genitals are frequently found abnormal amongst degenerates, and abnormal development in these organs has been already pointed out as a result of inherited lues in the third generation. In degenerate women the infantile uterus is quite frequent. In men hermaphrodit- ism is a stigma of degeneration, but there are deformities of minor importance, as hypospadias, defects of the prepuce, nondescent or rudimentary development of the testicles. In the general development of the body we have already had occasion to mention the infantilism and dwarfism, which we have considered as the result of syphilis in the third generation. We do not want to be accused of considering all degenerates as heredo-syphilitics, but we must say that the degenerates are frequently tainted individuals in the third generation. In the same way we do not maintain that all tainted individuals belong to the degenerates. In our practice we see every day boys and girls whose parents we have treated for syphilis, and even some of them we have treated in their infancy for inherited lues, go to school and obtain honors above their classmates. They show bright intelligence, quick perception, sound memory, and do not betray so far any trace of mental deficiency. Syphilis does not always produce degenerates, nor are all degenerates heredo-syphilitics, but without doubt luetic taint has an influence in the production of degeneration, and vice versa, a great many of the degenerates may recognize lues as the principal cause "of their defective mental development. In this way only do we understand lues as the cause of degeneration. SYPHILIS AND THE DECADENCE OF POPULATIONS In order that we may have an idea as to whether syphilis may be considered a cause of decadency of populations, or at least of a period in their history, it is necessary to briefly consider the first ap- pearance of this disease. Fra Castorius gave the poetical name of syphilis to the loathsome disease, which, it is related, was brought to Europe at the end of the fifteenth century and epidemically spread SYPHILIS IN RELATION TO DEGENERACY 371 over every country. Before this it received the name of the country from which it was believed to have come as a rebuke to the carriers, as morbus gallicus, mat de Naple, Spanische Pocken. Fallopius made the Spaniards responsible for the introduction of the scourge into Italy, and Leo Africanus claimed that the spreading of the disease was caused by the Marrans, chased from Spain by Ferdinand the Catholic. Writers, contemporaries of Columbus, maintained that the crew of his ships returning from West India carried the scourge to the Spanish and Portuguese ports, and from there it spread all over Europe. In fact, Columbus returning from his first voyage stopped first at Lisbon, then at Palos, before going to Seville, and thence, with many of his companions, he went by land to Barcelona to meet the King and the Queen in order to give them the report of his magnificent success. Barcelona, as Rodrigo Diaz, physician and historian stated, was soon affected by the new disease, and it made frightful progress there. In 1494 Don Pedro de Margarit was on his way back from his voyage, and in his ship everyone was infected with syphilis, not excepting the chaplain, a Benedictine friar, who was in a worse con- dition than the sailors. In 1496 Columbus, chained and handcuffed, landed in Cadiz, and it is related that 200 of the crew of that ship were infected with syphilis. The fact of the importation of syphilis from America was bitterly disputed by Diaz de Isla, Oviedo, Hernando Colon, the natural son of Columbus, and later on by Astruc, Swediaur, Girtanner and many others. But in spite of their efforts, there cannot be found in antiquity any description of a disease which can be identified with syphilis, such as the one we find in 1496, according to Aloysius Luisinus and after- ward according to Fracastorius. The progress of the disease at that time can be traced geographically from one country to another and even from one city to another. From Spain the new scourge was carried to Naples by the soldiery sent there to oppose Charles VIII, and from Naples it invaded the whole of Italy. So it was that from 1494 to 1498 nearly every Italian city and afterwards all the countries of Europe were infected, spread- ing the scourge all over the world. The disease was so serious and so severe for many years, according to F. Guicciardini quoted by Tommasoli, as to cause the fear that it would be transmitted to pos- terity as a dire calamity. 23 23 Tommasoli, P. " La sifilide e la decadenza del secolo XVII." Fest- schrift fiir Professor Neumann, 1900. 372 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS The disease did not remain limited to the lower classes of society, but also affected very prominent men in the highest ranks of life. Everybody knows that Henry VIII, King of England, had sentenced to death Cardinal Wolsey on the principal accusation of having spoken too near to his ear, w T hich was believed to be one of the ways of transmission of the French scourge. The noble d'Aubigny, commanding the troops of Charles VIII, was taken back to Florence and to Bologna in a kind of basket because he could not move himself on account of the ugly disease. If we want to have an idea of the spreading of the disease among the people w 7 e must refer to the writings of Luca Landucci, who stated that the new scourge made its appearance in Florence in June, 1496, and one month afterward the city was filled with diseased people. In December the disease had spread to the surroundings, and every city had to suffer its ravages. In Venice the disease had spread among the inhabitants so severely that in 1494 some Venetian galleys sta- tioned in Corfu were unable to leave on account of the fact that the men of the crews were nearly all infected and unable to work. Syphilis spread among all classes of society and even religious people were not excepted. In Tuscany, in 1505, the priests not yet infected demanded the privilege of having their communion service locked so as to prevent infection through it. In the Archives of the Sanctuary in Todi there was a register of the miraculous recovery of priests and nuns from the French malady. In the same way, professional people, writers, artists, etc., were not spared by the scourge. Benvenuto Cellini, according to his own testimony, could not finish a magnificent work in gold which had been ordered of him by Pope Clemens VII, on account of a terrible disease of the eyes which prevented him from seeing. He says : " The infirmity which I had, I believe to have been acquired from that pretty woman who was in my house at the time when my store was burglar- ized. That disease took nearly four months to show 7 its presence, and then appeared all at once. I was covered with a kind of red vesicles, the size of a cent. The physicians did not want to give it the name of the French malady, but I knew the cause, and I knew what it was." The disease in its spread did not find any barrier of rank in society, or of distance of sea, but like a conflagration invaded every country and all castes of society. According to Okamura and Tokujiro Suzuki, 24 it seems that syphilis was introduced into China and Japan in 1504, by the Portu- 24 Tokujiro Suzuki. " Ueber Syphilis in Altertum speciell in China und Japan." Inaug. Dissert. Rostock, 1903. Ref. Monatsh. f. prakt. Derm. Bd. 38, p. 487- SYPHILIS IN RELATION TO DEGENERACY 373 guese sailors. Before the time of Columbus no idea can be obtained of the existence of this disease in Asia. Fujikawa, 25 quoting from the Hoii-i-shuo, states that towards the end of the Kodi period there spread among the people a severe eruption, which was imported by the Cantonese, and in the Northern parts of China it was not known, and for this reason it was called the Canton eruption. He believes that the scourge invaded China about 1505 or somewhat later, after the landing of the Portuguese in India and Goa, with which the in- habitants of Southern China had great commercial intercourse. From China the scourge passed easily into Japan. In the beginning the disease was considered in China as one of miasmatic origin, but in 1580 it was recognized to be the result of impure sexual intercourse. According to Okamura, there cannot be found any mention of this disease in the old Japanese books, and only in the fifteenth century did this disease become known. In 1575 lues was described in Japan, and it seems that in 1569 the disease was imported to Nagasaki by the Portuguese and the Chinese. The Japanese have learned the peculiarities of lues from the Chinese physicians, and they held that chancre, bubo, exanthema were produced by the same poison. Our point is to show that syphilis was not a disease known in the China and Japan of antiquity, but was only known at about the time it made its appearance in Europe. The arguments which have been used by the distinguished writers to maintain that syphilis was known to the 'old Jews, to the Greeks and to the old Romans, are not so convincing as the plain history of the epidemic onset of syphilis amongst the European populations. Indeed, if syphilis had existed amongst the Greeks and the old Romans, it seems an impossibility that it should have escaped the attention of medical men, such as Hippocrates, Galenus and others, who have given the most accurate description of diseases known in their days. The study of the human bones which were found in old graves, especially in the Indian mounds in America, have revealed deformities and alterations which have been considered by observers as pointing to syphilitic origin. Many of them have so referred the existence of syphilis to a prehistoric age. Others, however, have denied syphilis to be the cause of those alterations and have maintained that it could also have been the result of other diseases. Some interesting illustra- tions of deformed bones of old inhabitants of America have been given by James N. Hyde, 26 and the increased thickness, abnormal 25 Fujikawa, Y. " Ueber den Ursprung der Syphilis in Ostasien." Japan. Zeitsch. Bd. ii, p. 346. Ref. Monatsh. f. frakt. Derm. Bd. 38, 1904. 26 Hyde, J. N. "History, Geographical distr.," etc. A System of Gen. Urin., etc. Morrow, 1893. 374 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS curvature, the appearance of exostoses, all point towards the possi- bility of syphilitic bones. Neumann 27 referred to the studies of Seler, who found in the old Mexican literature collected by Las Capas, that in old Mexico syphilis was known under the name of " nanauall " and that they had their means of treatment. He studied, moreover, anthropomorphic vases from Peru at the time of the Incas, and the figures often show a loss of the nose and alterations of the limbs. Although these de- formities could have come from inflicted punishment, yet Neumann, together with Polakowsky, Heger and others, concluded them to be nothing else than lesions resulting from tertiary lues. If we try to go to any depth in this subject we shall find abundant proofs of the knowledge of venereal sores of a contagious nature amongst the Romans and the Greeks, but there is no indication of the consequent phenomena, pointing towards syphilitic infection. After the return of the sailors of Columbus from the West Indies, in March, 1493, the disease was clearly known in an epidemic form, invading successively every country of Europe. This leaves but little doubt on the origin and on the importation of the disease. In the first part of our book we have seen and we have often repeated, that syphilis or its toxins have a great influence on the psychical functions. We have seen a great series of nervous affections result from syphilis, and the existence of syphilitic insanity and syph- ilitic dementia is to-day an established fact. It is more than natural that at the time when the disease was not known and no idea of rational treatment could be administered, affec- tions of the nervous system were much more frequent. Indeed, the fear of the epidemic, the lack of confidence in the physicians, and the impossibility of being cured, must have driven a great many to des- peration. Nicholas Leonicene, who described in 1497 the new epidemic, spoke of certain vapors which went to the brain as a result of the new disease, and on account of which the sufferers went to drown them- selves in rivers and wells. This dispirited mental condition which is often induced by the syphilitic poisoning, so well described by the old physicians was after- while overlooked and nearly forgotten. W r e must come to our times to find Fournier, Murri, Mairet. Tommasoli and others, who have called attention to the frequency of the cerebral affections arising from syphilis. Moreover, they have shown that syphilis induced mental disturbances, which are produced not only in the man primarily infected, but in his children and grandchildren may be shown psychical derangements from hereditary luetic taint. 27 Neumann, I. V Internat. Dermatologen Kongress. II Bd., 1905, p. 64. SYPHILIS IN RELATION TO DEGENERACY 375 We must state that after so many years the disease has somewhat changed in its virulence. It has been demonstrated that the modern ways of administering the remedy has greatly attenuated the virulence of the disease. Indeed, cases of malignant syphilis which frequently occurred twenty-five or thirty years ago are only rarely seen to-day. In those times, when nothing w T as known of the disease and nothing was known about the treatment, it was at the height of its virulence. From the historical records we find that the predominating symptoms were vapors affecting the brain, in many, dolores osteocopi in a great many, gummata and nodes in nearly all the sufferers. This report gives us reason to congratulate ourselves for the result which we have obtained in the management of the disease, which surely has been diminished in its intensity, and the ravages of the tertiary lesions have been in so great a measure controlled and avoided. It has been alleged that the frequency of the nervous diseases in our times is due to the excitement in life, accompanied by the modern appliances, the volume of business, and the necessity of being con- tinuously in a rush. Nordau so explains the so-called fin-de-siecle affection, and the supposed increase of degeneracy and of hysteria in our generation. At those times there were no railroads, no steamships, no compe- tition, he claims that life went on quietly and smoothly, as in the times of the ancient patriarchs. Nordau refers to the great difference be- tween the life of those blessed times and the life of to-day, in recount- ing the trip of the famous naturalist, Hoffman, who in 1822, in order to go from Bremen to Leipzig, took four days and four nights. He reached Leipzig in the night and could not find a restaurant open. He groped about the streets to find the door of the hotel, and was obliged to hurt his fingers striking the fire stone to light a tallow candle, so as to be able to find his bed. Compare this trip with a trip in our days. If Hoffman had had a railroad train, which in a few hours would have carried him from Bremen to Leipzig, if he had found the hotel 'bus at the depot, a bell boy to take him to his room, who by turning the switch would have given plenty of light to the room, he surely would have saved a great deal of strength, much discomfort and worry. It is. therefore. only nonsense to attribute so much nervous irritation, so much loss of nervous power, to the railroads and to other features of modern life which have made existence more comfortable and more pleasant than it has ever been before. If we follow Tommasoli in the consideration of the peculiar social circumstances at the time when syphilis made its appearance as an epidemic, we find that the conditions of mind of the populations were 376 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS not so quiet or so tranquil as is believed. On the contrary, it was just after the time when there occurred in England the death of Edward IV, an ambitious and licentious king, who was continuously planning to get rid of anyone who was in his way. He had his brother Clarence charged with treason and sentenced to death, giving him the privilege of choosing the method of execution, which was that of being drowned in a butt of malmsey. Prince Edward, his eldest son, a boy of thirteen, succeeded him, who, while he was going to London, was taken by the Duke of Gloucester and deprived of his tutors and friends. He was compelled by Gloucester to ride before him bareheaded, while he (Gloucester) was pointing him out to the populace with the order, " salute the king." Gloucester was appointed protector of the king- dom, and just at the moment when the Council was in session at Westminster, he sent a body of armed men to burst into the assembly, who with the cry of " treason," seized upon those members who were supposed to be inimical to the Duke. Among the members who were carried off and thrust into the Tower were the Archbishop of York, the Bishop of Ely, and Lord Stanley, the most prominent men of the kingdom. Lord Hastings, another suspected party, was soon con- demned to death and beheaded. It was at that time that Sir Thomas Ratcliffe with a large body of followers entered at Pontefract and put Rivers and Grey to death. The same hunchback, Gloucester, compelled the Archbishop of Can- terbury to give into his power the two York princes, whom he de- clared bastards, claiming that the marriage of King Edward IV with Elizabeth was bigamous, because he had secretly married another woman. He could not endure that the English throne should be filled by the spurious brat of his brother Edward, and he substituted his coronation to that of his nephew Edward, taking the title of Richard III. He got rid of the two innocent Yorks, both of whom were found suffocated in their bed by hired murderers. This hyena seated on the throne of William the Conqueror cut down anyone who was in his way, and in his hypocrisy never knew pity, love or fear. When Richard III scented the conspiracy of the duke of Buck- ingham, he had him beheaded immediately, and all his followers put to death. Henry of Richmond, with a little army helped by the desertion of some of Richard's soldiers, engaged in battle with him at the Abbey of Merivalle, near Bosworth Field, and punished the traitor by killing him. It was near the end of the same century when Henry assumed the crown of England as Henry VII. Under his reign came back all the horrors of the Norman invasion. At his time the Wars of the SYPHILIS IN RELATION TO DEGENERACY 377 Roses destroyed the feudal nobility of England, but the political dis- cord kept on and cost England nearly one and one-half million victims. Looking at this historical report, it seems that at the time of the epidemic invasion of syphilis, the minds of our English brethren were not so tranquil and so quiet as we might have thought. In Spain the nervous system of the inhabitants was also somewhat excited by the political secession. King Henry IV, incapable of reigning, the queen of not exemplary life, the ministers corrupt, the nobility seditious, the clergy greedy, the poor people oppressed and vexed, this was the condition of the times. Just at this point the civil war began between the two women, Juana and Isabella, the latter gaining the victory. Through the marriage of Isabella to Ferdinand the Catholic, Aragon and Castile were united into one kingdom. Under Ferdinand, the bigot king, the dreaded Inquisition ac- complished its purpose as a powerful institution. The Moors were chased from Spain, and the Jews were persecuted and then expelled. The most iniquitous persecution of the inoffensive children of Israel took place, who were driven out of their homes and turned naked into any part of the world into which they could make their way. At this time the Genoese adventurer, Columbus, succeeded through the munificence of the Queen in obtaining ships, and men, and found a new world beyond the Western ocean. In France Louis XI followed the same lines by keeping the French people in an excited condition of mind. He, a parricide and a fratricide, frenzied by the terror of death, spent his life in a voluntary jail, surrounded by bodyguards, monks, and friars, mixing the most ridiculous superstition with the most merciless cruelty. An execrable being, despised by everyone, he died of starvation for fear of being poisoned by Charles VIII, his own son. Charles assumed the throne at fourteen, and was an analphabet. In Italy at this time things were not much better; every town, city or community was alone, independent as municipal governments. It was just the beginning of the Dark Ages, and political unity had been destroyed. These small towns or municipalities kept on in jealous rivalry with each other, struggling for supremacy. It was a period when the morality of the people of a great part of Italy was at a hopeless ebb. It was an epoch of rapine and lawlessness. Property and life received no adequate protection from society. The country was infested with robbers and brigands, who preyed with reckless audacity on whatever industry had stored in hamlet, town or castle. Hired ruffians prowled about every place and used their stilettos under the direction and protection of their powerful masters. In Rome we 378 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS find Rodrigo Borgia pope under the name of Alexander VI, who on account of his treacheries, murders and robberies, was deposed and expelled from the papal states by Julius II. The close of the fifteenth century and beginning of the sixteenth are noted in the history of Italy for the invasion of the country by the armies of Charles VIII and Louis XII of France. Milan, which had seen Galeazzo Sforza assassinated at the door of a church in punishment of his crimes and cruelties, was under the domination of Ludovico Sforza, who was captured by Louis XII, and sent to prison in France. Two countries had seized Italy, the northern part was occupied by the armies of Louis XII, and the southern and- central parts by the armies of Ferdinand of Aragon. Louis XII then entered in collusion with Ferdinand of Aragon to divide the kingdom of Naples between them. Soon, however, they quarreled over the spoils and the French were defeated in the battle of Seminara by the famous Gonsalvo de Cordova, a general of Ferdinand of Aragon. Louis was then expelled from Southern Italy. In Venice the people, merchants by natural inclination, were at a high pitch of excitement on account of the discovery of Vasco di Gama. They feared that the new discovery would ruin their entire commerce. In 1507, Louis, after having defeated Genoa, formed with Emperor Maximilian, Ferdinand of Aragon and Pope Julius II, the celebrated league of Cambrai with the view of the destruction of the Republic of Venice. In Florence, the beautiful city, the cradle of the sciences and of the arts, the political conditions were by no means any better. The republic was divided into small parties, and Fr. Savonarola, the elected of the people, was striving to institute radical reforms of government. The Medici were expelled from the government and Savonarola was the most ardent republican. Pope Alexander VI., who made common cause with Medici, began the persecution against Savonarola. One night he was taken from his convent with two of his companions, and all were killed and then burned in a public square as heretics. We can see that the peoples were not in a very quiet and peaceful frame of mind when the syphilitic epidemic began to invade these countries. At the same time in the midst of their chaotic political con- ditions, of their civil dissensions, of their fratricidal wars, they began to see the ravages of this new disease, which filled them with terror and despair. The political dissensions, the wars, the persecutions, were not enough, but in 1522, just after the election of Pope Clement VII., the bubonic plague invaded Rome, killing 18,000 inhabitants. In 1524 the same plague attacked Milan, where over 50,000 people died in less than four months. SYPHILIS IN RELATION TO DEGENERACY 379 If we compare the century before the introduction of syphilis in Italy with the following century, we find it strange that in the midst of feuds, in the midst of the horrors of starvation and pestilence, litera- ture, science and art were flourishing. Boccaccio with his fantastic spirit wrote his stories of the Decameron. It was an era of poets, of artists of immortal fame. Michelangelo, Raphael, Cellini, were giv- ing to the world the most beautiful and divine artistic works. They were obliged to work with the sword constantly near them, and an artist ought to be a soldier also, in order to defend his life, threatened at every moment by the continuous factions. It was at that time that the celebrated Italian statesman, Nicolo Macchiavelli in Florence, the father of the diplomatists, was the chancellor of the government. With all his diplomacy, however, he did not escape the rage of Cardinal de Medici and of Pope Leo X., who had him deprived of his office and tortured under the accusation of conspiracy. A few years later an era of magnificent scientific and literary pro- ductions was opened in England at the time of Elizabeth. It was an outburst of intellectual activity, when the English mind felt the joy of emancipation. From Sir Thomas Moore with his " Utopia," Sir Thomas Wyatt, William Dunbar, Thomas Sackville, Lord Buckhurst, to Edmund Spenser with his " Belle Phoebe," was a magnificent epoch of poetical geniuses. This epoch was crowned by the giant and por- tentous mind of Shakespeare, who was the personified spirit of his time. Amongst physicians in the first part of the sixteenth century we find in Italy Mondino, Berengario da Carpi, Vesalius, BenedettL Benivieni, who made interesting discoveries in human anatomy. Nor must we fail to mention Philip Ingrassias of Naples, Constant Varoli, from whom some organs of the central nervous system have derived their names, Michel Servet, who described the circulation of the lungs and was then burned at the stake, Fabricius de Aquapendente, who studied the veins and described the valves, William Harvey, who clearh explained the circulation of the blood, which he had learned in Padua under his teacher, Eustachius Rudio. Gradually, as the generations of heredo-syphilitics were piling up in the world, science, art and literature began to lose ground. The interest was all concentrated in fantastic poetry of a religious nature, which was followed by the Protestant revolutions of Luther, Zwingle and Calvin. This prompted Adrian VI. to impose a gloomy Lent, which made sad all good livers of Italy and* of other countries. The studies of medicine, which had been g'airiing in the golden time, began to lose ground and ignorance began to give place to the most absurd superstition. Pest, syphilis and contagious diseases in general, were considered 380 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS as a result of the will of God. Paracelsus, who yet represented a learned physician of his time, stated that any contagious disease came from the planets, particularly from Saturnus, who devoured children. In the seventeenth century in Rome, 28 we find employed against leprosy, syphilis and other diseases of the skin the following treatment : " After the patient has been regularly purged, he was introduced into a Grotto near Bracciano, which was inhabited by innumerable snakes. The temperature of the Grotto was very warm and soon produced abundant perspiration, and the patient, who had taken a hypnotic potion, soon fell asleep. He was entirely naked, and the reptiles, attracted by the odor of the perspiration, came out of their holes, coiled up around the body of the patient, and licked his perspiration without doing him any harm. After three or four hours he was taken out of the grotto. This treatment was continued until recovery had been obtained." It was at this time that neurotic epidemics of mystic enthusiasm and of ascetic fanaticism of demonomania began to sadden the world. The Cardinal of Lorraine prompted and urged his brother, the Duke of Guise, to undertake the extermination of the heretics. The Huguenots began to be persecuted with heartless cruelty, and on ac- count of their temerity in doubting some of the dogmas of Rome, they were brought by scores and by hundreds before the tribunal from which was no appeal, and were burned at the stake. This generation of heredo-syphilitics gave to the world Catherine de Medici, who, from her castle, enjoyed the view of those poor wretches condemned as heretics hanging up on iron hooks, or executed in other ways. When, after the death of Francis II., the throne came to Charles IX., her sec- ond son, who was ten years old, she became the regent, and she had every chance for her crafty machinations and bigoted projects, which were nurtured by her Catholic fanaticism. The Huguenots and the Catholics came to an open war and made France a prey to the bloodiest spirits of the age. After the death of the Duke of Guise, Catherine, feigning peace with the Huguenots, wa 3 preparing the most atrocious tragedy. It was in 1565 that she, taking advantage of the peaceful conditions of the kingdom, met on a trip the Duke of Alva, prime minister of Philip II., with whom she planned the extermination of the Huguenots. The celebrated night of St. Bartholomew came, the horrible butchery of the Huguenots so well and so long planned by Catherine commenced. The honored head of Coligny was cut off and sent as an acceptable trophy to the Cardinal of Lorraine. The horrible massacre lasted seven days, until the murderers, drunk with the blood of thirty 28 Kircher. " De Arte Magnetica," lib. Ill, quoted by Cesar Cantu. " Histoire Univers ," vol. xv, p. 502. SYPHILIS IN RELATION TO DEGENERACY 381 thousand victims, stopped the carnage and went to sing Te Deitm I an damns. Charles IX. died when twenty-four years old, pursued by his re- morses, stricken with terror, continuously recalling the horrible- butchery. The third son of Catherine ascended the throne as Henry III., w T ho planned and executed the most vile and cowardly assassina- tion of his rival, the Duke of Guise, which was followed by that of the Cardinal of Guise. He was himself assassinated. In Germany Ferdinand I. was elected by the German Diet to the throne of the empire in 1558. Under his wise and tolerant rule, religious reforms were spreading. The famous Council of Trent after eighteen years had finally adjourned. In spite of the cry raised by the Cardinal of Lorraine, " Cursed be all heretics," in spite of the horrid theory that freedom of thought ought to be crushed by authority, the huge specter of mental slavery was gradually vanishing. Moreover, when after his death his eldest son took the crown of the German Empire as Maximilian II., the hopes of the reformers rose still higher. But when Rudolph II., his son, a pupil of the Spanish Jesuits, ascended the throne, all changed and the statutes of tolerance granted by Maximilian were abrogated. Here again the upholding of the decisions of the Council of Trent, that Catholic rulers might pro- ceed to put down heresy by the sword. England at this time, after the death of Henry VIII. , his son, Edward VI., a boy ten years old, having ascended the throne, was under the protectorate of Lord Hertford, Duke of Somerset. He, a consistent and able opponent of Rome, determined to make the Church of England independent of the papal hierarchy and bring the religious doctrines and religious ceremonies up to the standard of the Reforma- tion. The new liturgy was made to conform as nearly as possible to the usages of the primitive fathers of the Church, freed from all osten- tatious and superstitious practices of the Catholics, and the ritual was in the plain English language, understood by all. This, however, put difficulties in the way of the marriage of the king, who by the will of his father was to be married to Mary Stuart of Scotland. As Catholic influence was predominant in Scotland, the demand for the hand of Mary was met with refusal, because the heiress to the throne ought never to become the queen of so heretical an island as England, and the spouse of so heretical a king as Edward VI. It is interesting to note the difficulties and the hardships caused at that time among the English social classes through the change of the national religion. Difficulties arose in families of the higher class on account of their refusing to take up the new religion, as was the case with Princess Mary, the daughter of Henry VIII. Helpless monks 382 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS and nuns were turned out of the doors of their convents and dis- possessed of their properties. The peasants, who for a long time had rented and tilled the lands of the Church, paying a trifle for the privilege, were ruined by the act of confiscation ; and all vagrants and mendicants, who at every age have flourished around the doors of the monasteries, were scattered in a starving condition. Somerset found a great deal of difficulty in contending with so numerous a number of malcontents, and for this reason it was easy for Dudley of Warwick to arrange a plot against him, charging him with conspiracy and leading him to the block. Cranmer, who had prepared the English Catechism, guided by the works of Luther and Melanchthon, stooped to the miserable work of persecution. Two Anabaptists were arrested for heresy, condemned by his court, and, in spite of the protests of the king, burned at the stake. In the middle of the same century we find again in this same England Catholicism restored by the machinations of the Queen Mary Tudor, who could not find a bigoted husband in England and married Archduke Philip of Spain. After the defeat of Sir Thomas Wyatt, who wanted to confer the crown on Lady Jane Grey, she had Wyatt and four hundred of his followers condemned and executed. Lady Jane was also condemned to die, tormented by a priest who had been sent by the queen to convert the poor victim from her heresy. This same queen and her husband, with their faithful Gardiner, formed a plot for the extirpation of the heresy in the kingdom. The horrified world saw the burning at the stake of three hundred of the most pious and law-abiding citizens. Among them Hugh Latimer, bishop of Worcester, and Nicholas Ridley, bishop of Rochester, vener- able men, were burned in the public square in front of Baliol College in Oxford. After the death of Mary Tudor, when the peace and the liberty of England were restored under the wise reign of Elizabeth, the rivalries began between her and and the queen of Scotland, to give to the world the celebrated drama which ended with the execution of Mary Stuart. PmTip II. of Spain, after returning from England as the rejected husband of Mary Tudor, and more bitter for the rejection of his mar- riage by Elizabeth, formed the design to invade England in order to destroy Protestantism and restore the shattered dominion of Catholi- cism. This design ended like a soap bubble for Spain and in a great glory for England. Many years had passed in a continuous struggle for supremacy until a woman of great virtue, Elizabeth, was able to restore order. Since then Protestantism has been the religion of the kingdom, but the SYPHILIS IN RELATION TO DEGENERACY 383 external cult has had a tendency towards the pompous ceremonies of the Catholic religion. The austerity of the Genevese reformers did not meet the approval of Queen Elizabeth, and for this reason the Church of England stands still as a middle point between the Catholic and the Lutheran Church. At this time a degenerate, a monster of crime and iniquities, was reigning in Spain, Philip II., who by inheritance, had one of the great- est empires in the world. A Spaniard of the Spaniards, with his eyes constantly cast on the ground, it is said that he laughed only once in his life, when he heard of the massacre of St. Bartholomew. Holland at that time was under the crown of Spain, and as the people had accepted cordially the doctrines of Luther, they were made the object of persecution. Philip ordered the Inquisition established in the different provinces, and to proceed with all rigor against heretics. The task was given to Fernando Alvarez, Duke of Alva, the most cruel, relentless and infamous of all bloodhounds, who discharged the duty to the satisfaction of his master. Crime and blood were the work of Alva ; the people belonging to the lower classes were hanged, the nobles were beheaded, and the heretics were burned at the stake. Reaction came and the Prince of Orange took the part of the oppressed beggars. Here the world was astonished by the continuous butcheries in Flanders, until the Prince of Orange gained possession of the gov- ernment. We cannot enter into a detailed reproduction of the history of the sixteenth century, we only want to recall the outrages against humanity committed at the sieges of Utrecht, Maestricht and Ant- werp. And as if these carnivals of blood had not been sufficient, the Netherlanders began to divide into factions and instead of opposing the hated Spaniards, engaged in war among themselves. It is beyond doubt that at these times when syphilis was spreading as an epidemic amongst the populations, as Tommasoli said, there was enough reasons for all to have an exceptional vulnerability of the nervous system. To find some arguments so as to state that syphilis could have had some influence on the decadence of the nations during and after the sixteenth century is a difficult task, because the disease in those, times was very little or hardly known at all, and its influence on the nervous system was not even suspected. We lack descriptions, biographies, clinical histories, which could afford us some light on so difficult a question. As a consequence, we are obliged to approach this subject by arguments of analogy, and after we have seen the results of syphilis on the nervous system in our own patients, we can apply our conclu- sions to the nations in those times. In the course of our work we have seen the remarkable influence 384 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS of the syphilitic process on the nervous system. This begins from the first secondary manifestations as toxic poisoning, and ends with the late tertiary symptoms, as infiltrations and hardening of the blood vessels and of lymph vessels of the central nerve organs. We have seen, furthermore, the deleterious influence of the syphilitic infection of the parents on the health and development of the children. This in- fluence we have seen does not stop at the second generation, but descends to the third, giving us a class which we have called heredo- syphilitics. Syphilis so transmitted is no longer revealed by the well- known symptoms, but mostly through deformities, aberrations from the ordinary type in the development of the organs of the body and peculiar nervous symptoms, and through extravagances of a psychical order, which must be attributed to the sad heritage. We have seen idiocy and epilepsy in all degrees and forms affect children, and remain during their whole life, as the result of inherited syphilis. In the psycopathology of epilepsy we know how much influence this disease has in producing mental derangements. We have noted an epileptic mania, which is so terribly dangerous not only for the individual himself, but for others, as it is accompanied by a homicidal tendency. The most brutal crimes, the most cruel butcheries, are per- petrated by epileptics, on account of their penchant for committing acts of violence without a reasonable motive. We have likewise seen the influence of the epileptic attack on the crime which may be con- sidered a part of the epileptic fit. In our times epilepsy has been found to wield great influence on the eccentricity of some persons. It has furnished a reason for the theories of men of genius, for the exaltations of some enthusiasts, for the asceticism of some religious eccentrics. It has furthermore been alleged as a cause in the production of the perverts and of the large class of the degenerated. Epilepsy is found in families of criminals and is transmitted in a hereditary way. Dr. R. de Rocchi 29 referred to the history of a family where the first of three generations was an epileptic. He had been an embezzler and a thief. Of his five children, the third was an epileptic. Of his nephews, two were epileptics, and in all were to be found criminal tendencies of the old stem. They were of an uncontrollable psychical impulsivity, very quarrelsome, and inclined to wound others with intent of killing. The forms of epilepsy are so various and different as to be in many cases difficult to recognize. In some cases the epileptic begins 29 Rinieri de Rocchi. " Storia di una famiglia per tre generazioni." Arch, di Psich, 1895. Qnot. by Lombroso. " L'Uomo Delinquente," 1897. Vol. iii. p. 657. SYPHILIS IN RELATION TO DEGENERACY 385 to feel signs which precede the attack, he has malaise, sexual ex- citement noise in the ear, confusion of the eyesight, and at once opens his clothes and begins to masturbate, until with a sensation of satis- faction, he has obtained his purpose. He then remains stupid, as if he had awakened from a deep sleep, begins to cry, and does not recol- lect anything of the occurrence. This has been an epileptic attack, which has also been called an epileptic equivalent. Ottolenghi, 30 among 250 criminals, found 80 of them epileptics showing various forms of the disease. In 31 the attack was of a convulsive and motor order, and in 76 it was of a psychical nature. In 20 the attack consisted of epileptic vertigo, with inconsistent auto- matic acts, not violent in character. In 16 there was found ambulatory tendency, procursive epilepsy. In 9 the attack consisted in fleeing, and in 7 the form consisted in vagabondage, tramping around in idleness. In 25 there was found the true epileptic wrath with severe attacks, during which crimes of blood had been committed. Every one of these epileptic criminals showed clear marks of degeneracy, and their sensibility was found greatly diminished. In fact, in all those epileptics, the sense of touch, the general sensibility and the sensibility to pain has been found stunted and little developed. Indeed, in the criminal epileptics there is oftener found the morbid epileptic wrath, which is the exaggeration of the character of the born criminal. The epileptic criminals have the anatomical and the psychical characters of the born criminals, the complete criminal type, and on account of their diminished sensibility they are inclined to every kind of crimes, but more often to violent crimes of blood. When we consider that syphilis is one of the principal causes of epilepsy, we will easily understand the influence which the dreaded disease must have had on the successive generations. Syphilis produces psychoses of specific nature as a result of spe- cific encephalitis, and has also a peculiar influence in the development of other ordinary psychopathic conditions. In fact syphilis causes a severe depression in the ordinary mind of a degenerate, which will re- veal the pre-existing deficiencies and the psychical derangement in an intellectual or in a moral sphere. In some cases the mental derange- ments do not consist in a defined delirium, but rather in a kind of mental excitement, incoherence, extravagance, while in other cases there is mental depression and apathy nearing an idiotic appearance. In reference to the dangers due to syphilitic insanity Jeronimo Galliana 31 referred to a case of a man, who, having had some ante- 30 Ottolenghi. Archiv. di Psichiatria, 1896. 31 Galliana, J. " Folies toxiques et infectieuses." XIV. Congr. hit., Madrid, p. 30. 386 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS cedents of psychical derangements, acquired syphilis. After the fourth month from the infection, he began to show the most violent and excited mental condition. He alleged that he had acquired the infection from his intended bride, and in an attack of despondency shot her dead. The autopsy revealed no sign of syphilis in the young lady, as she was a virgin. Syphilis in the secondary period is capable of producing psychical deviations in the degenerated, with hallucinations, delusions and delirium. Before the syphilitic infection, those individuals have been somewhat unbalanced, but the toxic influence of syphilis has driven them to a violent insanity. There are cases where no signs of de- generacy or of mental derangement are present, but only some little deficiency, which is rather difficult to recognize. We have seen in another chapter that syphilis causes a moral affliction in the man who is infected, tending to lead him to suicide. In the moral depression resulting from the peculiar anemia induced by the virus, together with the toxins produced by the syphilitic germs, we find enough factors to induce mental alienation. Many other psychoses are of syphilitic origin because they are induced by syphilitic lesions of the cells of the brain. Gummata, syphilitic infiltrations pressing the delicate nervous cells, prevent their nutrition and cause their atrophy. In the blood vessels, syphilitic arteritis is also the cause of hemorrhagic effusions, and also of oblitera- tions of the blood vessels, which produce softening of the nervous matter. The consequence of all these lesions on the nerve cells is dementia, which at times is revealed by a strange delirium, at other times the demential delirium is accompanied by disorders of the motility. In some cases the patients, before showing psychical or motor symptoms, have suffered with vertigo or with cephalalgia during the night. Then gradually they have shown paralytic conditions of the motor nerves of the eye, more especially of the motor communis. In syphilo-psychoses the derangement of the ideas and their incoherence are quite peculiar, and the delirium is usually of a partial character in the form of mono- mania, melancholia, delirium of persecution, suicidal tendency. In the life of Benvenuto Cellini we find at first this genius busy in designing jewelry, sculpture, literature, always being diligent at his work : after he had been infected with syphilis he began to neglect his work and to dedicate himself to the art of necromancy. It shows a disordered psychical condition and an exalted phantasy, the descrip- tion of the devils which he thought he saw in the colosseum and which accompanied him home, jumping from roof to roof. In reference to hereditary syphilis, we have already seen in the SYPHILIS IN RELATION TO DEGENERACY 387 preceding chapters the great influence this has in the production of degenerates, deficients and mattoids, and in the following chapters we shall present much more in reference to criminals. We agree with Tommasoli and Barthelemy and others that the syphilitic heritage acts no less than tuberculosis and alcoholism in the production of the degeneration of the human race. If we return to consider the beginning of the sixteenth century, we see that in the splendor of those intellectual men, of those geniuses who brought about the Renaissance, a cloud could be perceived which produced shadows in many points. Masi referred to the fact that be- fore the era of the Renaissance had begun its decline, a gloomy and sad expression could be seen in the features of the last men, a kind of mystic preoccupation, a sense of uneasiness, or better, a presentiment of impending miseries. Josne Carducci remarked that studying the face of the divine Raphael, who young, yet died of a mysterious fever, it is easy to recognize a peculiar sadness ; on the face of Michelangelo there is printed rage and despite, while Ariosto and Berni in their smile reveal deep gloominess and wrath. The features of Macchiavelli and those of Guicciardini cannot conceal their moral sufferings. The human mind was groping under a cloud of restlessness and of uncertainty. Fear has been the enemy of mental achievements, and it has ever paralyzed the power of the human genius. At that time nobody was safe, nobody had an idea of what the morrow would be. It was necessary to please the nobles and the powerful, and do one's best not to incur their dislike. As a consequence, the activity of the human intellect was restrained, and to the melancholic depression there was associated a tendency to artificial manners, which began to mark the perversion. The studied artificial manners, called after a while mannerisms, began to appear in the poetry of Tasso, and is much more evident in the writings of Leopardi, both geniuses who had been tortured by the world, and mostly by themselves. Literary compositions of that epoch were dictated by momentary passions, were full of personal exaggerations, lacking in intellectual elevation. The years of political and moral oppression were passing. and the people were adapting themselves to the circumstances, and from the studied mannerisms they began to fall towards a kind of audacity. This period began with Bernini, and at the second part of the sixteenth century is represented by Borromino. Literature, poetry, art, architecture, all betray a kind of delirium, which is the character- istic of that century. Hobbes and Molines showed delirium in their fatalism. Painters showed a kind of delirium in the lack of harmony of their colors, and in their reckless vivacitv. Sculpture and architecture 388 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS showed it in the barocco style which has been well described as the extravagance of the art. In science, as in art, there are found only an artificial volubility, extravagance, and exaggeration, which clearly showed the delirium of that century. The men of distinction in arts and in literature of that epoch have in their life manifested signs of melancholia and extrava- gance which cannot be considered within the limits of the normal. Tassoni, an extravagant poet, having tried all his life to state new things, died of melancholia. Jodelle, who wanted to substitute some- thing new for the mystery play, morality play and the farce, died crazy at the age of forty-one. Chiabrera compared himself to Columbus and promised to discover a new world. The more we study that epoch, the more we recognize, together with the decadence, some psychological features which show mental aberrations. The peculiarity of the symptoms, the versatility of the manifestations point to that kind of alienation which has been recently known as paranoia. A mental disease, so-called by Mendel, which occurs in individuals capable of considerable education, even of brilliant acquirements, but yet possess- ing a mental twist, which makes them belong to a separate class. This affection consists in a structural weakness of the nervous system, nearly always inherited, bearing relationship to moral imbecility. We have already seen the chronic and progressive nature of paranoia, its delusions and hallucinations, while the patient still possesses reasoning faculties to conceal his mental aberration. The delusions, which are mostly in the nature of persecution, and the delirium of an ambitious and fastiduous character, have a chronic pro- gressive and systematized course. Paranoia shows itself, at times, in adolescence ; at other times, later in life ; constituting the two principal forms of paranoia originaria and of paranoia tarda. It is an hereditary disease, and heredity plays the most interesting role in the production of this disease. The disease is of a degenerative nature and is the result of any influence or any cause which perverts or alters the delicate structure of the nervous system. Syphilis, we have seen, is one of the most powerful causes which disturbs the nutri- tion of the nervous cells by its toxication and its infiltrating processes. And we would not hesitate for a moment to state that paranoia finds its preferred ground in heredo-syphilitics. If syphilis is hereditary, transmission produces syphilitic epileptics, and for the same reason it will produce syphilitic paranoiacs. Indeed, as Tommasoli remarked. comparing paranoia with paralytic dementia, many manifestations of both diseases show a great analogy. The syphilitic psychoses which we have mentioned, and those SYPHILIS IN RELATION TO DEGENERACY 389 which assume a chronic and depressive form, may lead to paranoia. In effect, literature, arts and sciences in the sixteenth century show some peculiar eccentricity and extravagance which clearly reveal the aberrations, or better the hallucinations and the delusions of the authors. It would take a long time to review the life and the works of the many distinguished people of that age who have been quoted as examples of paranoiacs. From all that which we have considered in this chapter, we can state that a new, unknown disease, syphilis, had made its appearance amongst the people. The decadence began to appear nearly fifty years after this disease had spread in an epidemic form among the individuals of the social classes. By this time we have two generations ; one which had acquired syphilis, and the second which had inherited syphilis. If syphilis at our age often affects the nervous system, and is capable of inducing psychoses, at that time it could in the same way produce mental dis- orders. AVhen syphilis has acted in the individuals as an hereditary taint on the descendants of the first or of the second generation, then it is capable of inducing forms of psychoses of a peculiar kind Which give us the right to consider it the reason for the decadence of the sixteenth century. If we compare the facts and the men of that time with the men and facts of the present, we will probably find a support for our thesis. At the moment we are writing a carnival of blood is being enacted in the vast dominions of the Czar. The horrors of the massacre of Kishinev have not only been repeated, but greatly surpassed. " Kill the Jews," have been the words shouted in Vyazma ; and hundreds of unoffending Hebrews, who were peacefully celebrating the proclama- tion of freedom granted to the people by the Czar, fell on the public square massacred by a mob drunk with blood and carnage. The mob not yet satisfied with their bloody work, went to the Jewish quarters, sacked the shops and broke into their residences, destroying everything and committing horrible atrocities. Dispatches of the same day, November 2, 1905, refer to horrible massacres having occurred in Odessa, where at least 5000 persons were killed or wounded in one day. The streets are absolutely unsafe for civilians. In the outskirts of the town, the massacre of the Jews con- tinues. They are being hunted down in the streets, killed and beaten, while their shops are given over to pillage. In the Jewish quarters bodies still strew the streets and the side- walks. Jewish women and children were hacked to pieces in the streets bv an infuriated mob. 390 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPEClS Indeed, nobody will find much difference between the actual con- dition of Russia and the times of Philip II. and Catherine of France. Carnivals of blood were enacted in those times and carnivals of blood are enacted in our times. At those times the Huguenots were hunted down in the streets and killed in their own houses ; to-day the Jews are the object of persecution. The same religious intolerance which to-day marks the horrible deeds in Russia flooded Europe with blood at the time of the decadence in the sixteenth century. The same sentiments of an exalted fanati- cism inspired the first conquerors of the two Indias, and they labored under the delusion that the heathen, savages, were of an inferior race, they had no right to the sky, sun, earth, or even to their own person. Consequently the most cruel and infamous outrages perpetrated on them was an act of merit. In all those brutal deeds we can see the exalted sentiments of a blurred mind fired by uncontrollable impulses arising from material interests and social vices, which have prompted in those times and to-day prompt the populace to rob and despoil in- nocent people of their properties, under the excuse that they are of a different religion. For those times we have found that syphilis spreading epi- demically, with no treatment or with an inadequate one, and trans- mitted to the second and to the third generations, could have produced heredo-syphilitics with a tendency to psychoses, with exalted and dan- gerous hallucinations. In the same way syphilitic virus, either by means of its toxic influence on the nervous system or by the anatomo- pathological alterations induced on the vascular system, may have prepared men with excitable, exalted, perverted, deficient mental facul- ties, capable of any cruelty. Can we find anything analogous in our days? Doboszynski 32 relates that in the district of Kasan an endemia of syphilis has existed for many years. Their habits are dissolute and promiscuity of sexual relations is admitted, for the reason that the women, at the age of twenty, want to have children. Syphilis is also spread by means of domestic utensils, and more especially by cigarettes, which the women constantly use. In 1902 the government tried to stop somewhat the progress of the disease, and a hospital was founded exclusively for syphilitic patients. In one year, in a population of 11,863, 5 20 cases of recently acquired syphilis came up for treatment. The number of cases of tertiary syphilis is enormous and is met with in thirty-four per cent, of the cases of syphilis. Of 106 children, 92 showed manifestations of recent syphilis; in 13 there were signs of hereditary lues, and in 1 of tertiary cachexia. 32 Doboszynski, L. " Przeglad lekarski," 1904. Ref. Monatsheft f. prakt. Derm. B. 39, p. 295. SYPHILIS IN RELATION TO DEGENERACY 391 Hyde S3 stated that among European countries syphilis is found to prevail extensively in Russia, especially in the large cities of Mos- cow and St. Petersburg. The colder climates, where one might sup- pose on a priori grounds that the habits of the enervated and effemi- nate residents of the tropics would not be countenanced, seem to have in the larger centers of population the effect of stimulating the passions of men and women densely crowded together in the cities, and seeking in drink and debauchery a respite from the cheerlessness of an inhospitable climate. According to Wwedensky 34 in his study on syphilis among the prostitutes of the brothels in St. Petersburg, he found that in 70 of those houses there were 689 women actually infected with syphilis and 273 not infected ; 102 had had syphilis, but were past the infectious stage, while 45 showed gummata. In all the houses of prostitution he found 39 per cent, of prostitutes in the condylomatous stage capable of spreading the infection. Sperk, 35 Fedorow, 36 and Graziawsky, 37 in their different reports taken from the police department, from hospitals and clinics, and from the houses of prostitution, bring the amount of syphilitic prostitutes with recent infection up to thirty-nine per cent., showing that syphilis in the houses of prostitution is flourishing. In the same way, from the testimony of Tarnowski, Petersen and Tschnelow, we may argue that syphilis in Russia is widely spread and is a dreadful scourge amongst the people. We have already seen that Tarnowski has coined the term syphilis binaria to be applied when heredo-syphilitics of the second generation acquire a new infection. In the higher classes of society in Russia we refer to the report of Thompson, quoted by Sanger, 38 morality does not appear to be at a high standard. He said, " immorality and intrigue are of universal prevalence, and in a social sense are hardly looked upon as criminal acts, while gambling and debauchery are the natural consequences of the tedious monotony from which all seek to escape by indulging in gross and vicious excitement." Sanger stated that the conjugal relations of the Russian nobility 33 Hyde, J. N. " History, Geographical Distribution," etc. " System of Gen. Urin.," etc. New York, 1893. 34 Wwendensky, A. A. " Die syphilis unter den Prostituirten der St. Peters- burger Bordelle." Arch. f. Derm, und Syph. B. 36, p. 127. 35 Sperk, Ed. " Theorie der Statistik bei Erkrankungen und Sterblichkeit, und Anwendung derselben zur Untersuchungen der Prostitution und Syphilis." Quoted by Wwendensky. 36 Fedorow, A. " Die Prostitution in St. Petersburg und deren polizeiartz- liche Beaufsichtigung." Arch. f. Derm. it. Syph. Bd. 25. p. 395. 37 Graziawsky, P. J. " Kritische Besprechung des Berichtes von Prof. Tar- nowski." Zdorowic, 1881, N. 5, 6. 38 Sanger, W. W. " The History of Prostitution." New York, iSoo. p. 27$. 392 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS were extremely loose and indefensible during the time when vice was the fashion, and virtue in a courtier would have been deemed con- demnation of the higher powers. Then, and even down to the reign of the Emperor Nicholas, marriage was simply an affair of convenience, the husband living at Moscow or St. Petersburg, the wife in Paris or Italy, such separations frequently lasting for years. In our study of the extraordinary happenings of the world, we have found that syphilis could be accounted as one of the most power- ful causes of degeneration amongst the populations of the sixteenth century. We have referred to the excitable feelings, to the exalted phantasy induced by syphilitic psychoses, the murders, the carnages and the pillages of these ages. Now we do not see any reason why we should not attribute a good part of the carnivals of blood, of pillages and of persecutions which are at present enacted in Russia to the excitement of the psychical faculties due to syphilitic disturbances of the brain. It is not necessary that every one of the infuriated mob should be led by a morbid condition of their mental faculties, but the leaders, or those instigating them to such atrocities must be afflicted with hallucinations and delusions. The insane easily find followers, the folie a deux is constantly at hand, and a crazy man with an exalted phantasy, with a morbid delirious mind, will find followers in his vicious and dangerous delusions. The followers look upon their delu- sions and hallucinations as the result of a mysticism, which they admire, and yet are not able to comprehend, but which stirs up their enthusiasm as if from a supernatural command. The thesis is one of too delicate a nature. It is based on the results of medical observations without positive data to prove that those men of the sixteenth century had shown secondary or tertiary symptoms of syphilis. In the same way we have no positive data to prove that the leaders of the massacres in Russia were syphilitics, or came from a generation of heredo-syphilitics. But one thing is sure, at the time of the sixteenth century, many had been affected with syphilis, and in Russia lues is quite frequent. It is possible that some, who had their minds in a morbid condition on account of the luetic infection, have given the start and the others have followed their vicious and delirious impulsions — impulsions which have been induced by lues in an ac- quired or in an hereditary form, and have been converted into criminal acts as a consequence of the stringent political and social circum- stances. SYPHILIS AS A PREDISPOSING CAUSE OF CRIME Criminality should be divided into two principal types, which are constantly in relation with the physiology and pathology of the SYPHILIS IN RELATION TO DEGENERACY 393 social spheres. One is called atavic criminality, and is more often connected with morbid conditions of the nervous centers, while the other, called evolutive criminality, is also perverted in the intention, only somewhat more refined in the means. The first form uses violent means, struggle, homicide, rape, theft, while the other substitutes keen fraud and deception for violence. Heredo-syphilitics are in general predisposed to the first form of criminality, while anyone who has a weak moral character, who is unable to resist a bad influence, is liable to fall into the second kind. A defective condition of the mind is connected with an arrest of de- velopment in the organs of the brain, which hereditary diseases and especially syphilis may induce. Indeed, as Clouston suggested, the tissues which mature slowly are more likely to be affected by hereditary disease. When the circulation, especially that of the capillaries, is impaired, growth and energy itself may do harm, because they cannot be properly distributed and rightly proportioned. When the distribu- tion of the nutrition from the blood is not rightly done, then each determinant cannot obtain its full share of the momentum and there is disproportion. Thus it is that in heredo-syphilitics we sometimes see the gain in height at the expense of the weight, or an arrest in the general development, as in infantilism ; at other times the lack of development affects the nervous system, which is left immature or not evenly developed. For these reasons the heredo-syphilitics on the one side, on account of the true pathological condition of their brain may be predisposed to the first kind of criminality, but it is not impossible that on account of an undeveloped condition of the brain they are likewise predisposed to the second. Lombroso referred to the observations of Sighele, 39 which show that the two forms of criminality are also found in associated criminal- ity ; the first, in the lowest classes, and the second, in the higher classes of society. On the one hand are rich people, politicians, etc., who bribe or receive bribery, by means of intrigue and deception steal the public money, and on the other hand are the poor and the ignorant, who in anarchistic meetings, in riots, etc., are trying to rebel against the con- ditions imposed upon them, and protest against immorality. The first form of criminality is essentially evolutive in character, the second is atavic, brutal and violent. The first comes from intelligence, rests on cunning means, such as embezzlement, fraud, etc., the second rests on the muscular powers and ferocious means, such as homicide and dynamite. In the Middle Ages we find the records of a bloody criminality, 39 Sighele. " Delinquenza settaria." Arch, di Psich. xvi, 1805. 394 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS which we have seen reproduced at this time in the unhappy Russian domains. The uncivilized conditions of the populations, and much more so of the governments, which have organized and maintained barbarous means of repression, are the cause of the association of criminals. Indeed, as Azeglio 40 stated, when the royal mail service used to defraud people with the letters, when the police were busy arresting honest patriots, w r hile leaving undisturbed thieves and high- way robbers, and allowing every transgression in the brothels and in the prisons to go on freely and unrepressed, there came as a necessity the protection found in the mafia or in the camorra, which was a natural adjustment of the people to the political conditions. The brigands represented a kind of savage justice against the oppressors. In Russia, the moujik, indifferent of his life on account of continuous sufferings in which nobody had ever taken any interest r was ready to commit murder to avenge his wrongs. In Italy, the wrongs committed by the landlords against the peasants formed one of the principal causes for the existence of the brigands. The poor peasants saw T in the brigand a man who redressed their wrongs. The communities which had been well administered did not furnish a single brigand, while those badly administered furnished large numbers of them. In provinces or in counties where the law shows inefficiency, a class of people of the most daring believe themselves superior to the law, and as a consequence the others be- lieving the law inefficient take the law into their hands. Kentucky has given us many instances of this in late years in its family feuds, and several other States in their lynching parties, as a protest against the inefficient administration of justice. In Rome, for instance, criminality was far greater than in anv other province of Italy. It was the result of the traditional impunity which was accorded by the fallen papal government. The common people of Rome, steeped in religious superstitions and lacking in in- struction, were incapable of restraining their passions and of consider- ing the results of them. A word uttered while playing cards, a sus- picion of infidelity or rivalry in business, was sufficient reason for the commission of murder. The cause was so disproportionate to the deed that often the judges have considered it an attack of sudden insanity. A few glasses of wine kindled the ire for any imaginary offense, the stiletto or the knife was readily at hand, and the reason was too much blurred to refuse its services and consider the sad consequences. This proclivity to crimes against persons, this disregard for human life was also increased by the barbarous superstitution, that whoever dare not take revenge for an insult is no man, that manly dignity obliged one 40 Azeglio, M. Quoted by Lombroso. " Uomo delinquente " vol. iii, p. 49. SYPHILIS IN RELATION TO DEGENERACY 395 to take justice in his own hands and not seek it through the legal authorities. It was the inheritance of violence, the atavic brutal in- stinct handed down from the old Romans. In any civilized country every decent man believes it his duty to assist the police to apprehend a thief or a murderer, but the lower classes of the Roman population, who were unable to understand the government, would either kill him, or, entirely unconcerned, would let him go. Tommasi-Crudeli related that in Sicily the name of malan- drino culprit lost the significance of infamy, and was applied by the people as a name of praise, meaning by it a man who has no fear, especially of justice, which in their blurred minds is confused with the government. In Corsica murders for revenge are exceedingly frequent and the causes are scarcely credible. Bournet 41 related that a dog belonging to Tafani which was killed by Rocchini, caused eleven victims in the two families. Nobody^ in order to help justice, would testify concern- ing a crime which they had seen. The increased civilization of modern times increases wants, and consequently wishes, in the people, who seek gratification in sensual excitement. It is not to be wondered at to-day that the number of those suffering from alcoholism and general paralysis is increased in the asylums, just as is increased in the penitentiaries the number of culprits against property and against morality. This kind of criminal- ity is mostly found in the large cities, and mostly in the educated social classes. The facilities for traveling, the railroads and commercial con- centration have tended to enlarge the centers of population. Delin- quents have found their way to the large cities, where they expect to find better profits and greater immunity. This, however, is not so, because if the incentives to crime are increased, vigilance and repres- sion are also increased. In the large cities more facilities for work are offered and also more seductions are at hand. But, as Lombroso thinks, the conglomeration of population acts a great deal as one of the causes leading to crime and immorality. Indeed, every one of us has had occasion to remark that a man who in his home is modest and reserved, in company with others may talk licentiously and even immorally. Moreover, it has occurred that men have stolen or committed immoral acts just to show to the others that they are good companions. This tendency is increased with the increasing of the masses, and it finds its proof in the fact that manu- facturing districts show a larger number of crimes than rural districts. Bertillon remarked in every man a certain violent or morbid tend- 41 Bournet. " Criminalite en Corse," 1887. Arch, di psich., viii. 396 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS ency to reproduce the sentiments and the passions which are fomented in our surroundings. It seems that the air, filled with the dominating opinions, acts as it does with contagious diseases. A faint instinctive tendency to theft, to homicide, and to lascivity is found in embryo in every individual, which disappear when culti- vated by education. These embryonic bad tendencies may at once assume greater proportions in company with others. It is found that in the schools and in the colleges the most virtuous learn from one or another the mysteries of vice. The relative develop- ment of the brain, together with the functions of the sexual organs, explains the tendency to offense against morality. The quantity of prostitution in the large centers finds its cause in the congestion of population. The increased use of alcoholics and of tobacco, and to-day the horrible use of opium and cocaine are other causes of the increase in crimes. The studied and well-arranged description of crimes in the news- papers is in many cases the cause of excitement and of a desire of emulation in the criminals. Quite often we have heard from criminals that they wanted to do as Tracy or Jesse James did, whom they consid- ered their heroes. The reading of dime novels, dealing mostly with criminal deeds, kindles the passions of the young people and leads them to misdeeds in imitation of their hero. In the same way the sensational performances in cheap theatres have a great influence in kindling the passions of the young theatergoers and prompt them to commit some misdeed. The crowding of men in the poor lodging houses, their dis- cussions on social problems, are often the cause of strikes and then of being led to theft. Bringing criminals together in jails and in penitentiaries makes them much more dangerous and daring. Among the inmates of the penitentiaries the greatest perversity is a glory, and any idea of virtue is a shame, and when a man has been in jail for some time, if he had good ideas, very likely they are lost. Yet philanthropic reforms, conditional liberty, discharge on parole, have not so far given very good results. The born criminal has certain conditions in the organization of his brain which prompt him to commit crime, and anything which is done with the view of elevating the manly dignity remains inefficient on the bad disposition of those criminals. On the contrary, when a criminal can have the hope of escaping punish- ment, he is more incited to crime. Armengol 42 wrote that Spain was a free penitentiary, where everybody could commit any crime without fear of punishment. By political influence, liberty could easily be obtained, and crimes increase to an enormous extent. 42 Armengol. " Estudios Penitenciarios," 1873. Quoted by Lombroso, /. c. SYPHILIS IN RELATION TO DEGENERACY 39; The progress of civilization is not to be called responsible for the increase of crime. It is possible that under a wrong interpretation some may see in the high degree of civilization an increased looseness in the family ties, and as a consequence an increase of illegitimate children, who, when adults, often join the ranks of criminals. Licen- tious ideas of the family ties are often the cause of an increase in rapes and in infanticides. On the other hand, the work of philanthropists, the work of the societies protecting children, are the means which society opposes to crime in its incipiency. The density of population plays a great role in the number of crimes. Wherever people live far apart, theft, infliction of wounds and prostitution are rather rare. But with the contact of families in tribes or clans, crime shows up in a ferocious manner with great fre- quency. The question is one of the occasion which the contact affords, an occasion which is lacking when the density is greatly reduced. Yet according to Lombroso the homicides are diminishing in the large cities, with the increase of the density, and are very frequent in sparsely populated places, where ignorance and barbarism are domi- nant, and the killing of a man is considered rather a duty than a crime. Thefts, rapes, violence against the officers of the law diminish with the increase of density of population, but on some occasions are frequently met with in the capitals and at times in great manufacturing centers. In France, the study of the relation of the density of the popula- tion to the monarchical reaction has shown that in the most densely populated districts the public is more inclined to revolutionary ideas. It is clear that in the most crowded districts political agitations are most frequent. For this reason the large cities are dangerous to the political conditions. The highest proportion of revolutionists is ahvays found in the districts where the population is overcrowded, while in the rural districts where the population is sparse, people have conservative ideas. Great cities are dangerous to political quietness, and as stated by Maxime Du Camp, France has too big a head and like hydrocephalic individuals is subject to maniac fits. We have already shown that syphilis is more common in large cities than in rural districts. We have found that a great percentage of the population have suffered from syphilis, and a great many of their children are heredo-syphilitics, who show prominently the marks of degeneracy. Amongst emigrants we find syphilis very common. In our private practice, hospital and clinics, we have had occasion to ascertain that syphilis is the principal cause of the ailments among Italians and Irish of the lower classes. Emigration itself is an occasion for crime. 398 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS and when there is already a predisposing one in the system, then we will not be astonished at the increase in crimes in the States where most of the emigration goes. In the Compendium of the Tenth Census of the United States, the States where Irish and Italian emigration is directed, have given the highest number of crimes. California comes first, with 0.30 con- victed to 1000 inhabitants, having 33 per cent, of emigrants. New York comes next with 0.27 convicted to 1000, with 23 per cent, of emigrants. In New York, of 49,000 arrested, 32,000 were emigrants. In France it has been remarked that among 100,000 residents in their native place, 8 were indicted, while living outside of their native place 29 had been indicted, and among 100.000 foreigners living in France, 41 were indicted. When the emigration from one country to another is in limited proportions, it usually carries men of intelligence and energy, but when the emigration is too large, the good and the bad elements are un- doubtedly found mixed together. Emigrants who have no intention of assimilating with the people of the country, and only intend to remain as temporary emigration, are the most dangerous, and often give the larger number of criminals. The most dangerous class of emigrants has been found to be those who have no trade or profession, but at random accept any kind of work. In France, emigrants who take up peddling have given the larger num- ber of crimes, frauds, and violence. Some emigrants, as Joly 43 remarked, arrive in large cities with good, honest intentions, but allured by the new surroundings are liable to make a mistake which will drag them over the precipice into crim- inality. A poor girl succumbs to seduction and becomes a prostitute. A workingman has lost his job, remains idle, becomes acquainted with bad companions, wants to enjoy pleasures with them, and becomes a thief. These are only occasional criminals in whom the predisposing cause has not much importance. People we are now considering are those who come to the large cities purposely to commit crimes. In the larger cities, occasions for crimes are constantly at hand, and the crime can be committed in so disguised a manner by frauds as to scarcely resemble an evil. Lombroso, in speaking of the emigrant, said that he belongs to that human agglomeration which has the greatest inclination to asso- ciated criminality. He has more needs, less surveillance, less shame, more facilities to escape justice, more frequently uses jargon, and has a tendency to wander. Pilgrims for religious purposes in Italy have committed a large number of crimes. Lozzi refers to the name 43 Joly. " France Criminelle," 1890. SYPHILIS IN RELATION TO DEGENERACY 399 mariolo, which in Italy is a synonym for scoundrel, as derived from those pilgrims, who used to sing Ave Maria while committing rapes and thefts, which they intended to expiate with the penitence of the pilgrimage. The crimes committed by pilgrims were so appalling that the king of France, in 1732, by a special decree, forbade pilgrimages to St. James of Gallicia, and to Notre Dame of Loretto, which were consid- ered^ the cause of crimes. In the provinces where the birth rate is very low criminality is greatly increased. Indeed, the lack of population caused by that diminished birth rate is replaced by emigration, which causes associated criminality and the rate of crime is suddenly augmented. In Cette and Marseilles, as observed by Joly, the birth rate has been greatly reduced and the emigration greatly increased, with an enormous increase in criminality. It has been found that in the provinces where are most early marriages and more legitimate children, the number of crimes is diminished. Syphilis is usually acquired on account of the alleged necessity of waiting for marriage. The man has not yet a position sufficient to support a wife and family, and marriage is considered out of the ques- tion until late in life. In the meanwhile, he must run around and see something of life, and one day or another he will be caught and syphilis will, be acquired. This is another cause of delay for marriage, as we have already shown, and in many instances a cause for sterility. In this case, if syphilis is not the predisposing cause to crime, yet with the hindrance which it is liable to cause in the family, may result as an indirect cause of increasing criminality. In the. negro race syphilis is so common that from our observa- tions we would venture to state that over fifty per cent, of the colored population are syphilitic. In colored families syphilitic hereditary taint is clearly shown, and in our hospital work we find colored men or colored women who, together with lesions from hereditary taint, show secondary symptoms of recently acquired lues. They afford to us the most striking examples of syphilis binaria, so called by Tarnowski, which is quite often revealed on their internal organs in the form of visceral syphilis or on the nervous centra. Epilepsy in all its forms is quite common in the negro race ; they often indulge in alcoholics, which with syphilis, lays hold of them in violent attacks which lead them to crimes. Atavic criminality is the common form of crimes in the negro. Burglary, rape, theft, homicide of the most violent character are fre- quent amongst them. In 1889 there were committed 3296 prisoners for different offenses to the Cincinnati workhouse. Of these, 2828 were white, and 468 were 4 oo THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS colored. The total population of the city was 325,000, of which only 14,482 were colored. On this basis the white prisoners were less than I per 1000 to the white population, while the colored prisoners were in the proportion of over 3 per 1000. So far all jurists who have worked on the subject of the increase of homicides have assigned as causes the sentimental enforcement of the law, whereby many escape full punishment. Yet we see that the death penalty by hanging or by electrocution has no deterrent action, and murders are constantly committed. The attempt upon human life, and even suicide, must be consid- ered in most cases as due to an aberration of the human mind. The rash act committed in a moment of passion is after a while greatly regretted. This feeling of repentance shows that the man who has committed the crime has done it under different influences, which have for a while destroyed the control of his will. One of the principal causes, in our opinion, is the pathological condition of the nerve cells, which we have already seen greatly influenced by the toxins of syphilis, or by the condition of their nutrition induced by the alterations of the blood vessels. Where syphilis is most widely spread, there degeneracy is most frequent, and where degeneracy is oftenest found, criminality fills the ranks of society. The more we study man the more we find that moral qualities are ultimately dependent upon physical conditions, which in some cases can be fully ascertained. Crime as a disease of society has its predisposing and its occasion- ing causes ; the anatomo-pathological conditions of the sensory organ is the predisposing cause, while the adverse social conditions are the occasioning circumstances. A man who has his mental faculties in perfect order, in adverse social conditions will worry for a while, then take courage, resist and conquer. The man who is defective in his mental organs, with a deficiency in his will power, with a superexcitable nature, is unable to control the impulse, succumbs to the adverse cir- cumstances and commits crime. There is good reason for saying that a direct relation between syphilis and crime exists. We have already seen in the previous chapters that epilepsy, general dementia, and varied forms of insanity are affections of the nervous system, which recognize syphilis as the determining cause. Epilepsy we have seen so intimately connected with crime that an epileptic is always to be considered as a dangerous member of society. In these cases the crime is independent of the will of the epileptic, the deed done in a fit of the disease, and after the crime is committed the epileptic has scarcely any recollection of the deed. In a family an epileptic son attacked the father with a poker,. SYPHILIS IN RELATION TO DEGENERACY 401 and after wounding him severely alleged that he had received a com- mand from God to kill his father. In many instances the psychological symptoms due to syphilis do not constitute a true mental alienation, but the patients are only excitable, exaggerated, extravagant, so much so that it is difficult to establish what is true insanity and what is not. We have already mentioned a chronic form of syphilitic insanity described by Fournier as intellectual asthenia, where a remarkable depression or mental weakness takes place. To the same syphilitic cause is to be referred incoherence of ideas, with partial delirium, the idea of persecution, with a suicidal tendency, as is often found in paranoiacs. The existence of moral insanity admits no doubt, and in many cases it is the result of syphilitic alterations of the blood vessels. Lombroso referred to the anatomo-pathological reports of Sandou, Laseque and Bonvecchiato, who in three autopsies of three cases of patients with moral insanity found meningitis, foci of softening, of' apoplexy, and more particularly an advanced condition of arterio- sclerosis. Arndt 44 found many cells of the neuron not completely developed, and the axis much smaller than usual surrounded by infiltrating cells, without the necessary isolation from the surrounding tissues. In some places the homogeneous appearance of the nerve fibers is lost and they are studded with inflammatory cells. The blood and lymph vessels are greatly altered in their tissues, which causes blood congestion, stasis of the lymph serum, and pressure on the delicate structure of the cells of the neuron. The alterations of the circulation anatomically show the impaired development of the neuron, and moreover explain the perversion of the sensibility of the will. The lack of nervous conductibility and of reaction such as apathy and analgesia are the result, but on the other hand the nervous activity may temporarily increase and give a sudden flash in the form of impulsion. We have already had occasion to refer to the studies of Hubner on the alterations produced by the syphilitic virus on the blood vessels, and consequently we must recognize syphilis as one of the most effective causes in the production of moral insanity. These degenerates are the most dangerous class of criminals. Being morally insane, they take as their specialty any criminal act to which their impulses may prompt, without any regret and often without cause. Crimes are committed in the presence of others, and in some cases as an alleged public benefit, instantaneously with irresistible impulsiveness. Guiteau wrote, that " when the mind is possessed by inspiration. 44 Arndt. Virchozv's Archiv., 61, 67, 72. 4 02 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS the mind is not able to reflect. Before, I had horror of a murder, but later I understood that it was a true inspiration. . . . For fifteen days I was inspired, I could not eat nor sleep until I executed the deed, after which I slept soundly/' Our object is not that of finding an excuse for crime in a pre- disposition caused by syphilitic taint, or by the syphilitic virus, in those who have criminal tendencies. Neither do we want to defend them on the ground of the limitation of free will, which is subject to the anatomical and pathological conditions of the nervous system, but we must emphasize the fact that the psychical functions are greatly im- paired in consequence of acquired syphilis and much more so in that of hereditary lues. Inquiring into the reports of Czolgosz, we find the assurance of the greatest experts, such as McDonald, Hurd and others, on his being of a sane mental condition. Yet considering the enormity and bru- tality of his offense, the cynicism shown, we cannot fail to see that he belonged to the class of the obnubilated, and of the morally insane. His photograph published by Harper's Weekly, and the photographs of the casts accompanying the report of the post-mortem examination 45 show a slightly uneven development of the right eye, which is some- what uneven with the left. In accordance with our views this scarcely perceptible dystrophy might have been the result of a periostitis of the orbits in his infancy, which would have had as cause a syphilitic taint. Moreover, in the examination, McDonald 46 wrote that he found two flat, unindurated cicatrices on the mucous surface of the prepuce, probably the result of previous chancroids. Here is an extremely im- portant point for us, for nobody is able to distinguish whether a scar is the consequence of a chancroid or of a hard chancre. Nobody can persuade us that those cicatrices were not the result of syphilitic initial papules, as the door of entrance for the virus. He denied having con- tracted any venereal disease, but the cicatrices were there. The finding of all organs perfectly normal does not exclude the possibility of spirochaetse in the system or of toxins in the blood, which affect the nervous centers. The blurred ideas of an ardent anarchist, which he proclaimed in his reply, " I don't believe in the republican form of government, and I don't believe we should have any rulers," show clearly an exaltation and an extravagance bordering on the abnormal condition. We are greatly indebted to Dr. D. Este Weatherhead, physician of the Hamilton County Jail, who gave us a list of the criminals there 45 Spitzka, E. A. " The Post-mortem Examination of Leon F. Czolgosz." Medical News, Jan. 4, 1902. 46 McDonald, Carlos F. " The Trial, Execution and Mental Status of the Assassin of President McKinley." Medical News, Jan. 4, 1902. Plate XV Leon F. Czolgosz (By courtesy of Harper's Weekly') Stigmata of Degeneracy in a Criminal SYPHILIS IN RELATION TO DEGENERACY 403 detained. In some of them syphilis has left indisputable signs, or is still present, or there are marks of hereditary taint. J. J., colored, convicted of highway robbery, was infected with syphilis for several years, has at present multiple ulcerated gummata of the legs, and signs of periostitis of the scalp. Wm. W., colored, convicted of murder, acquired syphilis five years ago; his skin still shows pigmented spots of papular eruption. J., C, and D., whites, are three criminals on trial for murder, hold-up and highway robbery; all three acquired syphilis between two and three years ago. C. S., colored, convicted of murder, has unmistakable signs of hereditary lues in the shape of his tibiae, in the condition of his teeth and in the shape of his skull. He contracted syphilis three years ago. W. B., colored, convicted of murder and sentenced for life, shows signs of hereditary lues. H. S., colored, convicted for murder and sentenced for life, has hereditary syphilis, and is subject to slight epileptic attacks. C. T., colored, up for grand larceny, bears signs of hereditary syphilis, and has symptoms of recently acquired syphilis — syphilis binaria, Tarnowski. The accompanying picture is that of a man twenty-nine years old, who has been in the toils of justice over nine times for drunkenness, disorderly conduct, assault and battery. Clinical history : the shape of his head and the peculiar malformations show the com- plete type of the degenerate, and of mental inferiority. His face is asymmetric, the ears of Morell type, the palate narrow, elongated and very high, with a scar and a perforation behind the incisors. The teeth are badly implanted and are of the notchy type. The crests of both tibiae are rough and show exostoses. His sensibility is dull, memory very poor. He claims to have been four years at school, but has forgotten how to read and write. He claims never to have had coitus, and not to feel any inclination for sexual relations. It seems to us that he can be referred without hesitation to the class of heredo-syphilitics. Syphilis, alcoholism, degeneracy and criminality from parents to sons are shown to be transmitted by heredity in all classes and in all stages of society. Syphilis is mixed in those criminals either as acquired or as hereditary taint, in many cases both together ; in others we cannot deny that syphilis in the third generation is capable of producing limited alterations in organs or in the nervous centra so as to cause physical as well as moral monstrosities. We have already maintained that in the negro race syphilis is more prevalent in all its aggravated forms; in their families hereditary 4 04 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS syphilis is very common, and also criminality of an atavic type is more frequent, burglary, rape and homicide being often committed. To show the importance of heredity in the maintenance of crim- inality in the families, it is interesting to refer to the studies of Dugdale 47 concerning the infamous Max Juke family, showing that from one drunkard as a stem, came 200 thieves, 280 paupers, 90 pros- titutes, and nearly every one was infected with syphilis. Epilepsy is often found in the parents of criminals. Knecht in 400 criminals noted 60 epileptic parents, and Ribaudo among 559 criminal soldiers found epilepsy in the parents in the proportion of ten per cent. Alcoholism, when associated with syphilis, is also a most important factor in crime. The deleterious influence of this combination is so great that French authors have made a special kind of syphilis, which they call la syphilis alcoholisee. The excessive craving for alcoholics, the impossibility of controlling himself from the abuse of them, forms in itself a form of mental alienation called dipsomania. The irritating action of the alcohol on the nervous system makes syphilis much more virulent and attracts its deleterious action to the nervous system, pro- ducing delirium, delusions, progressive dementia, epileptic attacks, etc. A strange relation exists between syphilis, crime and prostitution. In some cases syphilis, causing sterility in the mother, or the death of the child, can be considered as a providential law to stop in some families the monstrosity of crime. Prostitution, which frequently cannot be explained or excused by poverty or by special accidents, is to be attributed to hereditary syphilis. As prostitution and crime go hand in hand, in the families where the brothers are criminals the sisters are prostitutes. Syphilis is thus the tie between crime and prostitution, when it causes the affections of the nervous system, resulting in moral deformities. Syphilis is pre- dominant above every other type of disease, and when it induces in- sanity or epilepsy in the form of cerebral syphilis it must at the same time be considered as a predisposing factor to crime. It will be found of some interest to compare the criminal records of Chicago and New York for the months of January and February, 1906. Chicago New York Murders 22 18 Burglaries 840 400 Robberies 216 20 Assaults on women 30 26 47 Dugdale. " Thirtieth Ann. Report of the Execut. Com. of the Prison Assn. of New York." SYPHILIS IN RELATION TO DEGENERACY 405 The population of Chicago is calculated at 1,990,750, and that of New York at 4,014,504. In the reports of the American Dermatological Association we find that in the line of syphiloderma, Chicago has reported 526 cases, while New York has 349 cases. In proportion to the population it shows that Chicago has more syphilis and more crime than New York. Syphilis is also connected with pauperism. In ordinary hospital practice a great many once infected with syphilis show deformities, ulcers, visceral complications, and are compelled to remain as inmates in the Hospital. In the poorhouse a great many cases of ulcers of the legs, of elephantiasic condition of the legs and genitals, are but the result of syphilis which the patients acquired in their young days. As a consequence of old syphilis or of an hereditary taint, many are affected with syphilitic psychoses, such as to make them inclined to crime and vagabondage. When we are fully aware that syphilis as a highly contagious disease can be acquired not only intentionally, but also accidentally, without fault of the individual infected, when we know that syphilis increases the ranks of paupers, of prostitutes and of criminals, there comes as a consequence the conviction of the necessity of stamping out so dangerous a disease. The ridiculous utterances of some hypocrites must not prevent the work of municipal governments in adopting all means for diminishing the spreading of this sordid and abominable disease. SYPHILIS AND SEXUAL PERVERSION Just as prostitution, perversion too has its reasons in degeneracy. Degeneracy we have seen to be greatly the result of syphilis in one form or another. The perverted form a class of sexual neurasthenics who have an uncontrollable tendency to satisfy their sexual appetites in a strange, unnatural and brutal manner. They are insane, and of a dangerous class, against whom society has to protect itself. They are criminals against their will, and they should not be persecuted, but only segregated in order to prevent them from mixing with others. It is singular that the perverted in many cases strongly appeal to the sympathies of the physician. We have had occasion to be consulted in reference to sexual perversion by men of intelligence, who have under- stood the enormity of their actions, the consequences and the punish- ment they had to suffer, yet they were unable to control the impulse. Cases of perversion occur amongst all classes of society, but many cases are to be found among educated and intelligent people. Some of the perverted are epileptics, and during the epileptic 4 o6 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS attacks commit obscene acts. Their act is a substitute of the epileptic fit. Kowalewski 48 noted that coitus has some resemblance to the epileptic attack from the tonic tension of the muscles, the loss of consciousness and the mydriasis. Moreover, the epileptic attacks are often accompanied by a strong inclination to coitus, and sometimes the first coitus starts the first epileptic attack. DaCosta 49 referred to a case of an intelligent epileptic who in the excitement of the attack masturbated himself with his own mouth, in a very unusual manner. In many cases epilepsy is not recognized, and it is only found out later, when attacks show up in their classical form. An Italian of good education told us that he could not satisfy his sexual instinct unless by means of pederasty. He was discovered, lost his position, and punished. He had tried coitus with a woman but once, and could not accomplish the act. He only found satisfaction in pederasty, which came in attacks at different periods. When he was under this impulse he left his position, could not work, and went around looking for a boy with whom, as he said, he had fallen in love. Although he showed no particular marks, yet the conformation of his head was not entirely normal. The skull, of the brachicephalic type, was rather small in the posterior part, while the frontal portion was elongated and protruding. It seemed that the development of the head was confined to the frontal organs at the expense of the posterior ones. This peculiar anomaly gave him so strange an appearance as to show that he did not belong to the ordinary class of men. Krafft-Ebing considers these brutal tendencies as an inversion of the sexual appetite. He considers as a condition of the same kind, the abnormal propulsion of platonic love or an ideal cultus for an individual of the same sex with aversion for the other sex. The psychical life is all given to this abnormal love, with susceptibility, jealousy and irresistible tendencies, just as in normal love. One clear case of the kind was that of Miss A. Mitchell of Tennessee, who killed her companion, Miss Freda Ward, with whom she was in love, for fear that she would marry. Crimes against decency find their psychiatric form in satyriasis and in nymphomania, which sometimes occur in the prodromal stage of general paralysis, of epilepsy, of senile dementia. In some cases these conditions may be induced in boys at the time of puberty by reading obscene literature, and more often by masturbation. This horrible and dangerous habit excites the phantasy, increases the sexual appetite, and on being gratified, exhausts the power of the ganglionic 48 Kowalewski. Archiv. psichiatr. 1885. 49 DaCosta. The Journal of Nervous Diseases, 1887. Plate XVI Francesco Gioli SYPHILIS IN RELATION TO DEGENERACY 407 centers, so much so that the patient loses all sexual pleasure and seeks to regain it in an unnatural way. It is a singular thing in the psychological manifestation of these patients, that they usually lose all moral feelings and yet express exalted sentiments and superiority to all men. In our study of this class of patients, we cannot fail to recognize in them some marks of moral insanity. In all the morally insane Krafft-Ebing found, as did Lombroso, in many born criminals a re- markable precocity for sexual appetite and sexual perversion, often followed by impotence. Their sexual instincts are precocious, un- natural, and in some cases are preceded or accompanied by cruelty and bloody ferocity. Here we meet with the most horrible crimes, which bear the name of Sadismus, from the Marquis De Sade, crimes which cannot be com- mitted unless by beastly delinquents and insane degenerates. The atrocious exploits of Jack the Ripper in the Whitechapel district in London have remained celebrated in the annals of criminology, the barbarous mutilation of the bodies of the wretched victims have caused a sense of horror in all the civilized world. Indeed, as he himself said, he was a mental monstrosity. France had her Jack the Ripper in the person of a Russian religious fanatic, who called himself the savior of lost souls. Nicholas Wassilyi began his mission by trying to rescue girls from ruin in the Quartier Mouffetard, but after he had been shocked in a love affair, he turned, as a Jack the Ripper, into an atrocious murderer. In Spain Garrajo in a certain time of the year enjoyed himself by drowning and cutting into pieces such women as he could get hold of. Vergeni in Italy in a single year tried to strangle seven women, two of them he cut to pieces. He used to keep their flesh, which he would boil, and then eat. He confessed that the holding of his victim by the neck, the biting her, and her struggle in the suffocation, pro- duced in him the greatest pleasure. The sufferings of his victim in- creased and exalted his strength to such a point that with a small pocket knife he could break the spinal column. Lombroso referred to the horrible case of Francesco Gioli, who killed and mutilated with a small pocket knife two little girls, one five and the other seven years old, after having raped them both. When arrested he confessed that he had violated the girls, and said that it had been for him a great pleasure. His photograph, reproduced from the Corner e Illustrato delta Domencia for May, 1903, shows plainly the characteristics of degeneracy and criminality, and both his parents had been syphilitic. 4 o8 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS The mental development of Gioli was so poor as to impress any observer with the idea that he could only cope with children, because he would have been afraid to attack a grown person. He had only twice in his life the satisfaction of his sexual appetite, and both times in this atrocious way. The special characteristics of these crimes when committed by the perverted are the mutilations and the bites found in the victim, who is not chosen for her beauty, but taken at any age, from the child to the old woman. Crimes of this kind are usually found in certain seasons of the year, such as winter and spring, and diminish in number in other seasons of the year. The criminals are usually young men, deviating from the normal anthropological type, with stigmata of degeneracy on their faces and heads. They have a peculiar, sad expression, which reveals the moral abnormality. They are usually the offspring of parents addicted to alcoholism or insane. In most of the cases their parents have suffered the ravages of syphilis, and they are simply heredo-syphilitics. They are morally insane, or epileptics, and their perversion and crimes are to be traced to the heredity syphilitic taint. In some cases they are imbeciles or idiots, deficient in mental qualities, as the result of the same abominal syphilitic heredity. In other cases perversion and degeneracy may also make their appearance in older persons. In these cases heredity "may have had no influence, but acquired syphilis with its toxic influence on the nervous centra, causing meningeal inflammation, may be at the bottom and explain the criminal perversion. The criminal perversion which may be the result of a syphilitic inflammatory process of the meninges, or of intoxication of the neuron from its toxins, may be brought to act only on the association with the use of alcohol, opium, cocaine, etc., which have so deleterious an effect on the psychical condition of an already unbalanced individual. Habitual malefactors, degenerates and the perverted have to be considered, as does Lombroso, as a class apart from the generality of men, as they indeed show different tendencies and different feelings. The acts performed by the delinquent are the only visible results of the functions performed by the brain and reflective nervous system and are abnormal because the nervous system is in an abnormal con- dition. The anthropological studies of the bodies of that class of men have revealed anomalies, dystrophies, abnormalities indicative of re- gression and of an arrested development. The skull has often been found small with some anomalies in the position, shape and closing of sutures. Irregularities of the face, in the bones of the nose, of the SYPHILIS IN RELATION TO DEGENERACY 409 jaws, also exist, while anomalies of the convolutions of the brain have often been found in criminals, showing that they are physical as well as moral degenerates. Causes of disturbances of the action of the brain are to be found not only in the original development of the organs, but they may also be due to pathological conditions of the blood, of the blood vessels, membranes, bones, etc. In ten cases of dementia praecox 50 Pighini and Teoli found peculiar alterations in the blood corpuscles, especially in their hemo- globin. These alterations they maintained to be the result of toxic elements, which according to Kraeplin are produced by the development of the sexual organs. Indeed, the age of puberty has been found to be the age when crimes of violence are more often committed. It is a critical period, which is sometimes dangerous even for well-balanced minds. The affections in the degenerate are abnormal, so much so that he may assassinate his parents, and yet make great sacrifices for a companion in need. Sometimes they show exaggerated affections for lower animals, at other times they are cruel, thus showing inconsistency in their psychical functions. One criminal may commit a crime on account of the degraded anatomo-physiological conditions of his brain with reflection and not as impulsion due to the passion. Another, on the contrary, will, without reflection, wound or kill a man in the impetus of passion in consequence of an overwhelming stimulus. Both kinds of criminals, although dif- ferent in the action, yet merge into one another, and as Sergi asserts, the want of reflection shows an abnormal condition of the sensory organ. The multiplication of the defective, degenerate and criminal classes has become so prominent a feature in our modern civilization as to attract the attention of medical and juridical men and make them at- tempt to establish some measures for prophylaxis. These classes are not only a constant danger to the public, but they entail great expenses in the maintenance of public institutions. In the past, defective indi- viduals were left to the mercy of nature or to the maltreatment of the ignorant masses. Deficient men after all were not such a prominent feature in those times, when slower methods and less intense means were used in the struggle for life. For the insane and idiots there were no asylums, and they either died naturally in consequence of privations, or if they survived they were the fools of the towns. Crimes were not less frequent than at our times, but no telegraph wires or newspapers gave them the widespread notoriety of to-day. 50 Pighini and Teoli. Rivista Sperim. cii Franejatria, Vol. xxxi. 1005. 410 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS The new school of criminology which was founded by Lombroso and confirmed and established by Sergi, Ferri and other illustrious Italians, has entirely diverted the attention of the old penologists from the crime to the criminal. This has changed the criminal law into a study of criminal sociology. They have cast aside the dictates of Beccaria and Howard to diminish the punishment only as a reaction against the severity of the medieval laws, taking as their principal object the diminution of the offenses by decreasing the number of the criminals. This can only be obtained by an accurate study of the criminal and of the social environment leading to crime. We cannot believe that prevention of marriages of the defective can be enacted as a law. Nobody can go against the laws of nature, and the impediment to marriage on account of moral deficiency or degeneracy will never diminish the degenerates. Nature itself finds its providential laws, and with the mixed marriages families are either extinguished, or their tendencies will by education be gradually changed. In the Journal of the American Medical Association 51 there has been advocated a special legislation against degeneracy. It is not consistent with the views and with knowledge of physicians, the pass- ing of resolutions to be calling for laws against degeneracy without studying the causes which most often produce degeneracy. We have already proposed to stop the spread of syphilis by pre- venting men infected with the disease when inoculable from receiving a license to marry. From our studies it has been clearly shown that one of the causes producing degeneracy, neuroses, psychoses, etc., which degrade the human race is syphilis, and against syphilis we must direct all means to diminish the spreading of the disease which causes degeneracy. In reference to the deficient, dependent, and more especially to perverted boys and girls who have already shown signs of depravity, the juvenile courts, which decide their commitment to some institution, are to-day a step in advance. Instruction and education, associated with a strong inflexible discipline, will do a great deal in bringing to the right path a large number of boys and girls who, left to themselves, would grow up as criminals to fill the penitentiaries and the brothels. There are many poor children who are not well developed in their mental qualities, who have miserable homes where they have seen nothing but quarrels between their parents, and heard nothing but blasphemous talking, and once in a while they show symptoms of the hereditary syphilitic taint. These poor creatures have never heard a B1 Journ. Am. Med. Assn. Editorial, Feb. 15, 1902. SYPHILIS IN RELATION TO DEGENERACY 411 kind word addressed to them ; when sent to the public schools the teacher has never taken an interest in them and has tried to get rid of them, so they must continue in the inclination of their father and enter the career of the criminal. But when these children in destitute circumstances, with an improper home, are taken in well-directed institutions, reformatories, reform farms, houses of refuge, under the modern pedagogic rules, they will be educated until they can be released as good members of society. Ill SYPHILIS AND PUBLIC HEALTH It is an interesting question to determine whether syphilis has a tendency to shorten human life or not. We have already treated this subject in Chapter VII, " Individual Danger from Syphilis," and we have shown by statistical tables that death from syphilis is only of rare occurence. Yet in the consideration of various subjects connected with syphilis we have seen the tendency of this disease to affect the blood vessels, causing arteriosclerosis, with all the serious results con- nected with so universal an anatomical system upon which depends the nutrition of all tissues, and of all other systems of the organism. In the death reports syphilis but seldom appears, though it may often be at the bottom as the predisposing cause of death. When a physician is called to attend a case of apoplexy, or a case of paralysis, and the patient dies, the death report will be apoplexy or a stroke of paralysis. It would be risky and even indelicate towards the family to mention syphilis as a predisposing cause in the report of the death. It would be risky for the reason that syphilis is not the only cause of arteriosclerosis, but old age itself, the use of alcoholics, the quality of the food, sedentary habits, etc., may have some influence in the production- of the vasal disturbance. We have seen that aneurism of large blood vessels often has syphilis as its underlying cause, but we could not go on and state aneurism as the cause of death and syphilis as a predisposing cause. In many conditions of the heart, of the endocardium, syphilis may have been the cause, but yet we are not allowed to speak, and much less to write the dreaded name of syphilis. In hospitals we have seen cases of diseases of the liver go on record as cancer of the liver, and as interstitial hepatitis, and at the autopsy the liver was found studded with syphilitic gummata. In some cases diabetes has been attributed to syphilis, but yet nobodv would be justified in calling a case syphilitic diabetes. It would be risk)- when we consider that many other causes may have produced diabetes, and many other causes may have caused nephritis, and it may be that syphilis had no relation whatever to the disease in question. A number of affections have been called parasyphilitis because 412 SYPHILIS AND PUBLIC HEALTH 413 they may have had syphilis as a cause, and yet they are the result of a trophic process, which is not influenced at all by an antisyphilitic treatment. Even tabes and general paralysis, which we have seen to be the end of the syphilitic attack on the nervous centers, are con- sidered as parasyphilitic affections. Many neurologists object to the idea that tabes and general paralysis are always the consequence of syphilis, when they are the product of a degenerative process of the nerve cells, which may also be caused by other sclerotising processes. We find, therefore, that statistical reports are inadequate and cannot furnish us with true and positive data demonstrating death to be the result of syphilis. As an axiom we may state that in some cases syphilis abbreviates life. In a general way it cannot be stated that syphilis abbreviates life, because everyone has known and knows men at a ripe old age in splendid health, who in their younger days have had syphilis, and after a while they have been troubled with no more manifestations whatever. While we do not often have cases of individuals who, after having been infected with syphilis, have never regained their former health, yet they may soon show symptoms of tertiarism and die of other diseases, hastened by syphilis. Syphilis acts in different ways in the different individuals affected. We have seen that in the experimental inoculations with syphilis in the chimpanzee, not one of the infected animals survived over thirteen months after the infection. In man, of whom this disease seems to be a sad and an almost exclusive possession, the effects are not so severe, but in some cases either on account of a weak constitution, or on account of other diathesic conditions, or on account of habits debilitating the system, it causes so deep an impression as to ravage the whole organism, and gradually lead to death along with some other degenerative processes. Other diseases, too, show the same tendency to affect some indi- viduals in a benign form, and others in the most malignant and virulent way. In cases of small-pox, we see some cases showing only a few pustules and a very mild fever, while others will be affected with an hemorrhagic small-pox which will imperil life. In this matter we must think that the origin of the virus is not so much at fault, because from a very mild case of small-pox, or of syphilis, an individual can be infected and suffer a severe case of these affections, or vice versa from a case with a malignant tendency there may result a case with rather mild symptoms. As Hyde J said, instances of incoercible syphilis in the absence of all treatment, in the presence of even the best treatment, often indeed, before any treatment worthy of the name 1 Hyde, J. N. "Syphilis as Related to the Problems of Longevity." Medi- cine, 1905. 4 I4 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS can be instituted, pursue their disastrous career without let or hin- drance. The soil seems especially fitted for the multiplication and fructification of the germ. In these cases the skin is often riddled with half-formed scars and ulcers, the bones embossed with gummatous nodes, the arterioles plugged with obliterating new growths, and the viscera dangerously involved. It is a wonder that these wrecks of humanity survive with the mind in process of degeneration and the body often paralyzed. Yet certain of them are long in evidence, the shame of society and the reproach of the profession. It is not of much interest for us to examine cases of hereditary syphilis in their frightful mortality, or cases of early acquired syphilis in infancy. In a general way we can state that syphilis is acquired in the third decade of life, and it is more prevalent in large cities, while in rural districts cases of syphilis are rather rare. From the Census reports not much trustworthy information can be obtained on this delicate subject. In the Census report of 1900 for the United States, in the areas of registration and non-registration, 1,039,094 persons died. For every 1,000, 109.9 died of some form of tuberculosis, and 32.9 of some variety of cancer or tumor. The total number of deaths from venereal diseases was 1591, of which 934 oc- curred in males, and 657 in females, thus giving a proportion of 1.53 of deaths from venereal diseases. Indeed, it is difficult to understand the meaning of venereal dis- eases when we think that syphilis is only a part of this miserable family of diseases. Death may have occurred from other conditions related to venereal affections entirely different from syphilis. On the contrary, cases of visceral syphilis may have been reported as diseases of the different organs and the name syphilis may have been withheld. The uncertainty of such a calculation shows in itself the unreliability of these statisti.es. In reference to the mortality from the two diseases, which are considered as the result of syphilis of the nervous system, general paralysis and tabes, in the same census, 1900, there were registered 947 males and 356 females who died of general paralysis, and 537 males and 175 females who died of tabes, which in the statistics is given as locomotor ataxia. This gives a rate in each thousand of 1.8 of males and 0.8 of females for general paralysis and 1.0 for males and 0.4 for females for tabes. These statistics show the already mentioned relative immunity of women against tabes, which, however, is only relative. Both sexes are subject to the dreaded diseases, only on account of the slighter amount of work of the nervous system tabes is not so frequent in women. If we take it for granted that all cases of death from general SYPHILIS AND PUBLIC HEALTH 415 paralysis and from tabes, recognize syphilis for their sole cause, we have reason to assign to this disease 2015 deaths. In 1,039,094 deaths, 2015 represents a little less than two per thousand, representing one- sixteenth of deaths occurring from cancer and tumors, and nearly one-fifty-fifth part of the deaths caused by tuberculosis. If all the deaths in the United States reported as due to venereal diseases were summed up with those coming from general paralysis and tabes as a result of syphilis, it would give a total of 3606, which is exceedingly small in comparison with 32,000 deaths from cancer and tumors, and 109,750 from tuberculosis. Moreover, we have already seen that the largest number of deaths from syphilis occur in children affected with congenital lues, and also a few in young people before the fifteenth year of age as hereditary lues. All these cases of death do not enter into the conception of longevity when their life is smothered out in the very beginning of their development. • Although it is a difficult task to establish an approximate number of cases of syphilis on account of the patients trying to conceal their troubles, changing physicians, etc., yet as Hyde did, we too can form an idea from the annual reports of the American Dermatological Association. Their members, experts in the dermatological and syph- ilological science, have reported all cases coming under their observa- tion in the cities of Boston, New York, Philadelphia, Washington, Chicago, St. Louis, Cincinnati, Ann Arbor, Cleveland, San Francisco and Montreal, Canada. The total number of cases of syphilis observed in each year by so many specialists in such large cities, average be- tween two and three thousands, and this from the year 1878, when the reports began to be given, to the report of 1902, a total of 46,437 for syphilitic cases. Indeed, these reports are not given as general statistics, they rep- resent only the reports of a group of men, while many other luetic cases are observed and treated by general practitioners, and are not reported. Yet we must also admit that these specialists have cases of syphilis coming from a wider district than their own cities alone. Many populous cities of the United States are not included in the report of the American Dermatological Association, and every one of these cities must furnish a certain contingent to the number of the infected. The reports of the dispensaries and hospitals of the L T nited States Army and of the Marine Hospital Department give an average of 5000 cases of syphilis annually, which has to be included. Following the account of Hyde, we can calculate that in the whole United States 100,000 cases of syphilis occur with a mortality of 2 per roo cases of the disease. If we study the statistical tables of the U. S. A. and the Marine 416 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS Hospital given by Samuel Treat Armstrong, which we have already- had occasion to quote on page 146, we find that mortality from syphilis is much lower than 2 per 100 cases. UNITED STATES MARINE HOSPITAL SERVICE. Primary Syphilis. Secondary. Deaths 1881 284 804 8 1882 257 677 5 1883 197 690 11 1884 156 650 10 1885 135 583 9 1886 278 626 5 1887 405 660 7 1888 367 805 9 1889 299 777 10 1890 263 809 9 MORTALITY OF MALES CAUSED FROM SYPHILIS IN ENGLAND. YEAR All Under ages 5 years 881 882 883 884 885 886 887 888 889 890 1090 1158 1 180 1174 ii6t 1 168 1095 984 1069 1049 912 994 1024 1020 986 ion 920 809 877 842 5 10 15 20 ; 25 35 45 ! 55 65 131 40 56 32 23 8 12 42J 41 35; 15 6 ii| 36J 42 32! 18 10 n 37; 42, 30 15 7 II 46J 38 32; 22 14 9j 38! 41! 33i 25 5 11 38 37 38! 25 1 14 14 43! 42 36; 22 6 9j 46 54; 35 27 12 7, 40, 54 52 25; 9 75 85 11,137 9,395 32 24 47 108 406 447 355 216 91 MORTALITY OF FEMALES CAUSED BY SYPHILIS IN ENGLAND YEAR 881 882 883 884 885 886 887 888 889 890 All ages 998 1069 1 133 1 106 1035 1063 969 943 984 1007 10, 307 Under 5 years 77i 833 932 898 827 878 786 757 776 774 232 15 20 25 3 21 76 IO 21; 58 8 19 62 4 19 49 Q 20 60 35 45 2 7: 16 47 5 \ 3 15 5o 4! 8 11 52 5 3 12 69 4 2 17 62 35 62 171 585 55 65 56 30 29 61 401 29 54 35 TI 54 42| 30I 3 53 30 19 12 55 27, 19! 8 45 31 19 42 33 21 11 46 41 16 11 65 42; 20 13 53i35i;2i3 86 75 85 1 1 1 2 2 3 2 4 3 18 1 SYPHILIS AND PUBLIC HEALTH 417 Although the statistical tables have a tendency to confirm the rarity of the cases of death from syphilis, yet they show that in a certain number of them syphilis, especially when acquired, directly or indirectly diminishes longevity. The statistical tables from the Army hospitals and from the Marine Hospital Service are taken from young men in the full vigor of life, who have acquired syphilis only recently, and the mortality in these conditions is surely one of rare occurrence. When we consider the statistical tables of men and women dying of syphilis in the United Kingdom, as referred to by Armstrong, we find it true that mortality from syphilis is low, because it scarcely reaches 2 in 100 cases. One interesting point is brought out in these tables, as it shows at wiiat age this disease is capable of causing death. That syphilis is a cause of great mortality among children is clearly shown by the tables given. The larger number of deaths in syphilitic children takes place under five years of age. After five years the number of deaths from syphilis diminishes, but gradually after the age of twenty-five it increases again until it reaches the maximum of mortality between the ages of thirty-five and forty-five. This age is just when the man has all the responsibility of the family, when his life is more precious for his wife and children. At this age the children rely on their father for support, for their education, and for the hopes of their future. We cannot and will not deny the possibility that many para- syphilitic affections may also be the consequence of causes other than syphilis, but we must accept, as everyone has to do, the fact that they are the sad end of lues on the nervous system. It is true that the age between thirty-five and forty-five is the period of life when business men are pressed by the rush of business, are struggling for success, and at times are also laboring under anxiety on account of illness or the loss of someone in the family. In some men, with the care of business there is also associated some amount of dissipation, abuse of alcoholics, tobacco, etc., which makes them a careworn wreck at the age of forty. If in a general way syphilis is not a determining cause in shorten- ing life, in a certain order of cases it plays, if not directly, indirectly the role of an additional cause for an early demise. Most of the cases of syphilis of the nervous system have affected men who have never had any idea that they have had syphilis, and consequently they have never taken any treatment. The time in which the severe nervous symptoms have occurred has* been ten and fifteen years after the infection. In many instances the symptoms have come at once, en- tirely unexpected after many years of excellent health. In one 418 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS case the patient was affected with an obstinate deep ulcer of the base of the tongue, which had been diagnosed by several physicians as car- cinoma. It was a gumma which healed up easily under the mixed treatment. In one case the existence of syphilis had never been found out ; the patient could not recollect any time of infection, yet he had a form of glossitis hypertrophica, which gradually yielded to the use of mixed treatment. The tongue had returned to the normal condi- tion when he began to show a deep papular syphilitic form under the nails of the fingers and toes. A man of fifty with grown children began to complain of weakness in the left arm, and finally one morning he was no longer able to get up. He was hemiplegic, and died of apoplexy. Not long ago there came for consultation a man affected for three years with syphilitic amaurosis ; he had been totally blind ; he re- ferred to having had a case of gonorrhea, from which he recovered fifteen years ago. At the same time there was some phimosis, and he thought he had a little sore beneath the phimotic prepuce. A physi- cian treated him for gonorrhea, and although he called his attention to the possibility of a chancre under the prepuce, he assured him that there was no syphilitic infection. He recovered and forgot the occur- rence. Some five years after he married a young lady, who has always enjoyed good health, and does not show any luetic sign. In the be- ginning she had one miscarriage, and she has since given birth to two children in good health, who so far have never shown specific symp- toms. If we consult statistics from hospital and from dispensary practice we find that mortality from syphilis ranges from I to 2.3 per cent. Cases of primary syphilis which are usually tabulated as ulcers of the penis, vary from 3 to 5.2 per cent, of all other diseases, while cases of secondary syphilis vary from 12.1 to 15 per cent. It is necessary to note a certain variation in the reports between the number of cases occurring in hospital and in dispensary practice, so much so that primary syphilis among the hospital patients is rated at 1.94 and among the clinic patients at 1.58; for secondary syphilis in the hospital the average is 5.29, and in the clinics it is 7.77. It will be found of some interest to produce some statistical data from the department of the venereal diseases in the male and female wards in our service in the Hospital of Cincinnati, from 1890 to 1902. SYPHILIS AND PUBLIC HEALTH 419 ON 00 ON 00 ON 00 CO ON 00 10 on 00 VO ON 00 on 00 00 00 00 ON ! ON o\ 3 H 2 39 2 '28 IO I I 32 10 3 4 1 3 1 5 3 5 1 2 3 1 37 4i I 3 I 4 2 38 Primary, with gonorrhea. . Secondary syphilis Secondary, with gonorrhea Secondary, with chancroids 56 8 95 9 1 43 34 33 43 36 22 53 28 91 22 124 no I 117 32 784 369 5 3 7 8 2 1 1 2 4 12 1 1 2 2 4 1 Secondary, with pregnancy 1 5 4 15 7 10 11 8 6 9 98 1 1 105 4 1 1 4i 1 Cong. & hered. syphilis. 16 5 3 75 8 5 35 10 1 5 17 5 3 2 5 52 1 7 5 95 7 1 66 9 2 1 4 44 7 1 1 88 4 6 5 256 2 I 4 140 1 2 4 2 24 1030 57 34 14 4 9 3 47 1 Gonorrhea, with chancroids Gonorrhea, with ven. warts 3 2 2 1 8 2 1 Syphilitic rheumatism .... 1 1 1 2 2 4 6 10 6 4 5 2 1 1 1 1 1 1 1 5 Syphilitic pharynx 1 5 4 1 1 1 2 Syphilitic stomatitis Syphilitic stricture, rectum 1 1 4 1 = 1 2 2 6 1 1 ic 1 11 '■*€ 1 1 ] 1 1 7 83 Chancroids 2 ; 14 1 A Chancroids, with bubo Chancroids, with ven. warts Chancroidal ulceration. . . Bubo 4 ] k [ . . . ) 1; 5 2 1 > : I ■■ \ : 1 . . ( > : > : [ ] > ] [ . . c [ . / 1 r I ( 23 » 52 c > ; Venereal warts > 24 Total 11 7 16. M3 [ 14: 2 22 122< 318 2 IQA TAz M4< m* *52< ?32<< I 2768 RESULT o\ 00 On CO ON 00 On CO *3- ON CO 10 ON 00 ON CO ON CO 87 84 23 00 ON 00 ON ON 00 1 1— 1 8n 1902 Total Well 49 59 9 63 78 17 6 39 87 4 1 43 80 n 8 76. 129 14 5 135 73 n 1 61 99 21 1 49 85 TO 43 87 16 3 14S 2/10 tt;> ttIs Improved 78261 l87 T*87 Unchanged 21 I 28 ">"> 207 Died 3 29 Total 117 164 131 142 224 220 182 194 IAA 149 ?/|8 529 3-4 276S 420 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS AGE Under i Between 1-5.. . " 5-io.. " 10-15- " 15-20. " 2030. 30-40 " 40-50. " 50-60. " 60-70. " 70-80. Unknown Total "7 164 131 1 1 79 104 I5i 24J 16 4 10 vO on ; o x , 00 71 115 142 224 220 182 2 I 57 106 19 194 144 o ' w o O 0> 149 2 6 76jI40 139 364 14 g, Total 248 529 1 3 84 207 22 5 1 1 324 18 18 9 48 865 1481 241 72 17 9 2768 OCCUPATION 00 CO CM On CO CO X X 10 MD CO 1 X 1 X X X X 0> 13 H Actresses I 2 Artist 1 3 Bookkeeper I 1 1 18 Bookbinder I 4 Cooks I I I I 1 I I 2 4 I 1 2 I 1 1 38 1 3 1 49 1 Candymakers Clerks 3 4 2 Cigarmakers Cloak maker 59 1 88 50 74 1 91 2 95 3 81 77 60 53 60 1 875 9 Dressmakers Factory hand <• . . Furrier 1 34 12 13 16 or, 31 20 35 29 19 18 31 35 1 4 313 Journalist Laundresses I 1 1 7 1 2 2 1 12 Milliner No occupation 7 TT 32 4 6 8 5 2 1 6 9 1 3 4 Nurses 3 8 Peddlers 3 3 i34o 6 Prostitutes 29 ^8 IQ 30 87 87 W 70 46 66 1 147 1 1 444 220 Stenographers 1 1 4 2 2 1 1 1 2 2 2 6 1 1 4 2 3 1 1 2 1 1 9 2 1 1 1 I 1 2 1 6 1 2 4 16 2 7 3 2 1 1 4 1 3 1 2 6 Total TT7 t6/| T 3 T T/|2 22/| ??o t8? 194 T/f/I 149 248 529 SYPHILIS AND PUBLIC HEALTH SOCIAL RELATION 421 Q\ o Married , Single . Widowed Unknown Total . . , 29 116 19 18 101 12 34 169 20 1 70 102 10 20 117 42 190 16 94 402 32 1 59 245 5io 2034 17 216 3! 8 117 164 131 142 224 182 194 i44 [49 248 529 324 2768 HOW BROUGHT ON 00 ON 00 CO rO Os 00 00 10 CO 00 On 00 00 On 00 CO ON 1 O as 3 H Ambulance 4 4 2 5 7 7 6 11 7 28 6 18 2 8 7 17 4 15 1 23 IO 20 I I 53 11 25 333 9 10 205 2 76 191 1 Cab Daughter Father 1 6 2 Health Dept 597 11 House Refuge 1 2 8 Humane Society 1 3 2 Husband 2 Infirmary 1 1 Mavor 1 1 3 1 20 9 5 13 177 4 06 Mother 1 19 1 23 2 3 1 43 3 4 3 7 3 13 2 4 Patrol 2 2 7 9 19 Police 3 8 3 2 2 1 1 88 Sister . 1 Unknown 106 155 109 114 1 142 164 168 133 ti6 115 113 141 J 35 1657 1 224 220 Total 117 164 131 182 194 144 149 248 529 324 2768 The total number of venereal diseases treated in this long period has been 2768; the mortality has been 29, which is 1.02 per cent. In looking over the details of the result, we find among the cases of primary syphilis that one woman died of hydrosalpinx, which had nothing to do with syphilis. In the table of secondary syphilis we find that two died, both from Bright's disease. We are not, however, ready to state whether the nephritis had been the result of the syphilitic process or of some other cause, but we will not deny that syphilis may have been one of the determining causes. In the table of secondary syphilis with phthisis we find a total of seven patients, of which five died ; two left the hospital improved, one improved and one unchanged. We will not hesitate to say that syphilis has acted as a cause to render tuberculosis more deleterious, but it has not acted alone and no physician would report those five deaths as produced by syphilis, but by tuberculosis. 422 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS Of the ninety-eight cases of tertiary syphilis, we find four were fatal owing to syphilitic cachexia, and one with tertiary syphilis was accompanied by mania and death came while this condition lasted. Of nine patients with cerebral syphilis, three died in the hospital, and one died of syphilitic meningitis. Twenty-four children were affected with congenital and hereditary syphilis, nine of whom have died as a consequence of syphilitic cachexia. One died with a phagedenic chancroidal bubo, which really could not be ascribed to syphilis. The age when the infection occurs and when the symptoms of the general infection are developed is entirely in accord with the sta- tistics referred to by others. The data for primary syphilis begins with 10 cases between the ages of fifteen and twenty, 25 cases between the ages of twenty to thirty, 2 cases between thirty and forty years of age, and 1 case be- tween forty and fifty, giving in all 38 cases. Primary syphilis with gonorrhea was found in 5 cases between the age of fifteen and twenty, and in 6 cases between twenty and thirty. Of the 784 cases of secon- dary syphilis, 3 occurred in the age between five and ten, 11 between the age of ten and fifteen, 254 between the age of fifteen and twenty, 410 between twenty and thirty, 75 between thirty and forty ; 24 were found between forty and fifty, 5 between fifty and sixty, and 2 between sixty and seventy. The same age has given cases of secondary syphilis complicated with gonorrhea. Between the ages of fifteen and twenty, 115 cases, while 237 cases were found between the age of twenty and thirty, 12 between the age of thirty and forty. Two w T ere found between the age of forty and fifty, 1 between fifty and sixty and 1 between the age of sixty and seventy. Of the 98 cases marked as tertiary syphilis 8 have been referred to an age between fifteen and twenty, which rather ought to be con- sidered as late hereditary lues. Thirty-five are between twenty and thirty, 33 between thirty and forty, 15 betAveen forty and fifty, 5 be- tween fifty and sixty, and 2 between sixty and seventy. One case of tertiary syphilis was reported associated with mania, at the age of thirty to forty. Xine cases of cerebral syphilis were ob- served, of which one occurred from hereditary lues, between fifteen and twenty, 4 between twenty and thirty, 1 between thirty and forty, 2 between fifty and sixty. Three cases of syphilitic meningitis have occurred, one at an age between twenty and thirty, another between the age of thirty and forty, and one between fifty and sixty. From our statistics we obtain the same results, namely, that deaths from syphilis are very rare. In the City Hospital we have always our 10,000 patients per year for all diseases. From 1890 to 1902 would SYPHILIS AND PUBLIC HEALTH 423 give a total of 130,000 patients. Of this large number for all diseases, 2768 were in the venereal wards for venereal diseases. This gives an average of 2.1 per cent, of venereal affections on the total of the common diseases. The mortality of 29 in 2768 is absolutely so slight, that as we have already stated in a general way, longevity is not much affected by syphilis. Unfortunately, syphilis with alcoholism tends to make poor and helpless wrecks, who often remain as a charge on the com- munities. Death from syphilis has occurred mostly between the ages of thirty and forty, but we have seen that death in several cases was not the result of syphilis alone, but was due to other infectious diseases in association with syphilis. The same statistical table also gives an idea of the social relations of our infected. At first glance it shows that men and women living single are more likely to acquire syphilis and venereal infections. In fact, of the 2768 cases, 2034 were in single persons, while 510 were in married and 216 in widowed people; the social relations of eight of them could not be ascertained. For this reason early marriages have to be recommended as a prophylactic means to avoid syphilis. It should be the duty of the parents to prompt their children to contract early marriages. It is a great mistake of the parents to prevent their children from getting married. It is better that the children learn the mysteries of the generative functions from their parents as a scientific teaching, than that they learn them from their companions as a mischievous and obscene enjoyment. Parents must remember that after the sixteenth year the idea of innocence is better " abroad " than at home, because their children will learn the things practically and will be in danger of infection. The table giving the occupation of the infected shows the larger number of infected to be the prostitute, in the number of 1340. It shows once more that prostitution is the hot-bed of syphilis and ven- ereal diseases. Second in the list are domestics with 875, and then housewives in the number of 313. One hundred and one could give no occupation, and usually those individuals who take anything to do without any permanent occupation, are very easily infected. Many other occupations give their contingent to the venereal diseases and to syphilis only in a moderate quantity. It will be found of some utility to have added a statistical table to show how these patients came to the hospital to be treated of their ailments. The largest number came of themselves without any urging from anybody, in the number of 1657. Five hundred and ninety-seven were sent from the Health Department compulsorily. One hundred 424 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS and ninety-one came by themselves in cabs, and 76 were taken to the Hospital by the ambulance. One hundred and seventy-seven were brought in the police patrol wagon, and 26 were taken to the Hospital by policemen. Some were sent to the Hospital from other institutions, as from the House of Refuge and the Infirmary, some were accom- panied by their parents or relatives, and a few women were accom- panied by their husbands. The question of the Hospital for treating syphilitic patients is of the greatest interest, as it is intended to accomplish the greatest benefit to society, to remove the infected from the midst of the healthy people. The principal reason of the spreading of syphilis is that the infected remain free to mingle with others without any precaution. They do not think of the danger of infecting others, and as a consequence we see patients infected not only as a consequence of illicit acts, but also accidentally. From the table referred to we find that although many have applied willingly to the hospital for treatment, yet a great many ought to be sent compulsorily by the Health Department or by the police. We hear declarations concerning the necessity of maintaining personal liberty, that the dispensaries and the clinics are sufficient for the treatment of the venereal diseases, but we firmly believe in the necessity of receiving the infected in the hospital, where' they cannot have relation with others. The preaching of morality, and good ad- vice is all very well, but amounts to naught in this case if not accom- panied with a certain degree of coercion. In our hospital practice we also try to detain the men in the w^ard as long as they have secondary symptoms of any infectious nature. To keep in the hospital the pros- titutes when infected is of the greatest prophylactic importance, be- cause they are the principal cause of spreading syphilitic infection. In this regard we meet with another difficulty, which is that the hospital is an institution for the treatment of sick people, and not for trans- gressors who are affected with loathsome diseases on account of their indiscretions. Considering the question with respect to preventing infection, we meet with another difficulty; that a hospital is not an institution for public prophylaxis. In Italy it has been stated by Santoliquido 2 that the government has provided by instituting wards for syphilitic patients in different hospitals, the government paying the expenses of these wards. Of these wards there were 121, a number insufficient for the communities, which reach 8225. In order to place the institutions within the reach of everybody the government pays the expenses of the trip when this 2 Santoliquido. "Institutions Hospitalieres." Compt. rend. Confer. Intern, pour la Prophylaxie de la Syphilis, etc. Bruxelles. SYPHILIS AND PUBLIC HEALTH 425 is necessary. This has been done not so much for the individual in- fected as for the public welfare. When we consider syphilis a contagious disease, we must apply to it the same prophylactic rules which we apply for all transmittable diseases. The venereal diseases are highly contagious and therefore they must enter into this class of diseases. It is, therefore, necessary to find out the centers of infection and sterilize them so as to prevent their spreading. The number of patients treated for venereal diseases in the City Hospital is rather low and gives an idea of the number of those people who could not be treated in any other way, on account of lack of means or on account of the severe symptoms which compelled them to remain in bed. Santoliquido too remarked that the number of prosti- tutes registered in the public houses in Italy at that time, 1901, was 5000, of which half had not been affected with venereal diseases in one year. Yet among all hospitals and dispensaries of the kingdom 20,000 women and nearly 50,000 men had been treated for venereal affections. This is the only way in which the number of syphilitic infections can be made to diminish. The foci of infection have to be found and the infected have to be treated for their individual benefit, and at the same time must be placed in a condition in which they cannot spread the contagium. The work which is now in progress against tubercu- losis has to be undertaken against syphilis. It should be done in a way that would make the patient not attempt to hide his affliction, but on the contrary make him seek relief for it. Prostitution, which is the principal focus of syphilitic infection, has to come under surveil- lance, clandestine prostitution has to be looked after, and when those women are found infected with diseases of a contagious nature, they should be taken to a hospital and detained until any danger of infection has entirely passed. SYPHILIS AND LIFE INSURANCE Modern life has been greatly benefited by the most humanitarian of institutions, the life insurance. It is unselfish and has for its object the protection of the wife and children, who after the death of the husband and father would be without support. It entails self-denial and forethought on the part of the insured to meet his premiums, and this reacts advantageously on him and on his habits, engendering economy and the habit of saving. We can state that from the number of the insured, we can have an idea of the prosperity, honesty and uprightness of the community, as it is, according to Vanderpoel, 3 an 3 Canada Medical Record. November, ■ 1S09. 426 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS evidence of thrift, forethought and consideration of others, upon which social comfort and happiness chiefly depends. Life insurance is an American pride. It began as a small private institution in England, but has been developed through American energy into the greatest institution of the world. It has extended its great benefactions to all civilized society, and the whole world must greet and appreciate the blessing of this American enterprise. There comes up then for us the interesting question, whether a man who has had the misfortune of being infected with syphilis should be in any way prevented from enjoying the benefit of life insurance. In former times a man when found affected with syphilis was rejected as a dangerous subject, the risk for the insurance society being con- sidered too great. Gradually the medical examiners, inspired by the progress of the scientific treatment and by the results obtained, began to consider many questions in reference to the admissibility of some risk on the lives of persons who had been affected with syphilis. This study cleared the horizon of some of the clouds rolled up against the future of a syphilitic person, and we can say to-day that no objection is made against the admissibility to the benefits of the life insurance policy of a man who has had syphilis. We have seen from our statistics that deaths directly due to the disease are exceedingly rare in acquired syphilis, consequently syphilis in itself offers but a small risk. And as a matter of fact we have remarked cases of longevity in subjects who had suffered from severe cases of syphilis. Refusing insurance to a large number of insurable risks is a financial loss to the companies, and a painful disappointment to the applicants. This in a great number of persons once affected with syphilis can be safely spared, since we find in our daily experience that this disease in the ordinary cases, after a short duration of the early constitutional symptoms, dies out and only exceptionally shows up in the form of tertiary manifestations. To determine the degree of risk which a Company incurs in in- suring a person once affected with syphilis, it is necessary to take under consideration the constitution, the habits, and the treatment taken by the applicant. Medical directors are usually led to the acceptance of an applicant who has had syphilis, by this criterion : When the applicant, before being infected, has always enjoyed good health, and he is of a good physical constitution, it is an evidence that the morbid condition cannot have so deleterious an influence as in a weak and sickly individual. The nature of the case of syphilis has also to be taken under consideration, and so when the attack has been of a mild character, and no serious symptoms on the part of the organs SYPHILIS AND PUBLIC HEALTH 427 have occurred, we can say that the attack of syphilis has been of a benignant type, and under ordinary circumstances it will disappear without relapsing. The successive relapses and their persistency make a questionable point as to the health of the applicant, and such appli- cants are usually rejected. But in the cases where no symptoms after the first eruptions have occurred for several years, no objection is made to insuring the applicant. The consideration, however, of the treatment undergone is another important question. We know that most of the cases showing tertiary symptoms are those which have had an insufficient treatment or none. It will be interesting to add a statistical table from Fournier 4 in reference to this subject. In a total of 1664 cases of syphilis he found Secondary syphilis of a benignant type 1424 Secondary of a medium type 131 Secondary intense and grave 45 Tertiary forms 64 1664 This shows that tertiary manifestations can follow any kind of secon- dary syphilis, of a benignant as well as of a serious type. But not rarely tertiary symptoms occur after cases of very mild secondary symptoms, in the proportion of one to ten. Treatment of a heroic nature is that which in the greatest number of cases prevents and removes the danger of the ravages of the tertiary period of syphilis. In consequence, a consideration of the treatment undergone by the applicant is a good basis for the judgment of the risk which the society assumes in accepting a syphilitic applicant. The habits of the applicant have also to be taken under considera- tion. Alcoholism in these cases is out of the question, for if this is dangerous and risky by itself, it is much more so in association with syphilis. The habits of living, the excitement of a business life, the way of taking meals, the continuous mental strain, worry, these have to be considered all together, as all of them, in association with syphilis, may have dangerous results on the nervous system. Dr. H. Mireur 5 after considering the difference in the character of syphilis and the relation to the different individuals and to the treat- ment, concluded that there is no uniform line of procedure to be es- tablished by the insurance companies ; it is necessary for them to act according to the family and the personal history of the case and the 4 " Traitement de la syphilis." Paris, p. 39. 5 Marseilles Medicate, 1881. Quoted by Samuel Treat Armstrong. '* A System Gen. Urin. Diseases," etc. Vol. ii, p. 829. 428 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS general condition of the applicant when examined. It is a rare ex- ception that the pernicious influence of the disease is not exercised upon the infected individual at the time it was acquired and the sta- tistics show that it has slight influence upon mortality. In this regard Sam Treat Armstrong refers to the experience of the companies with mortality from syphilis. He could obtain only from two companies positive data, but from all he had replies agreeing that the mortality caused by syphilis was extremely small. In one company in the large number of 22484 deaths, only five deaths had been caused by syphilis, while in another company, out of 10,952 deaths seven only were due to that disease, forming in all so small a percentage as to cause prac- tically very little risk. From the above considerations it results that the larger proportion of the American insurance companies have taken the same position as the European companies, accepting persons who have had syphilis, when they have been properly treated, and when they do not show any secondary or tertiary symptoms. We will refer to the opinion of some prominent medical examiners, who with their experience, confirm our views on this subject. Dr. Thomas Glover Lyon, Medical Officer of the Mutual Life Assurance Co., London, in reference to syphilis said that, " generally speaking, we should take anyone who has proved to have no symptoms, that is, in whom it can be reasonably expected that the disease is cured and in whom there was no reason to suppose the disease was not cured. If syphilis has had the ordinary mild course, and the symptoms ended some little time before two years' duration, a very short time after that two years we would take the applicant at ordinary rates. This is the general custom in England." Geo. W. Wells 5T on the same subject expresses himself in the following manner: " Syphilis is a disease which can be cured if taken in hand early, and persistently treated for a sufficient time. There does not seem to be any medication which will prevent the disease from reaching the secondary stage. While some cases of syphilis will ter- minate favorably without medicine, it is not safe to rely upon a spon- taneous cure. It is a fact that proper treatment will lessen the length of the secondary period and prevent the patient reaching the tertiary stage, or will cure the disease." He agrees with our observations, and says that " syphilis is not, however, such a formidable malady as it was thought to be in former times, because its malignancy has been proven less, and methods of treatment are improved so that, whereas in former times the subject of syphilis was little better than ostracized, to-day he is looked upon as 6 The Medical Examiner, September, 1897. SYPHILIS AND PUBLIC HEALTH 429 having received but little harm, if any, by reason of his having had syphilis, provided he has undergone proper treatment for a sufficient length of time and leads a proper life subsequently." These conditions make possible the insurability of the applicants who have been infected with syphilis. There has been a time which we all remember, when an applicant who admitted having had syphilis was declined simply because he had had that disease. It was thought that the consequences were such that he could not be considered a proper risk under any consideration. A man once syphilitic was always syphilitic. This was the dictum, and for him there was no insurance. The point was taken from the period of life in which the tertiary symptoms appear, which is from five to fifteen years after the infection, manifesting themselves between the ages of thirty-five and forty years. At that time (after forty), the insurable age was considered too small. Moreover, there was to be considered the effect of the syphilitic virus on certain other diseases or diatheses, which are usually aggravated or made active by its presence. Tuberculosis, for instance, is made active in consequence of syphilis, and in the same way it has a tendency to arouse into activity gouty conditions, and by affecting the kidneys it may cause Bright's disease. Recently syphilologists began to study much more accurately the prognosis and the future of subjects who had been infected with syphilis. They showed statistics favorable to the infected — no bad effect upon longevity, — deaths from syphilis exceedingly rare, — cases of tertiary ravages nearly exceptional, so that medical directors began to change their mind in favor of insuring applicants who had once had syphilis, and a few years ago some companies began to accept this class of cases. We take from the article of Dr. Geo. Wells 7 the opinions of several medical examiners of foreign companies. Dr. Fr. B. Erman (Hamburg). The practice of insuring syphilitic persons may be safely followed in his opinion. European companies are very liberal, as they grant policies even for life rates and without extra charges in cases with syphilitic antecedents, provided three years have elapsed since syphilitic infection, and the general condition of the applicant i? good at the time of the examination. Most companies grant twenty-year endowments. This practice corresponds with the general opinion of European physicians, who hold that syphilis does not abridge life generally. Cases of syphilitic dis- eases of the nervous system, paralysis, atheroma of cerebral arteries, of the bones, liver and lungs are known to occur and destroy life : but these cases are rare, and they are apt to change the general impression that syphilis does not heavily influence the duration of life. The Gotha a. c. 430 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS Insurance Company issues policies for the whole life, at ordinary rates to syphilitics, when three years have elapsed since the disappearance of syphilitic symptoms, and when the general health of the applicant is good. In general, German companies insure luetics, but try to diminish the risk of the supposed mortality by limiting the term of insurance. Not less interesting are the ideas expressed by Dr. Carl Herzcka, Budapest. Syphilis can be cured. When is it to be looked upon as cured? The possibility of a relapse does not warrant us to consider a man perfectly cured after the disappearance of all manifest symptoms. Calculated by such a disappearance a declaration of a cure is an arbitrary matter. This question cannot be answered in a general way ; collateral circumstances must be taken into consideration, and above all the gravity of the case, the duration of the manifest disease, the extent to which the affection is shared by the whole organism, and especially what organs are affected, whether relapses have appeared, whether sequelae of the disease can be discovered, what treatment was followed, how long it lasted, whether after treatments were employed. It is also important to examine the constitution of the applicant, his manner of life, and the state of health of his children. Then only the time since the disappearance of the last symptoms can be taken into consideration. with regard to whether the applicant can be considered as totally cured. Of course a cure before two or three years from the disappearance of manifest symptoms is out of the question. Dr. G. Ferrari (Genoa, Italy) says that to refuse insurance to persons who have at any time suffered from syphilis would be justified if syphilis were always an incurable disease, but we have abundant proof of its curability. He does not mean that all cases are curable, but he firmly believes that many infected persons, when well treated, and for a sufficient length of time, will remain healthy for life. In the prognosis of syphilis, great attention must be paid to the ground upon which the syphilitic virus falls. In people who abuse tobacco, alcohol, or who are subject to malaria, scrofula, obesity or diabetes, syphilis is very dangerous and will never be cured. Italians accept Fournier's opinion regarding the prognosis of syphilitics and syphilis. His per- sonal opinion is not to grant insurance to all persons who have been affected with syphilis, but only : first, to those who at the expiration of three years from the cessation of the disease, being thoroughly cured, have shown no symptom of syphilis ; second, to those who are of a very healthy constitution and live hygienically ; third, to those who stand the test of a most severe examination of every organ, or anatomical struc- ture, including an ophthalmoscopical examination. The opinion expressed by Dr. Edwards Ehlers of Copenhagen is also very favorable indeed. Syphilis has gradually lost much of its SYPHILIS AND PUBLIC HEALTH 431 former intensity, because of a diminished inherited predisposition, and possibly also because it has lost part of its malignancy. A person who has gone through a regular course of mercurial treatment, after the first appearance of syphilis, and who lives regularly, can become as good a " life " as any non-syphilitic. The main cause for syphilis reaching its tertiary and dangerous stage is the lack of thorough treat- ment, or of defective treatment. The problem in insurance is to draw a line between syphilis which has been rationally treated, and syphilis which has had no treatment, or an incomplete one. A syphilitic appli- cant who has undergone a thorough and rational course of treatment is undoubtedly a more valuable risk than a person who has had pneumonia, pleurisy, typhlitis, and similar diseases. From the above considerations we see that syphilis in the ordinary cases, when the person is living a regular life, after a prolonged treat- ment, is not a disease capable of abridging life, and in consequence must not exclude an applicant from the benefit of life insurance. It is true that we have no positive signs to judge whether the person who had been infected with syphilis has perfectly recovered, but we have positive knowledge from cases of reinoculations that the person had recovered from syphilis. We have known a gentleman who died at the rioe age of ninety-seven, who in the twenties had passed through a severe case of syphilis with persistent relapses. Life insurance is business, and must be treated in a business-like way, without hypotheses and without poetry. Dr. Solomonsen 8 of Copenhagen, read a paper before the Second International Congress of Physicians of Insurance Companies, in Amsterdam, 1901, in which he expressed his views that even during the three or four years following the infection, and notwithstanding the absence of any suspicious symptoms, he believed that rejection was justified, because recurrences are most frequent in the first years. We do not see any reason for rejecting an applicant when he has no symptoms whatever, but simply because of the danger of recurrences. Life insurance does not insure against disease, but only life, and no harm would result to a life insur- ance company if a man insured three years after the infection, and with no present symptoms at all, should afterwards have a mucous patch on his tongue, or a papule on the palm of his hand. Solomonsen quotes Professor Runeberg, the chief medical adviser of the Kallon Company, who believes that all deaths due to cerebral softening, cardiac affections, sclerosis of the coronary arteries, are the result of syphilitic infection when they occur before the fiftieth year of life. In another article he maintained that limited arteriosclerosis recognized syphilis as a prin- 8 " Syphilis and Life Insurance." The Medical Examiner and Practitioner, Oct., 1901. 432 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS cipal factor. We can say with Fournier, " vous voyez la syphilis par tout,'' we can place syphilis as a remote cause of a long series of dis- eases, but we cannot prove that a case of apoplexy or of heart disease recognized syphilis as its cause. Syphilis has a great tendency to affect the blood vessels in their tunics in the form of arteritis ; in some cases it may even cause thrombosis of the capillaries, with disastrous con- sequences on the skin, nervous tissues, lungs, etc. These conditions are always found as a consequence of the tertiary stage of syphilis, which only rarely occurs, and then as a consequence of neglected treat- ment and of a debauched life. Dr. Bayet 9 of Brussels, on syphilis and life insurance, after considering the diseases and the other affec- tions as sequelae of tertiary syphilis, expressed the opinion that one ought to refuse : 1. Any applicant showing signs of active secondary or tertiary syphilis. 2. Any applicant who had had syphilis within three years. 3. Syphilitic applicants who showed signs of intemperate habits. 4. In some cases, syphilitics suffering from malaria. 5. Syphilitics, who during the early stage, showed symptoms con- cerning the nervous system, as transitory paralysis, diplopia, epilepsy, apoplectiform deafness. In the cases of syphilitics who had undergone a proper course of treatment Bayet would admit them to a life policy on exactly the same conditions as those on which we allow them to marry. That they have been well and thoroughly treated for a couple of years, continu- ously at first, and then intermittently, and that for a year at least they have not shown signs of syphilis. In regard to the possibility of cerebral syphilis : When a syphilitic has been thoroughly treated, and for six years has presented no symptoms of any kind, he can be considered safe as far as cerebral affections may arise. In several of our cases where nervous symptoms have occurred the patient never knew he had ever had syphilis, and consequently had never taken any treatment. For this reason Bayet, in cases of syphilitics who had never had any treatment, would not accept their application unless for fifteen years after the infection, no syphilitic symptoms have made manifest the latent infection, and if no nervous symptoms have shown implications of these delicate organs. The treatment is thought to be sufficient after three years by Bayet, but, he adds, it is better if it has been continued for a longer time. In fact, he admits that the longer the treatment, the better he considers the life risk. 9 Internat. Congress of Medical Officers of Life Ins. Com. at Brussels. Med. Examiner, Nov., 1899. SYPHILIS AND PUBLIC HEALTH 433 T. B. Crosby in a discussion of " Some Extra Rating of Healthy Lives," which was presented by Dr. G. A. Heron of London, in refer- ence to syphilitics to be admitted into the insurance companies, said: " Our friend, Mr. Jonathan Hutchinson, who is a very great authority, said that he should only like to belong to a Syphilitic Life Assurance Society at ordinary rates. He stated that when a man has undergone a certain amount of treatment for three or four years, and shows no signs, enjoying a good state of health, he is pretty safe." On the other hand, we have hysterical writers, who see the shorten- ing of life from syphilis, and therefore establish circumstances and con- ditions in which companies can accept applicants who have been affected with lues. Bramwell 1G is of the opinion that syphilis shortens life at least by eighteen years, and he states that syphilitic applicants have to pay an extra premium. J. J. Graham Brown " after twenty years of practice as medical adviser of the Scottish Life Assurance Company, was called by the directors to formulate rules to be observed in the contracts demanded by men who have been infected with syphilis. He rejects all hospital observations in this matter as injudicious, because the patients with syphilis who go to the hospitals have more severe manifestations than those who apply for life insurance. Indeed, the applicants for life insurance belong to a social class- where the hygiene is better observed and the treatment is better followed. In reference to the risk concerning the assurance companies, the influence of syphilis on human longevity is not to be taken into con- sideration at the time of the secondary period. At this time the disease is never fatal, and usually no one comes up for application during the eruptive period. He recognizes that mortality is connected with the tertiary period mostly on account of late lesions in the cere- brospinal system as tabes, general paralysis, etc. It is of the greatest interest to know if the applicant has had a good regular treatment, and this is not easy to find out. Tertiary accidents appear from twelve to fifteen years after the infection, and as a general thesis the life of a syphilitic must be con- sidered always as shortened. Tertiary symptoms of a grave nature occur only rarely. Nine-tenths of individuals infected have to be considered as having recovered after the fifteenth year, but in one- tenth, serious disorders will undoubtedly result. For this reason Dr. Brown advises that a tax be imposed on those insured after infection, which should cease after the fifteenth year. 10 Bramwell. " On Syphilis and Life Assurance." Edinburgh Med. Chirurg, Society. Ref. Brit. Med. Journ., Dec. 27, 1902. 11 J. J. Graham Brown. "Syphilis and Life Insurance." The Scottish Med. and Surg. Journal, vol. xii, No. I, January, 1903. 434 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS When a man has had secondary manifestations, and at the time of his application has no signs, there is very little possibility for the occurrence of tertiary accidents. An individual of good and strong constitution, who lives regularly, takes plenty of fresh air, will be less menaced than another who is weak, compelled to lead a sedentary life on account of his occupation, and in poor hygienic surroundings. When syphilis is contracted at an advanced age, the risk for a company is too great, and the expectancy is not considered bright. The idea that when the first syphilitic manifestations are mild, late symptoms are liable to appear of a severe character, is no longer tenable. All depends on the quality and the quantity of treatment. The patient would have been protected from the tertiary manifesta- tions if he had taken sufficient treatment. Brown insists on the quality of mercurial treatment at least for the first two years from the infection. Longevity depends on an early and vigorous treatment, and it is of vital importance for the assured as well as for the insurer. It must not be forgotten, however, that sometimes we find severe tertiary symptoms in individuals who have received and followed good and well-directed mercurial treatment. From these considerations Brown concludes that the syphilitic has not the normal longevity, and as a consequence he cannot be in- sured at the ordinary rate. In case of a man who has had syphilis, is in good health, is temperate in his habits, in whom the infection dates above four years, who for over a year has not seen any secondary symptom, and who has undergone a regular treatment, he will be accepted as a good life, but he must, if a man in the thirties, stand a light tax at least for five years, so as to cover the insuring society. If treatment has not been well followed, the tax should be some- what higher, as tertiary manifestations make life insurance a bad risk, no matter what extra tax is charged. In these cases of applicants who have been affected with syphilis, Brown advises that a blank be sent to the regular physician who has had charge of the treatment of the applicant. The blank ought to contain the following questions : i. When did X. consult you the first time in reference to the subject? 2. Character and seat of the chancre, date of its appearance. 3. Date of the onset and character of the secondary symptoms. 4. Description of the treatment and time it was continued. 5. How long has he not shown syphilitic manifestations? 6. Has he shown anv tertiarv form? SYPHILIS AND PUBLIC HEALTH 435 7. Does he drink liquors 8, Has he any signs of tuberculosis, rheumatism or other con- stitutional disease? 9. Do you believe him to be insurable, or do you think his premium ought to be increased with a tax, and how much? We cannot object to precaution in business matters, but yet look- ing to the statistics of mortality, which are so closely searched by assurance societies, the small rate of mortality from syphilis appears so clearly that they make of an applicant not only a " fair," but a " good " risk. Personal experience shows that syphilis when treated does not shorten longevity. From the medical studies it is plain that this disease, which has been so much dreaded, easily yields to the power of the mercurial preparations judiciously applied, so that we can justly claim that a man affected with syphilis can in a certain time be considered as cured. We think, therefore, that the Medical Directors for Insurance Societies have done well in removing from the examination blank the old question, whether the applicant has ever had chancre, gonorrhea or syphilis. If by chancre was meant a chancroid or soft chancre, everybody knows that it has no influence on the general health, that it remains as a local affection, which when healed leaves no consequences. The same can be said for gonorrhea, which, however, may remain latent as posterior urethritis or as gleet, having caused a stricture. In these cases it will be easy to recognize the condition from the appearance of the urine, as the urine will then be cloudy, show shreds of different kinds, and the microscope will reveal ^epithelial cells, lymphoid cor- puscles, pus cells, etc. In reference to syphilis, which is the most important point of our study, when in the secondary period the medical examiner can easily find out for himself with a careful examination of the skin, mucous membranes of the mouth and throat, and the lymphatic glands of the applicant. In looking at the general surface of the skin it is possible that some small papula or a pigmented spot, a syphilitic lesion, is still on the palms or on the soles. In a case where the first eruptions have entirely disappeared, the skin, which has been the seat of a macular or papular eruption, still shows a peculiar pigmented hue, which has been called cutis variegata. In women with thin and white skin. anomaly of pigmentation is greatly exaggerated in the neck as a form of syphilitic leucoderma or syphilis pigmentaria, which remains for years in the form of a yellowish or brownish discoloration. This light pigment staining is sometimes diffused, sometimes in the form of 436 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS roundish patches, at other times in a reticulated form, but it is char- acteristic, so that when present it very rarely fails to disclose the pre- existence of syphilis. In men this peculiar appearance on the neck is not easily found, but on the chest, especially when remaining exposed in a cool room, cutis variegata is quite perceptible and its presence may give some hint for finding other symptoms of latent syphilis. The mucous membranes of the mouth and of the throat will in most of the cases show some erythema, in the form of a diffused redness on the ring of the palate, which does not cause any incon- venience to the patient, with the exception of some dryness, and in consequence the patient does not complain of it. This erythematous condition of the throat, syphilitic angina, lasts for a long time on account of its tendency to recurrence. Sometimes there are on the mucous membrane of the dorsum of the tongue, on the fauces and tonsils, limited infiltrated areas from the size of a lentil to that of a penny, which are nothing else than the repetition on the mucosa of the erythematous eruption on the skin. When we find such a con- dition of the mucous membranes of the mouth and palate, there is no difficulty in establishing the diagnosis of syphilis. The mucous patches on the mouth and throat are quite common during the first two years of the course of syphilis. They appear in the form of flat reddish elevations sharply defined, covered with grayish detritus. They are found on the mucosa of the lips, cheeks, tongue, especially at its borders, soft palate and faucial tonsils. On the tongue they are in the form of round, or oval, reddish patches scattered about the middle of its dorsal surface, or as whitish points at its edges. At the angle of the lips on the mucous membrane just where the two surfaces of the mucous membrane of the lips touch each other, small patches are found, which when present will reveal to the examiner the presence of an early syphilis. The examination of the lymphatic glands will in nearly all cases complete the diagnosis. It is true, that the lymphatic ganglia in some individuals are naturally enlarged, and it is also true that in some cases of syphilis very little engorgement of the glands takes place, but' yet it is one of the most constant symptoms and one which will reveal for a long time the course of syphilis. The lymphatic glands of the cervical, subaxillary, inguinal and epitrochlear regions are the most important to be examined. They are, as the result of the irri- tative process of syphilis, hard, the size of an almond or of a hazel-nut, movable, firm to the touch, and at times, when pressed with the finger, slightly tender. When syphilitic symptoms begin to disappear, then the glands slowly diminish in size, but yet for months and years they remain as the most evident sign of a past syphilitic infection. The SYPHILIS AND PUBLIC HEALTH 437 examiner, consequently, always will find the study of the lymphatic glands a great help to his diagnosis. In cases of late syphilis the examination is somewhat more com- plex, but with some care it will also succeed in ferreting out the presence of the disease. The scars of healed lesions will give an idea of the latent disease. In fact, the cicatrix which results from a syphil- itic infiltration, when of recent date, is surrounded with a copper- colored pigmentation, lasting for a long time. When old they are of a whitish and brilliant color. They are round and superficial, and when scattered on different places of the body they will stand as the witnesses of a rupioid eruption. Small round cicatrices disposed in a round area, in the vicinity of the nose, mouth, anus, or on the joints, will recall patches of multiple superficial gummata or otherwise called syphilis tuberculo-ulcerosa in a circinate form. Round, isolated scars, scattered on the legs, without an infiltrated condition of the surround- ing skin, are usually the result of multiple gumma. The mucous membrane of the mouth and throat often gives some help to the examiner in finding out a case of old syphilis. The pres- ence of leucokeratosis, a kind of milky white patches, consisting of a thickness and turbidity of the epithelium, covering the mucous mem- brane of the cheeks running back from the angle of the lips, towards the region of the molar teeth, and sometimes spread on the tongue also, is to be considered suspicious of pre-existing syphilis. In some cases the mucosa is only superficially thickened, of a white opaline color, and smooth, but in some other cases it is somewhat rough, hard and uneven to the touch. This condition, called leucokeratosis or leuco- plasia, has been found in persons who have never had syphilis, and this fact has led to great confusion. We do not wish to enter into so difficult a question ; we recognize the fact that some white patches may also appear on the mucosa of the mouth and of the tongue without syphilitic antecedents, probably only from smoking (plaques des fumeur of Buzenet), but we must never forget that syphilitics are predisposed to changes induced by smoking, and are more liable to show this condition of the mucous membrane of the mouth than others. When the mucous membrane of the mouth has been affected for a long time by persistent eruptions of mucous patches during the secondary period of syphilis, it is not entirely be- yond possibility to find that mucous membrane covered by a whitish hard thickened and imperfect epithelium. To this condition add the continuous irritation from smoking and chewing tobacco, and it will be easily seen that the presence of opaline plaques, of leucokeratosis, or leucoplasia, is oftener found in persons who have had syphilis, than in non-syphilitics. 438 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS The examination of the lymphatic glands will not in all cases, but certainly in some, reveal a latent syphilis. The cervical and the inguinal glands are the first to disappear during the course of syphilis, so that after three or four years the glands are scarcely perceptible. The epitrochlear and the subaxillary glands are usually felt in late stages of syphilis and the presence of these glands will call the attention of the examiner to syphilitic antecedents. The lymphatic glands, how- ever, once engorged and enlarged, cannot return to their normal size, and for many years they will remain perceptible to the fingers of an expert as small kernels. In fact, we have found in our own researches that the enlargement of the glands from syphilitic infection is not a genuine inflammatory one, but is due to an infiltrating process affecting the follicle of the gland, which produces a stasis of the lymphoid ele- ments into the cavitary system of the lymph glands, as a consequence, although the lymph returns to its normal course, yet the once infiltrated and engorged follicle of the gland will undergo a sclerotic process, causing a peculiar hardness, which remains hard for a long time, if not for life. In case of suspected tertiary syphilis an examination of the tibiae will often reveal a peculiar roughness of their anterior surface and especially of the crestse, which when present will tend to prove a pre-existent syphilitic periostitis. Any symptom which has any value for revealing an attack of syphilis on the nervous system has to be taken into serious considera- tion. An attack of facial paralysis, ptosis of one of the eyelids, are valuable signs to show that the nervous system is already affected by late syphilis. In these cases an ophthalmoscopic examination will be of great value in determining the condition of the fundus of the eye. We have already shown that the life of an applicant who has been affected with syphilis and has been well treated, after three years has to be considered not only a " fair but a good " risk. We cannot say the same for an applicant who has shown signs of tertiary symp- toms, and in our opinion it is more advisable to have him refused on account of the constant danger of serious visceral complications. That infiltration which in a limited surface under the skin we call gumma, may be formed in almost every organ or tissue, destroying their func- tion. The origin of the gumma is from the vascular system, and from it the bones, the joints, the nervous system, the liver, the kidneys, the lungs, and every part may be attacked with dangerous results. The companies recognize the importance of the scientific examina- tion, and they expect and demand continual watchfulness on the part of the examiner. They want a decisive reply, yes or no, and no recourse to explanatory notes. On the other hand, the examiner must be just SYPHILIS AND PUBLIC HEALTH 439 towards the applicant, remembering that a hasty rejection of the latter may deprive him of the rights of life insurance. We are of the opinion that the examiner must not rely too much on the answers of the applicant, not because of any doubt about the veracity of his replies, but because in many instances he does not know much of the mild symptoms of the affection. When the examiner has found unmistakable signs of a recent syphilis, and he asks positively, " how long ago did you have the chancre? " the applicant cannot deny and will answer without hesitation. An applicant who has had syphilis three years before making his application, when he proves he has had a good and sufficient treatment, if for several months no syphilitic symptoms have appeared, if he is in good general health, and if he leads a regular and temperate life, can be accepted without much risk, as he can be considered as cured. The idea of imposing a tax on the life of a man who has had syphilis is a bit of red tape of the character of an unnecessary precaution. If it is true that nine-tenths of syphil- itics will never have any tertiary accidents, and only one-tenth will show severe symptoms, then we must say that insurance companies will undergo much more risk with any other insured than with syphil- itics. How many insured at thirty will turn alcoholics at fifty? how many in splendid health at the time of the insurance will be attacked by appendicitis or pneumonia a short time after having been insured? The imposing of a tax on the life of a young man in excellent health who four or five years before being insured had syphilis, for which he was regularly treated and has to be considered cured, is unjust, because the risk of the companies is not increased. When, however, an applicant has symptoms of old periostitis, has had forms of circinate syphilides, has shown gummata, caries, and is still under syphilitic infection, he has to be rejected as a dangerous risk. PUBLIC PROPHYLAXIS IN REGARD TO PROSTITUTION In the preceding chapters we have studied syphilis as a menacing scourge, and have affirmed that society must take steps to limit its ravages and to check its spread. Society has begun to wage a war against tuberculosis and leprosy with good results, and the same has to be done with syphilis. Syphilis as a social evil attracts international interest, not only on account of the sad results on the moral and physical condition of the individual, but also on account of the economical and material loss. forming a question of political economy. The object of public hygiene is to preserve the health of the people 440 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS so that human life may be prolonged to its natural end. Every life represents a capital for the state and for society, which assume as a duty the preservation of this life in good health. A large number of individuals are rendered unable to work and so to earn their living on account of the ravages wrought on them by syphilis and other venereal diseases, so much so that many are not only of no value because un- productive, but they represent a constant expense to the communities as objects of public charity. In a general way we must state that the infection from syphilis and other venereal diseases is, in 90 per cent, of all cases, through sexual intercourse, while the other 10 per cent, is from extra-genital or accidental infection. The professions in some cases may be the cause of spreading of syphilitic infection. In the chapter on " modes of infection," we have mentioned acci- dental infection. We will only briefly recall the fact that cases of accidental infection occur quite often in our own profession, and when a physician has syphilitic lesions, such as mucous patches of the inter- digital region, it is his duty to be careful so as not to be a cause of contagion. In the brief statistical tables referred to under the head of profes- sions, the infected domestics were 875. This is a large number and is worthy of serious consideration. A cook or a dining room attendant affected with syphilis constitutes a continuous danger for the family that employs them. In our practice, over seven cases of initial lesions have been com- municated by barbers, especially through their practice of removing what they call wild hair. With the infected tweezers the barber has removed the hair from a healthy person, and the infection has been communicated. It would be of great advantage, and probably would save much suffering for the customers to demand that young barbers should be instructed as to dangers of infection and how to prevent it. If barbers were compelled to have a sterilizer with boiling water where they could place their instruments after using them, it would be a great benefit to humanity. It is always dangerous to employ men infected with syphilis in the factories, shops, etc., and let them mingle with healthy boys or girls. We had occasion to see three cases of hard chancre of the lips, which occurred in a glass factory, in three workmen, who received the disease from an infected companion through the glass blower. A musician lent his brass instrument to a friend of the same profession so as to enable him to earn some money. The instrument was returned. The musician did not think of cleansing the mouth- piece of the instrument and played on it. Some three weeks afterward SYPHILIS AND PUBLIC HEALTH 44I there appeared a chancre of the upper lip, which was followed by severe manifestations of syphilis. Although the accidental infections of syphilis are reckoned at 10 per cent, of all syphilitic infections, yet the public has to be en- lightened upon this possible source of the evil. The glasses, cups, etc., in factories, in shops, in railroad cars, steamboats, have to be rinsed before applying them to the mouth. Table utensils, as forks, spoons, knives, which are left on the free lunch stands, and are used promiscu- ously by everybody, have to be looked upon with some suspicion, as they may become the cause of carrying infection. The unclean habit of promiscuous kissing has to be pointed out to the public as a possible cause of contagion and as an undesirable practice. Not very rarely have we had occasion to find in patients of both sexes hard chancres of the tongue, of the lips and of the tonsils, for which the patients could not give any possible explanation as to the infection, but it is clear that a kiss very likely had been the carrier of it. Illicit sexual relations, especially with prostitutes, are in most cases the means of syphilitic infection. Immorality and syphilis are the results of free prostitution. When a woman allows illicit sexual intercourse in consideration of money or other value, she is a prostitute. Before she reached the point of selling her honor and her body for money she was a woman. Unfortunately she loved a man, she was conquered by him, then she was betrayed in her affection, in her hopes, and she was left to her fate. This was the beginning of her downfall. That man should carry the blame, as he was the cause of the ruin of that poor girl. If that man had had respect for the gentle sex and had understood the re- sponsibility of sexual intercourse, he would not have acted so shame- fully and so cruelly. In the United States we have severe laws against such cases ; let the law be enforced and teach reform by its effect. Kromayer 12 believes that he finds the origin of prostitution in the disproportion of strength in the two sexes. The man with aggres- sive strength, in spite of the law, conquers the woman for the sake of satisfying his passions, and the woman on account of her natural weak- ness is unable to resist the sexual voluptuousness and concedes to his powerful aggression. These considerations may hold good for the woman who is betrayed, but for this reason only she is not a prostitute. The name of prostitute to be correctly applied requires a com- bination of circumstances, which debase and disgrace the unfortunate 12 Kromayer, E. " Zur Austilgung der Syphilis." Berlin, 1898. 442 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS creatures who fall into so abject a social condition. Yet a woman who abandons herself to dishonor, who gives herself to the first man she finds, is not a prostitute, she is a licentious woman, and from this tendency she may fall into prostitution. Parent du Chatelet 13 established the following circumstances as constituting the puella publico: recurrent relapses well established, pub- lic notoriety, arrest in the act of committing the crime proved by witnesses. This, however, limits too much the meaning of prostitution, separating the class of the debauched women, and circumscribing the prostitutes to those who have to be considered as belonging to the class of the perverted. Indeed, we have seen in another chapter that licen- tiousness and lewdness pass as a miserable heredity from the mother to her daughter. As a constant law of nature all living creatures resemble those who have produced them, and from one generation to another bad qualities of the body and of the mind are constantly transmitted. There occurs to us from our personal experience the idea that syphilis excites the nervous centers connected with the sexual activity, so as to make an affected person, whether the disease be acquired or hereditary, belong to the class of the degenerated and of the sexually perverted. The evil of prostitution, viewed either in reference to its effects upon the unfortunate females themselves or in reference to the ob- noxious influences upon society, is one of the most interesting socio- logical studies. When we consider the life of those unfortunate creatures, we find ourselves before an object deserving human sym- pathy. Everyone with a human heart, who has seen the lives of these women, especially the physician who has seen them suffering upon a bed of sickness and has heard the confidential outpourings of their soul, cannot do otherwise than feel pity and sympathy for them. A physician who has often witnessed their agony, who has seen them overwhelmed with the sense of the enormity of their guilt, despairing even of the mercy of God to forgive their transgressions, is capable of showing pity towards them, and of invoking from society means and reforms to succor them. The life of a prostitute can be compared to that of a butterfly, and it is interesting in every stage of her career, from the day she makes her debut on the public streets to the last hour when she closes her eyes in death. The same woman wTio has been decked in the dress of a peeress, is now in the rags of a beggar, without hope for anything better, with only a pill of morphine or a drink of whisky for her relief. But, as William Tait said, even in these unfavorable circumstances she is a woman and she still has the heart of a woman. If she, on account 13 Parent du Chatelet. " De la prostitution dans la ville de Paris." 1857. SYPHILIS AND PUBLIC HEALTH 443 of scandalous habits, on account of deleterious surroundings, has re- nounced society and its laws, let society take pity on her and prevent if possible her fall to the very bottom of the pit. We find very com- mendable the institution of St. Denis in Paris, where all prostitutes suffering from physical or mental infirmities, such as rectovaginal fistula, cancer, incurable organic disease, idiocy, are cared for while incapacitated from pursuing their calling. Only a few are sent to St, Denis in the course of a year, and the mortality, according to Parent- Du Chatelet 14 was not less than 25 per cent, per annum. Prostitution is a plague which can be considered coeval with society and is the greatest source of syphilis and it is against prostitu- tion that we must direct our efforts. The public does not care to know much about it and prefers ignorance on this subject. Of this social evil they usually speak in a whisper, and whoever tries to raise the veil to inquire into its mysteries, its origin, and its consequences, must meet with censure. It is, however, much better to know the exact dimensions of an evil than to keep it unknown and content ourselves with treating its frightful effects. Reticence is not a good policy. Public safety de- mands prophylactic measures to regulate the evil and prevent the spread of venereal- diseases. Vice in man, arising from a natural impulse, is the first origin of prostitution. Lack of education, laziness, idleness, together with the stern problem of living on the part of the woman, complete the work. It is absurd to believe that prostitution can be eradicated ; it is like any other evil of society which can be restricted, regulated, but will always exist. Physical punishments administered to men and women, the threat of future punishment after death, have never de- terred men from seeking and women from granting sinful pleasures. Guilty women have been banished, scourged, branded, and even exe- cuted ; their partners have been subjected to the same treatment, de- nounced publicly as immoral, divested of civil rights, and yet prostitu- tion has continued. The so much talked of teachings of morality and virtue have been powerless. In some cases amongst high-class and cultured individuals, it may restrain to a certain extent, but it will not have much power in the masses of the population. In the same way science has shown the sad effects resulting from venereal diseases on the man who is infected, and on his offspring, and yet even such terrible thoughts have not had influence enough to check the current. There remains, therefore, the only way to regulate prostitution 14 Parent du Chatelet. Vol. ii, p. 273. 444 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS and by restraining it under the strictest surveillance try to avoid the evil, which every civilized country has the right to combat. Prostitution is a kind of a trade, an industry ; the persons who are interested in this trade sell their bodies. On the other hand, it is a duty to see that the women are in a healthy condition, and that they do not constitute a danger for the community. The cure after the damage is done is a necessity, but the prevention is much better in order that we may prevent sufferings and financial losses to society. Ravages of syphilis can be checked by compelling public women to remain under strict surveillance. When one of these women is found infected with the initial lesion, she should be taken to hospital and treated for the chancre and then for the secondary symptoms. When free of symptoms she should be released. Meanwhile, she still remains under surveillance, and when a symptom reappears she is again confined to the hospital and the treatment is continued. In our personal experience we find this system of surveillance beneficial to the woman ; she has a regular treatment and is saved from the ravages of a neglected syphilis ; it is beneficial to society, for who knows how many young men would be infected by this woman dur- ing the condylomatous period, if she were left free to pursue her calling? When the houses of prostitution are under police surveillance, this is in itself a restraint against a great many showing themselves in those places, where they may lose their reputation. Minors will not be ad- mitted ; the admission of a boy in those places may be for him the poisoning of his mind and of his body, for in many cases a criminal career has begun with the first entrance into such dens. Surveillance may only succeed in obtaining a reform of a courtesan by giving a chance to good philanthropic people to show these people the enormity of their position. In a question of so vital an interest, which involves not only the welfare of the members of society, but also their descendants, every means which can check the spreading of syph- ilis and of venereal diseases has to be advocated. Legal Penalties for Prostitution. — It has been proposed to make any person legally responsible for damages who, knowing the danger of transmitting the disease, has sexual relations causing infection in the other party. This law should be founded upon the rule existing in nearly every country, that whoever causes bodily damage to another should be compelled to pay an indemnity for the expenses and losses caused to the other. Berenger 15 referred to cases where parents have been made re- 15 Berenger, M. Conference Internationale pour la Prophylaxie de la Syphilis, etc. Bruxelles, Sept., 1902. SYPHILIS AND PUBLIC HEALTH 445 sponsible for damages on account of the infection of the wet nurse, to whom they had entrusted their syphilitic child, fully knowing that it was capable of infecting. Court of Paris, January 10, 1884, and Novem- ber 27, 1896. In two other cases indemnities had been granted by the Court of Lyons against the directress of an employment bureau who had placed a syphilitic woman as wet nurse in a family, causing infection of the baby, January 14, 1858; and by the Court of Dijon against a physician who had not cautioned a wet nurse about the disease which she acquired by nursing the babe, and then communicated to her husband, March 14, 1868. The same responsibility has been placed by the Court of Paris on the administration of public assistance, when on account of a neglected medical examination a child had been given to a woman to nurse, and she contracted syphilis from the contact of its lips. February 24, i8 93 . The penal responsibility would rest on three conditions: 1, attempt against morals ; 2, a train of suffering on account of infection ; 3, the knowledge of the possibility of contagion, as the points whereon to base the punishment. The transmission of venereal diseases would be made a crime either when it had occurred intentionally, or if it had occurred through volun- tary indiscretion. Some dispositions of a general order on crimes against the public health and on the transmission of venereal diseases have been enacted in Norway. M. Breda de Morgenstierne 16 of the University of Chris- tiania, referred to the penal law enacted in Norway May 22, 1902, by Bernard Getz. Whoever knowingly will expose to an imminent danger the life or the health of another shall be punished with reclusion to the extent of three years, or with imprisonment for three months ; in case of death the reclusion will be for five years, and the imprisonment for one year. If the culprit has spread disease knowingly for the purpose of gain, the court will add a fine, which can be increased to fs. 10.000. Whoever by his or her negligence has caused an attempt against the body's integrity or to the health of a person shall be punished with a fine of not more than fs. 1000. If the attempt is grave the court may sentence the culprit to prison rather than impose a fine. If the culprit has committed the offense while in the discharge of his functions, profession or industry, the court will punish him with imprisonment of not more than five years. 16 Breda de Morgenstierne. Conference Internationale, ete. Bruxelles. tooj. 446 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS If the negligence has been committed for the sake of gain, then the court will add a fine of not more than 5000 francs. In the law of Norway, and also of Switzerland, the transmission of syphilis is considered in different articles. In these articles are comprehended the transmission of syphilis in an extragenital way, the transmission of syphilis by marriage, and also the infection through the sexual act outside of marriage. In the last occurrence there are cases where the sexual act is punishable for but one of the two, as in the seduction of minors and attempts on children. With these dispositions of general law, a judge will not hesitate to imprison a man who under promise of marriage has seduced an inno- cent girl and has infected her with syphilis, or with another venereal disease. The penal responsibility, however, ceases when the disease is com- municated in the sexual act by the prostitute to her client. In this case there is a consent to the damage by the damaged party. If a captain of a vessel has accepted sailors whom he knows to be infected with a transmittable disease, it is also considered a crime against public safety. Whoever, knowing or presuming that he is affected with a con- tagious sexual disease, has infected or exposed to infection another person, either by sexual intercourse or by debauchery, shall be punished by five years' imprisonment. The same punishment shall be applied to anyone who shall have aided and abetted an individual, knowing or presuming him to be af- fected with a contagious sexual disease, to infect another person, or to expose her to infection under the stated circumstances. If one of a married couple suffers infection, or thinks he is exposed to contamination, then prosecution shall not take place unless by request of the first complainant. Art. 358 punishes anyone who employs a wet nurse for a syphilitic child. In the same way it punishes anyone who, affected with syphilis in the contagious stage, enters into a family as a domestic, or accepts the care of the children, and also him or her who knowingly employs a syphilitic person to nurse children. In the German penal law, Paragraph 327 says : " Whoever knowing himself to be affected with contagious sexual disease, shall have sexual intercourse with another person, shall be punished with reclusion for not more than one year, and a fine to the extent of 1000 marks. If the act is between man and wife, then prose- cution shall take place only on the complaint of the damaged party." This article met with great objections on account of other articles SYPHILIS AND PUBLIC HEALTH 447 of penal dispositions against prostitutes, which concern the body's in- tegrity. Reichstag 8, Leg. II, 1892. In the Austrian penal code there is an article which says that anyone who knowing himself to be affected with a venereal or syphilitic disease shall have intercourse with another person, shall be punished with detention. In case of conjugal sexual intercourse, there shall be no judiciary prosecution. To the detention can also be added hard labor or any other more severe punishment, according to cir- cumstances. In the sense of the code actually in force in Austria, the fact of being infected with a venereal disease constitutes a grave circumstance for a person with the calling of prostitute. The penal code of Finland, chap. 20, par. 13, punishes with hard labor, or with detention to the extent of two years the contamination by sexual intercourse. The same dispositions are in the penal code of Denmark, par. 181, in the penal law of Schaffhouse, par. 185, and in Canton Ticino, art. 425. In the United States the law would reach the culprit, but it is difficult to find the damaged party in order to institute prosecution. In many States punishment is very severe in order to protect young girls from seduction and rape, so much so that in North Carolina it is a crime punishable with death. The responsibility of an infected individual who communicates the disease to another is in our States just the same as in the code of any other nation. Whoever produces an injury or in any way is the cause of suffering and of financial losses to another is responsible for, and is compelled to pay indemnity to the injured party, or suffer an adequate punishment. We have already stated on page 322 that in the United States the case of a husband who knowing himself to be affected with contagious disease infects his wife, is considered as a case of extreme cruelty and is a ground for divorce. This same disposition has been accepted in the penal code of many nations. It is a point of justice that this offense ought to be punished in the same way as if somebody by negligence has injured the body or the health of another party. In the case of rape of children, or minors, or other crimes of the kind, together with the penal responsibility for the rape, there is the contamination with the disease. A man who has not only seduced a woman, but has also ruined her health, must not be exempt from punishment. In many countries amongst the lowest classes of society there is still the superstition that coitus with a virgin is the remedy against syphilis. The law must punish severely such nefarious acts. 448 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS The social relations of the person infected with syphilis forms a great difference in the gravity of the occurrence. When a young man, single, contracts syphilis and behaves well, there will not be much danger of the spreading of contagion. But when a man who has con- tracted syphilis continues in his gay life, he may expose the health of others. In this case the penal responsibility can be considered as a just system of prophylaxis to prevent the spreading of venereal dis- eases. The idea of punishment might inspire fear, and contribute to check the spreading of the infection. The degree and the quality of punishment has to be left to the legislation of the different countries. One thing will always stand firm, that the offended person who has been subjected to financial losses has to be indemnified. If a man with syphilitic manifestations has seduced and infected a woman, this will cause her not only direct expenses but also inability to attend to her occupations. His act will be punishable not only as an attempt on the bodily integrity, but the law furthermore will authorize the woman to claim an indemnity for her financial losses. The circumstances will probably change the de- gree of responsibility when the infection has taken place without knowledge, or through grave negligence, as in extragenital infections, or also in the case of sexual infection in case of marriage. PROSTITUTION OF MINORS The law can reach this lamentable prostitution of minor girls ; the most dangerous element in the spread of venereal diseases. In general it is accepted in the majority of the States, that a girl who has not yet reached the age of twenty-one is a civil minor. E. Passez, 17 secretary of the committee for defending children brought to justice, said, that society has never taken so much interest in the protection of childhood as in our times, yet the evil does not diminish, but is rather on the increase, which is a sign of bad social conditions and of degradation of the young people. Minot 18 referred to the decennial reports of the Ministry of Justice in France, as showing an increase' of criminality at all ages, but es- pecially among minors. From statistical tables he concluded that juvenile criminality in France has advanced from 13 to 36 per 1000, more than double, and suicides among minors has increased from 15 to 47 in one year. Criminality has increased among adults in the proportion of from 3 to 7. In 1841 in France 75444 were indicted, and in 1891 the number increased to 165,769. Suicides among adults 17 Passez, E. " Rapports et vouex." 1890 to 1900. 18 Minot, H. " Prostitution des minenres." Conf. Intern. Bntxelles, 1902. SYPHILIS AND PUBLIC HEALTH 449 from 2700 in 1841 had increased in 1891 to the number of 8416, in the proportion of 9 to 28. The progression is much faster among the minors than among the adults. Statistical data show an increase of depravity amongst the young folks, and an increase of prostitution among the minor girls. Parent du Chatelet 19 relates that at the installation of the police des moeurs in Paris, the registration of the prostitutes commenced in 1796, and a great number of girls were registered at the age of ten, twelve, fourteen, fifteen and sixteen years. Their youth was at that time no objection to their inscription, and the way in which those registers were kept shows that a much larger number of prostituted children were in Paris. In the archives he found many complaints sent to the administra- tion in reference to the scandalous way these girls acted, especially in the gardens of the Royal Palace. In these complaints there is men- tioned the great number and their extreme youth, their age being between twelve and thirteen years. Many more and even stronger complaints were sent in August, 1804, and in the following year, asking the aid of the administration against the immense number of young prostitutes not registered be- tween the age of twelve and fourteen years. From the same registers there results that from 1816 to 1832, 12,550 girls were inscribed as prostitutes, of whom 2043 were less than eighteen, and 6274 of the whole number had not completed their twenty-first year. Therefore, of 12,550 registered prostitutes, 8317, or two-thirds, were minors. From 1855 to 1869 in 6407 new registrations in Paris, according to Lecour, 20 4190 were of age, while 2217 were minors, and of these 513 were under eighteen years of age. In the beginning the girls were registered as prostitutes without distinction of age, but after a while in consequence of serious com- plaints, the inscription has been refused to minors. It is true then, that lately the number of minors has diminished. This is shown by a Report of the Municipal Council of Paris. Year Of age Under age Total 1872 732 280 1,014 1873 643 326 969 1874 687 326 1,013 1875 641 272 9*3 1876 424 190 614 19 Parent du Chatelet. L. c. 20 Lecour. " La Prostitution a Paris et a Londres," 1872. 45o THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS Year Of age Under age Total 1877 398 155 553 1878 451 173 624 1879 259 J 3 272 1880 345 9 354 1881 390 137 527 1882 452 42 494 1883 485 131 616 1884 684 322 1,006 1885 890 409 1,299 1886 775 37o i,i45 1887 592 276 868 1888 442 265 707 In Marseilles, according to Mireur, 21 in a total of 3584 prostitutes inscribed from 1872 to 1881, 374 were minors, of which 104 were less than eighteen, 12 only fifteen, and one fourteen years old. Reports of other cities show that the proportion of the prostitu- tion of minors, which for some time constituted two-thirds, has now diminished to one-third, and these are not on the increase. The Central Committee of Statistics of the Ministry of the In- terior in Russia made an investigation of the prostitution in the Em- pire with the results that of a total of 17,603 prostitutes, 7840 were harbored in brothels and 9760 were free. Their age varied between fifteen and fifty-five years. Of the girls not yet fifteen years of age, 14 girls were found in the brothels and 30 free. It was found that 3040 girls in brothels and 2508 girls free had not yet reached twenty years, while 3272 girls in brothels and 3465 free were between twenty and twenty-five years of age. 22 Although the statistics cannot be considered very exact, yet the investigation showed that 26 per cent, of all women in the brothels began their shameful career before twelve years of age, and 86 per cent, before attaining the legal age of twenty-one, while 25 per cent, began before sixteen years of age. In reference to the girls registered outside of the brothels, 50 began their life of shame before the twelfth year of age, 1978 before sixteen years, and 7305, 75 per cent., when under twenty-one years of age. Consequently four-fifths of all prostitutes registered in Russia were minors when they entered the calling. In New York the juvenile degradation is clearly shown by the 21 Mireur, H. " La prostitution a Marseille." 22 " Statistique de l'Empire de Russie XIII." " La Prostitution a la date du 1-13 aout." 1889. SYPHILIS AND PUBLIC HEALTH 45 1 statistical tables taken from the answers given by those women who asked to be inscribed as prostitutes. Sanger 23 refers to 2000 prosti- tutes, of whom 750 were under the age of twenty, so much so that between the age of fifteen and twenty are found over one-third of the whole number of those belonging to this calling. The inscription of minors as prostitutes has always raised severe objections on the part of philanthropists. On the authority of Parent- DuChatelet it can be asserted that since 1836 one of the most serious questions for the administration of moeurs is to establish the age and the registration of minors. Public prostitution, however, is not all, but there is also the evil of clandestine prostitution, which offers many interesting points. According to Dr. Commenge, 24 chief of the dispensary of the prefecture of police in Paris, the arrests of minors made by the police des moeurs from 1878 to 1887 were 12,615, and those of the prostitutes of age, during the same period, were 14,392. From the report of Dr. Fiaux on the actual organization of the medical surveillance of prostitution, the arrests of minors from 1888 to 1898 have been 14,072, and of those over twenty-one years of age 14.736. From the comparison of these data it results that while in the period 1878 to 1887 minors arrested as clandestine prostitutes were 46.7 per cent. ; during the period 1888 to 1898 they represented 48.8 per cent., showing a small increase. Commenge remarked that young girls in the beginning of their career of shame are rather prudent and conceal their actions, so much so that the police have occasion to place them under arrest only many months, and even some years, after they have entered their calling. Indeed, the attention of the police is attracted only by their imprudence and eccentricities. As a consequence more adults than minors are placed under arrest. Jullien, at the conference of 1899, on his own statistics based on 1000 diseased prostitutes under his service in Saint Lazare, showed that 3 of them had been initiated into debauchery between twelve and thirteen years of age, 6 at the age of fourteen, 8 at fifteen, 24 at sixteen, 135 at seventeen, 146 at eighteen, 143 at nineteen, and 103 at twenty. Beginning with twenty-one years of age the proportion diminishes considerably. In this table, minor girls appear in the proportion of 67 per cent. Fournier in his wide experience, declared that his ob- servations were in accordance with those of Jullien and Le Pileur, and 23 Sanger, W. W. " The History of Prostitution," 1899. p. 452. 24 Commenge, O. " La prostitution clandestine a Paris," 1897. 452 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS maintained from his observations that the great majority of prostitutes began their vile practice before twenty years of age. Although we have not any exact statistical tables based on our experience, we believe that we are right in asserting that the largest number of prostitutes in our hospital service began their life of shame before twenty years of age. In their youth, led on by their sensual passion, they are very soon infected with syphilis and other venereal affections, and are one of the principal causes of the spread of syphilis. Moreover, when these young girls have been diseased, on account of their false fear of being detected, they remain a long time without treatment, and when they cannot stand on their feet any longer they will ask for medical attendance. CAUSES OF PROSTITUTION The insufficient moral education plays a great role in placing those poor girls on the downward slope. The inculcation of moral principles in both sexes must be the safeguard of society. The principles of morality rest on a just sentiment of indignation against any action which leads to indiscriminate sexual relations, and against all which tend to excite illicit sensual passion. The feeling of indignation against that which is immoral is acquired by education, or by inculcation, and makes us detest all that we judge to be bad and which ought not to be done. This sentiment of morality rests on the idea of a supreme law, which attaches hap- piness to virtue and punishment to crime. This sentiment also causes indignation against a criminal, who instead of punishment has had good luck, and causes admiration for virtue which remaining unknown has not been rewarded. In this sentiment rests the distinction between • good and evil, and makes us feel bound by an obligation in our own intelligence. In this is contained the principle of the natural harmony of virtue and of social happiness. Indeed, the idea of good and evil belongs to the order of truth, which morally does not admit demonstration. It is imposed on our intelligence, and with an absolute rigor appeals to our conscience. It- forms the law of our conduct, which we know as moral, or better as our duty. Everyone who has the idea of duty finds a moral satisfaction- connected with an act of virtue, and an internal joy when he has con- quered his passions. On the contrary, one who has fallen, who has violated the law of morality, and has succumbed to his passions, feels a secret mental suffering which comes from the conscience and is known as remorse. It is an agony, which can be considered as the SYPHILIS AND PUBLIC HEALTH 453 beginning of the expiation. This mental agony has often compelled criminals to denounce themselves so as to meet human justice. In the evasion of morality in our cases there are two motives, the satisfaction of lust and the venal gain. In the first they prefer pleasure to happiness, and sacrifice the future to the present. In the second, pleasure is reduced to calculation, the woman violates morality, sells her honor for the sake of money. The punishment is the direct consequence of their error, and the sexual diseases are often a severe punishment connected with the mental sufferings. In the human mind there is a natural wish for happiness which cannot be blotted out. The aim of the human mind is happiness, which in some exceptional cases on account of virtue may be denied. Hope, however, then takes place of the happiness denied, if it has not been consented to on account of virtue. But in general happiness and virtue are so intimately connected that they form an eternal harmony. The inculcation of religious principles, the idea of God as the only absolute infinite Good, the foundation of all human happiness, will elevate the morals of the young girls and strengthen their senti- ments with the idea of virtue, which is an emanation of God. The explanation and the inculcation of the duties of man toward ourselves, toward others, and toward God, will teach the foundations of morality. It is a natural law that man and woman must maintain their health and be developed according to the tendency of their nature. They must not obtund their sensibility, nor restrain their liberty, but all must be guided by their intelligence to keep the natural law. This will make them respect in others, and cause to have respected in them- selves, liberty, which is the principle of the morality of human actions. The social condition is the natural requisite of man and woman, who cannot live alone. This places upon man and woman the many duties of different orders of the social sphere, some concerning the family, some the nation, and others humanity. Social morality teaches to everyone respect for the rights of others, which means justice. The knowledge of God will maintain the morality of our children and the submission to his will will keep the generations moral. Another cause of prostitution is claimed to be laziness. The idea that woman has to be dependent on man is wrong. Man has to sup- port his family, but woman must not be entirely dependent and wait for the man to come and take charge of her. This was the condition of society in older times ; but to-day amongst enlightened nations woman has her employment and her occupations, so much so that she is no more dependent. In Europe, even amongst the working classes. 454 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS woman works like man, yet the work of the woman does not receive equal compensation. Female employees generally receive smaller salaries. From recent accounts it appears that the women who are working for their existence are four and one-half millions in France, five to six millions in Germany, five millions in Italy, one million in Belgium, over five millions in the United Kingdom and nearly five millions in the United States. Work, whether of a manual or of an intellectual kind, has a moralizing influence on woman which makes her feel free and independent. The idea of earning her own money, of paying her own expenses, makes her careful and saving, and gives her the re- sponsibility which is proper for human dignity. This is well under- stood in our United States, where woman is introduced into so many occupations, just as man. Wherever work is sovereign there the people are free, there morality and happiness dwell together, the race is strong, industry is developed, public wealth is abundant. Lib- erty and prosperity are inseparable companions, and they are obtained only by work, which constitutes human dignity. Jules Simon said that when a town builds factories there working people are abundant, and when a town distributes charities then beggars take their place. Liberty, work and prosperity are absolute companions and are so for everybody, for every family and for every nation. The female workers, however, have to struggle not only with the competition among themselves to obtain work which is of ex- clusive pertinence to woman, but also against men who are opposed to seeing women placed in industrial establishments. Male workmen object to female employees for fear that female work may have the effect of diminishing their wages. Another serious objection to female work is that woman while engaged in work cannot attend to her duties in the family. This is true to a certain extent, because not onlv girls and single women take up occupations in factories and shops, but married women also in order to try to increase the resources for the support of their children. In families with means the girls are usually given a fine education, and the boys after finishing their college term usually go out to enjoy Ufe. In many of these cases marriage is considered a simple con- ventional affair. The family is often disrupted, corruption sets in, and the children grow up good for nothing. The working girl when she finds her earnings insufficient, looks upon male protection as a necessity, and marriage is considered by them as a kind of refuge. Marriage, however, is regarded by young men with growing repulsion. Their idea is to shake off the respon- SYPHILIS AND PUBLIC HEALTH 455 sibility of the family, and their ideal life is the satisfaction of the brutal appetites. This condition of affairs makes it difficult for many girls to find a legal union, while on the other hand they are the object of solicitation by the man. Not all have a strong will to resist these suggestions, and thus many unwillingly accede to them, accepting concubinage in the hope of succeeding through fidelity and tenderness in having their situation legalized. L T nfortunately after some time just the reverse happens, they are forsaken, either because they have become mothers, or because they have aroused the dislike of their paramour. In this way poor women who would have been good mothers are by degrees led to prostitution. In the manufacturing cities of Europe young men after having lived with a woman for a while, abandon her and their children, and leave town to go to live with some other woman whom they will after a while abandon in the same way. These poor women, without support, easily accede to the suggestions of the first man who shows interest in their position, so they have a new lover and let themselves be carried down with the stream. The young men, on the other hand, imbued with the idea of delay- ing as much as possible their marriage, do not abstain from sexual relations, but from adolescence have learned to enjoy life, and as they say, make mashes. They boast among their companions of the num- ber of their good fortunes, without a thought that a seduction, followed by abandonment, makes a victim. Returning to the high social classes who can afford to send their girls to boarding schools, they find there only frivolous and insufficient education. All the sentiments developed are those of looking beautiful, the idea of the foyer, egotism, caprice, vanity. Nothing is substituted for a strong moral education, all is done for pleasure, and the girls are not prepared for the struggle of life in case of a reverse of fortune. In the working classes, unfortunately, very little is done to fortify their moral sense. Children are left in the street by their parents, to run all sorts of risks, where in company of larger boys, they learn things which ought not to be learned. Life in the tenement houses is another source of danger ; there parents and children live together, girls and boys find themselves in contact, often modesty is absent, and the imagination is polluted. In some families, unfortunately, drunken- ness and libertinage are found, either the father or the mother or both set a bad example to their children, and so the evil is multiplied. From the reports of the Juvenile Court of Cincinnati, in nearly every case of delinquent or of dependent children, the father was found to be a drunkard and the mother of questionable character. 456 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS In England there have been recognized as one of the causes of physical and moral detonation the overcrowding of population, bad air, unhealthful conditions of work, alcoholism, a tendency to leave rural districts and crowd into the cities, bad and insufficient food, parental ignorance and neglect of children. Children are quite often underfed and they are morally and physically badly developed. They cannot study and compete with others in the schools who are well nourished, they are a trouble to the teachers, and receive no benefit from the imparted instruction. In the shops and in the factories there is the same promiscuity which is lamented in tenement houses. The girl does not find there a place to fortify her moral sense, but she is constantly in danger on account of continuous temptations and easy occasions. They have occasion to see other companions better dressed, another displaying a gold watch which she has received from her fellow, and they have the desire to imitate the others so as to obtain better dresses or a gold watch. Cheap literature with alluring titles is easy to obtain. Some go to the beer house, to the balls, to the concert hall, and the others, too, want to go and have a good time. There they hear immodest songs, interpreted with doubtful and suggestive gestures, amid the applause of the public, and these poison and pervert the imagination of the young girls. Under these circumstances it is necessary to admire and con- gratulate those girls who remain virtuous in so difficult and hard a struggle for life. The greatest danger of the working girls comes mostly from their workingmen companions, who in seduction see only a simple matter of pleasure. In this class of society, where the instruc- tion is only rudimentary, the education nil, morality a simple conven- tionality, where the necessity of earning their living affords them great liberty, the virtue of woman runs a great risk. PROXENETISM AND PROCURESSES These pests of society use innumerable arts to attract poor, in- experienced girls into their nets and give them as victims to the infamous Minotaur. They are in attendance at every public place, rail- road depots, landings, wharves, public parks, coach offices. They pre- sent themselves as old respectable ladies to entrap innocent girls. On some occasions a respectable-looking woman shows herself interested in industrial work and offers a situation to girls, who, when allured, are introduced to her male customers. At other times the procuress is disguised as a mother of the family, who allows some free relations of her son with the girl. In some cases they advertise in the news- SYPHILIS AND PUBLIC HEALTH 457 papers to solicit girls for easy work at a good salary. Their purpose is to sell the newly acquired girl to her regular customers at a private sale, and when the first gloss is worn off, they cast them on the public market. It would take long to refer to all the different ways employed by those go-betweens in order to allure poor girls and make of them white slaves. There is no doubt that prostitution has been in the past, and is at the present, the result of the pretension of the man who wants to have the pleasure of life without the responsibility. He wants to enjoy. This is the preoccupation of that man. It is a brutal tendency, which has ruined the most precious lives. If we admit that woman is dependent upon man in a financial way, she is also dependent upon him from the sexual point of view. Renaud 25 wrote that woman seems to have been created essentially to satisfy the genesic needs of the male, and this is the predominant idea in marriage. For this reason woman in many cases tries to develop as much as possible the art of pleasing, of increasing her power to look beautiful so as soon to find a husband to support her in the struggle for life. Fallot said that anyone who asks a prostitute how it happened that she began her nefarious calling, will receive as a reply that she began her life as most of the girls do. Never did anybody tell them of the shame towards which they were going. An accident occurred in her life, an injustice which she thought she had received from her parents. or from a so-called friend, she was over-powered and everything, all good ideas, changed in her life. The same ideas were expressed by Commenge. 26 He does not believe that the simple sexual satisfaction and the need to have sexual intercourse with the man are the true causes of prostitution. We have asked this question of thousands of women, and only a very small number have admitted to having been led to prostitution through the generative passion which they needed to satisfy. Parent du Chatelet said that many girls are drifted to prostitution as a consequence of the loss of shame, which they could not explain and which can be considered as a mental alteration, which greatly diminishes their guilt in the eyes of the sociologist who studies their condition. Everyone who has had any occasion to study the life of the prostitute finds that in allowing the sexual act she does not consider it as pleasure, but as work. They are practicing a profession which has no attraction for them; it is. repulsive, but they continue in the trade for the simple reason that it gives them the prospect of gain 25 Renaud, Joseph. " La faillite du manage et l'union future." 26 Commenge. " La prostitution clandestine a Paris." 458 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS in a less troublesome and hard way than if they should make their living by working. In prostitution, as in any other business, there is the offer and the demand. When men try to avoid married life, they try to satisfy their sexual instinct with ephemeral relations. That is what makes prostitu- tion a nourishing business. Although we are in favor of a strict surveillance of prostitution from a sanitary point of view, yet we cannot disagree with others on the moral point of view, that licensing prostitution makes it considered as a necessary business in social life. Men in general are persuaded that by physiological laws they must satisfy their sexual activity just as they have to satisfy their hunger. Many married men are so imbued with this idea that in case of pregnancy or of illness of their wife, they resort to prostitution, fearing to remain in forced continence. Many young men find themselves weak in generative power on account of the sexual excesses and the diseases which they have con- tracted in their adolescence. Minot 27 severely criticises physicians who in this regard are not entirely strangers to the upholding of these shameful ideas amongst young men. Many physicians teach that chastity is harmful to the general health of young men, and often advise adolescents to have regular intercourse with women. The demand, therefore, is always on the increase and procuresses are mostly looking for very young girls, who are much more in demand, and also more easily caught. The explanation of this demand in reference to very young girls we leave to Augagneur. 28 The man who is on the lookout for good luck, craving ideals, whatever they may be in his conception, looks for a woman who does not belong to the vulgar prostitutes. If he cannot obtain anything outside of prostitution, he will then go among pros- titutes, and will always choose one who is very young. This is not only because the young girl is more inviting, but also on account of a sort of poetry which still remains in the beginner, and is entirely lost in the older prostitute. The more dissolute and older a man grows, the more attraction he finds in the young girl. Ambroise Tardieu, 29 in reference to at- tempts to rape, remarked that the age of the criminals is in an inverse proportion to the age of the victims. Old criminals, in the lubricity of their lewdness, make children or adolescents the victims of their dissoluteness. 27 Minot, H. "Prostitution des mineures." Conf. Intern. Bruxelles, 1902. 28 Augagneur. " La prostitution des filles mineurs." 29 Tardieu, A. " Etude medico-legale sur les attentats aux mceurs." SYPHILIS AND PUBLIC HEALTH 459 Minor girls are more easily taken. The usual education they receive is not a sufficient safeguard from these dangers. An adult woman who has experience knows the consequence of the act, can understand the difference of the social situation, is less feeble, less impressionable, and is able to resist seduction. SANITARY CONSEQUENCES The same reasons which carry minor girls to their ruin, soon make them the victims of venereal diseases. They are exposed to these diseases on account of their tender age, inexperience, carelessness and the multiplicity of sexual contacts with the first man they meet. In the same way, when diseased, they spread the diseases without any restriction. Commenge gave an accurate list of the affections which were found in minor girls arrested in Paris, between the period 1878 to 1887. MINORS VENEREAL YEAR ARRESTED DISEASED SYPHILIS AFFECTIONS SCABIES 1878 1200 438 189 269 16 1879 1086 394 246 157 26 1880 1792 614 428 242 50 l88l IIII 476 295 176 41 1882 140 1 581 386 202 52 1883 1449 479 301 176 35 ■ 1884 1391 438 265 184 19 1885 1232 487 227 280 19 1886 1065 416 172 237 32 1887 888 389 142 246 26 Total 12,615 4712 2651 2169 316 This table, although old, clearly shows that in the period of ten years, 1878 to 1887, 12,615 girls of an age between twelve and twenty- one were arrested in Paris on the charge of prostitution. Four thousand seven hundred and twelve of these girls had been found dis- eased, and 2651 were affected with syphilis, 56.26 per cent.; 2169 had other venereal affections, and 316 were affected with scabies. During the same period 14,392 girls over twenty-one years of age were arrested on the charge of prostitution, 3232 had been found dis- eased, 1777 had syphilis, 54.98 per cent. ; 1372 had other venereal affec- tions, 42.45 per cent., and 191 had scabies. , Of 7944 diseased girls of all ages arrested during the ten years, 2681 were servant girls, of whom 1375 were minors, and 1306 were over twenty-one years of age. Of the 1375 servant girls under age, 652 were affected with syphilis, 639 with venereal affections, and 84 had scabies. Of the 460 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS 1306 servant girls over twenty-one years of age, 70 had syphilis, 550 had venereal affections, and 55 had scabies. From these data, taken from Commenge's accurate work, we can infer that among the minor girls arrested by the police des moeurs in Paris, the proportion of the young girls found diseased is 37 per cent., while of those of age the proportion is 22 per cent. In reference to syphilis among 12,615 minors, there have been found 2651 or 21 per cent, affected with syphilis, while of those of age of 14,392, 1777 had shown manifestations of syphilis, or 12 per cent. This disease is about doubly as prevalent among minors as among those of age. Le Pileur, 30 physician of Saint Lazare from 1890 to 1899, found among 1963 diseased prostitutes 1011 affected with syphilis. Of the ion syphilitic girls he could follow the history of 718. Five hundred and nineteen had begun a life of shame at an age between thirteen and twenty years, while 199 had begun after reaching twenty-one years. Of the 718 women 69 had contracted syphilis before beginning the career of prostitution, some from their lovers and some from their husbands. Four hundred and eighty-nine had acquired syphilis in the year of their debut in prostitution, 101 in the second year, and 59 somewhat later. As a consequence, 91 per cent, of these women had contracted syphilis almost at the very beginning of their career as prostitutes. Of the ion affected with syphilis during the service of Pileur, 431 were registered in the Bureau des Moeurs as Mies soumises, and 40 as girls in the brothels. Amongst the 431 girls free, 318 had acquired syphilis before their registration, and 113 after registration; 247 had contracted syphilis between the age of twelve and twenty years. Of the 40 women in the brothels, 33 had contracted syphilis before their registration, and 7 afterwards ; 28 contracted syphilis between the age of fifteen and twenty, and 12 between age of twenty-one and twenty-eight. The statistics of Dr. Barthelemy, 31 also physician of Saint Lazare, show that of 417 prostitutes affected with syphilis in his service, 219 were minors. Jullien, also a physician of Saint Lazare, found among 1000 dis- eased girls, 823 clandestines and 177 Mies soumises. The age was from twelve to sixty-three years. Seventeen were between the age of twelve and fifteen, 24 at the age of sixteen, 527 between seventeen and twenty years, 289 between the age of twenty-one and twenty-six, 143 from twenty-seven years on. From his statistics it results : that among 1000 diseased women, 30 Le Pileur. Rapport a la Conference Intern, de Bruxelles. T. 1. 32 Barthelemy. Compte rendu des seances de la Conference de Bruxelles. T. 1. SYPHILIS AND PUBLIC HEALTH 461 56S were minors. Of 823 clandestine prostitutes, 340 were syphilitic, while of the 177 registered in the brothels, 81 were affected with syphilis. In reference to the age when syphilis was acquired, Jullien starts his calculation from the initial chancre. He found 123 chancres among his 1000 patients, of which 99 were among the clandestines, and 24 among the regularly registered prostitutes. He found 80 cases of hard chancre in minors, while 43 were in women above twenty-one years of age. Jullien derives the following conclusions : That the age when infection of syphilis mostly takes place is that of eighteen, somewhat less at the age of seventeen, and still less at the age of nineteen. It is of great interest to refer to a statistical table presented by Dr. Fournier, to the Congress of Brussels, which was taken from the city practice of Alfred Fournier, and from his hospital service of Hospital Saint Louis, Lourcine and du Midi. City practice — men io 3 ooo syphilitics 1432 minors City practice — women 1,000 syphilitics 313 minors Hospital practice — men 2,322 syphilitics 473 minors Hospital practice — women 2,949 syphilitics 1418 minors City practice was among people in good financial circumstances, while hospital practice was among the lower class of society, where there was lack of means. HIGH CLASS OF SOCIETY LOW CLASS OF SOCIETY MEN WOMEN MEN WOMEN First youth, 14 to 19 years Second youth, 20 to 29 years Maturity, 30 to 39 years Declining, 40 to 49 years Old age, 50 8 66 18 5 3 21 58 16 5 0.7 13-5 55- 20. 5- 5- 37-5 52.3 7- 2.6 0.6 Fournier from all these data tried to show that hospital patients are infected with syphilis somewhat earlier than city patients ; in other words, syphilis is earlier acquired by the common people than by the bourgeoisie. Among women of the common class of people, syphilitic infection takes place at from sixteen to twenty-three years of age ; after this age the infection is more frequent among the upper classes of society. Finally the proportion of minors infected with syphilis in the upper classes of society is 14.32 per cent, males, and 31.3 per cent, females; in the lower class, 20.37 P er cent - males, and 48 per cent, females. We have already seen the large proportion of prostitutes which is given of girls not of age in Russia, and the enormous number of them infected with syphilis. Sperk 32 refers to syphilitic women ad- mitted for treatment in Kalikinski Hospital in St. Petersburg, between 32 Sperk. " (Euvres completes." Vol. ii. 462 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS the years 1872 and 1875 ; 3104 women applied for treatment of venereal affections. These were all non-registered and requested admission of their own accord; of these 2165 were affected with syphilis, and 437 of the syphilitic girls were between the age of fifteen and twenty. Seven hundred and six non-registered girls had been sent from the office as diseased., and 403 were found infected with syphilis. One hundred and fourteen of them were between the age of fifteen and twenty. Of 835 registered prostitutes, but free, treated for syphilis, 398 were between the age of fifteen and twenty. Of 1261 girls, inmates of brothels, treated for syphilis, 696 were minors between fifteen and twenty years of age. Sperk's conclusion is that among non-registered prostitutes the average of syphilitic minors is 21.4 per cent., and for the registered prostitutes it is 50 per cent. The same conclusions were reached by Nicholsky, 33 who referred to the conditions of prostitution in Kieff. The girls practicing pros- titution are nearly all between sixteen and twenty-seven years of age. Among 495 prostitutes, of whom 192 were registered as free, 252 as residents in the brothels, and 51 as clandestines, he found that half of them were infected with syphilis at the age of nineteen, giving an average of 48.7 per cent. In 1842 Tait published the results of an inquiry into the causes and consequences of prostitution in' Edinburgh. He gave a statistical table, which he compiled from the clinical histories of the patients who had been treated for syphilis in the Lock Hospital in 1835. Of a round number of 1000 female patients, 42 were found to be less than fifteen years of age, and 662 were between fifteen and twenty, so that of the whole 1000, 704 were minors. Some interesting statistics were given by Le Pileur at the confer- ence of 1899. Among ion syphilitic girls under his service in Saint Lazare, from July, 1890, to June 30, 1899, he was able to obtain from 582 the age of their first intercourse and when they began their life of shame. AGE OF DEFLORATION AGE OF DEFLORATION Years 10 to 11 . 6 Years 18 to 19 67 " II tO 12 2 " 19 tO 20 38 " 12 tO 13 8 " 20 tO 21 24 " 13 to 14 . 24 " 21 tO 22 II 14 to 15 • So " 22 tO 23 II 15 to 16 . 142 a 23 to 24 3 16 to 17 . 106 " 24 to 25 1 17 to 18 . 86 te 25 to 26 3 Nicholsky, P. Remit ' de morale progressive, May, 1889. Quoi :. by Minod " Statistiqnes de la syphilis et du chancre mou parmi les prostituees inscrites de Kieff." SYPHILIS AND PUBLIC HEALTH 463 TIME ELAPSED BETWEEN DEFLORA- TIME ELAPSED BETWEEN DEFLORA- TION AND PROSTITUTION TION AND PROSTITUTION Less than one year . . 270 Six years ... 2 One year . . . 103 Seven years ... 12 Two years ... 86 Eight years ... 3 Three years • ■ ■ 33 Nine years ... 4 Four years . . .21 Ten years ... 7 Five years ... 22 Between 11 to 34 years . 15 This table clearly shows that the most dangerous age for the girls is that between fifteen and sixteen years ; indeed, it points out the fact that 373 girls out of the 528, sixty-four per cent become prosti- tutes in less than one year after their defloration. Le Pileur from these statistics concludes that the most dangerous period for a girl is between fifteen and seventeen years of age. Statistics of the same kind have been given by Martineau, 34 who fully agrees with those of Le Pileur. He finds, however, that the most dangerous age is between seventeen and eighteen years. The arguments are nevertheless very weak for reaching conclusions of any importance. Anyway, we can say that more than half of all prostitutes are minors at the time when they start in their life of shame, and being inexperienced soon become infected, and conse- quently they are the cause of spreading infection. PREVENTION AND COERCION The States and sociologists have had under consideration this social problem, and preventive and coercive rules have been already- adopted. In France since 1862 there was added to the penal code Art. 331, which severely punishes any attempt to violate a girl under thirteen years of age. After thirteen years the girl is protected against an attempt with violence, but she is left to herself, if she is violated with her consent. This is just at the most dangerous period of life, when the girl on account of her natural weakness has to be most protected. Childhood ought to be protected against its own inclinations and against libertinage. The young girl is often a desired prey and is often abused on account of her feebleness and ignorance. When she has fallen she lets herself go down the slope. In Paris especially there is found the administration of moeurs and instead of being helped she is plunged to the bottom. The girl is arrested and is kept in jail for six months on the ground of prevention. Parent du Chatelet justified this way of doing, and Reuss said that in the con- ditions of society the registration of minor girls is an absolute and in- exorable necessity. 34 Martineau. " La prostitution clandestine." 464 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS In this regard Mme. J. Leroy 35 beautifully said that the maison de correction ought rather to be called maison de corruption, since it supplies the criminal court and the penitentiaries with the toughest characters. It has been already judged as injurious and must be con- demned. The youngsters who are sentenced to the house of correction have lost hope ; they have no more illusions, they know that it is hell for them, and that they are lost forever. The convent, especially in countries of the Catholic faith, has not given any too good results. The Good Shepherd, the penitents, etc., with their monastic and repressive rules, have given results similar to those of the prison. Parent-DuChatelet praised the Bon Pasteur in Paris, saying it is not at all doubtful but. that the establishment is a useful one, and if it did not exist it would be necessary to create it. This asylum was established by benevolent ladies and it was until lately supported by an annual vote from the City of Paris, and an allowance from the hospitals. The institution admits prostitutes who desire to reform ; feeds, clothes and instructs them, provides them with places when they wish to leave, or with work when they remain in the estab- lishment. It does not admit prostitutes under eighteen years of age, nor over twenty-five. It seems that beyond this age every effort has proved fruitless. They claim that no compulsion is used by the man- agers, and the girls are free to leave as they are free to come. As long as they remain they must obey the rules of the institution, which are stern and strict. From the report of the institution, according to Saenger, it results that in the first twelve years twenty prostitutes each year were admitted. The mortality was found to be very high, so much so as to reach 20 per cent, of all girls admitted. In all twelve years 245 girls were admitted, of whom 40 were dismissed for insubordination, 2J left of their own accord and probably returned to their old calling and 15 were returned to the police. The remainder were either restored to their families or placed in situations, in hospitals or elsewhere. This remainder, however, is 163, which in twelve years gives 13 and a fraction per year. Indeed, thirteen prostitutes per year have been reformed, but this number in comparison with the enormous army of prostitutes in the city of Paris is only an insignificant item. Mme. Leroy is right in her statement, that the rules of the convent form a deplorable system, which is just as bad as that of the prison. The places, the surroundings, the rules, the kind of work, all is against the possibility of giving good results in the reform and in the educa- tion of the fallen girls. 35 Mme. J. Leroy. " Droits de l'Enfant." SYPHILIS AND PUBLIC HEALTH 465 JUVENILE COURTS Indeed, we feel very 7 well pleased with the system of the juvenile courts, as adopted in our American cities, and we are sure that these courts, when handled by capable men, will be of great advantage and will diminish the lamented evils. One of the best results of the establishment of juvenile courts has been that they have clearly established the causes which lead to juvenile delinquency and dependency. When society is no longer compelled to rely upon suppositions, but is armed with facts, it will not be difficult to restrain and diminish these evils and abuses. The juvenile court of Chicago has clearly established as a fact that juvenile delinquency and dependency, and also other social diseases, are due to parental ignorance, to parental neglect, to parental debauchery. In the first eleven months of existence of this court 1460 bad boys and 328 wayward girls were tried by the court. At the same time the judges had been asked to decide the future of 786 homeless boys and 641 neglected girls. The causes of dependency are shown by the records of said court as follows : CASES Lack of parental care . Drunkenness of father Drunkenness of mother Drunkenness of both Desertion by mother Desertion by father Desertion by both . Separation of parents Neglect by father Death of father Death of mother . Death of both parents Insanity of parents Poverty of parents Sickness of parents Incorrigibility Incorrigibility, preventable causes Incorrigibility, non-preventable causes GIRLS BOYS TOTAL l62 I48 310 85 75 l60 40 52 92 31 32 63 IS 14 29 51 96 147 10 15 25 9 7 16 8 5 13 30 53 83 41 32 73 24 4i 65 13 19 32 3 22 25 39 4i 80 5 3i 36 — — 465 — — 395 These data clearly show to what an extent parental neglect has to do with the future life of their offspring. The Juvenile Court was established in Cincinnati and Hamilton County on July 1, 1905. This court must not be used for criminal trials when avoidable. The institution of the juvenile court has re- moved the darkest blot from the pages of the history of the old criminal and police court. 466 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS It was indeed the most heartrending spectacle to see children, tender in years, indiscriminately mingled in the court with notorious characters and hardened criminals of all kinds, forced to listen to coarse accusations and testimony, subjected to the same procedure, and condemned or released upon the determination of guilt or inno- cence of a specifically charged crime in the same manner as adults. It very rarely occurred that a child ever came away from such a place repenting of the wrong he had done. Yet from the juvenile court, where the child is treated kindly and is shown the wrong of his action, he comes out with exalted feelings of hope and encouragement, with mind and heart full of new ideals to be and do something better than he or she had ever done or been before. There is no doubt that environment plays a great role in shaping the desires and ideals of individuals. Environment, influences for good or for evil, are great factors in children before their will and power of discrimination are fully developed. For this reason, in order to preserve and develop the good faculties in children, it is necessary to remove from them whatever has a tendency to degrade. The special court room for young folks, separate from all others, secures privacy, which is so desirable for the hearing of their cases, since it does not crowd them into the regular court rooms. In this court every possible fact, material or personal, connected in any way with the present or past history of the boy or girl is fully considered. The personal history of the young person recited by himself is very significant and reveals his real life, and the conditions and elements which have shaped it. This preliminary work requires patience, tact, keenness of observation, and power of discrimination, and above all the ability to obtain the confidence of the young people. The investigation discloses the circumstances which are connected with the alleged delinquency or dependency of the boy or girl, the con- ditions of their homes, their school records, the quality of the neighbor- hood, the environment, the habits and character of their parents or relatives, their religion, creed, occupation, etc. The most of the minors who are taken before the court are accompanied by their mothers, who usually belong to the lower classes of society, representing that element upon which the evils of our social organization bears most heavily. The results of the sins of men and women are brought to light, and the saddest consequence is to see the young, who are in no way responsible, suffer. The judge who at present presides over this court is one of the most eminent jurists of Hamilton County, Honorable John A. Caldwell. He does not sit on a high bench, clothed in a long robe and look stern SYPHILIS AND PUBLIC HEALTH 467 and severe, but on the contrary he is an everyday sort of a man, merry and cheerful., with a smile spreading over his countenance. With his kind, gracious and sympathetic manner, he takes a personal interest in every case, exercises rather the power of love than that of fear, and thus gains the confidence of the poor unfortunate children. The influence of the juvenile court has been felt in many homes where more than one lad and lassie has been guided away from en- vironments that threatened to precipitate them into the abyss of crime and social ostracism. The study of the special cases offers a field of great sociological interest and promises great benefit for our future generations. In one family the parents were separated. The father was a drunkard, of weak character. The mother was of questionable character. She had two girls, who were following the example of their mother; the judge committed the two girls to the house of a married sister, maintaining them under surveillance. In the case of a colored family the parents were separated. The father was a good, hard-working man, the mother, rather young and pretty, was frivolous and was living in a house of ill fame, together with her children. The children were taken away from her and com- mitted to an aunt. In another family the parents were also separated ; The father was blind ; the mother, a woman of low grade, was living with another man, and used a fifteen year old daughter for immoral purposes. The daughter was taken away from her and committed to the house of refuge. It would be a long task to bring before the reader all the sad and dolorous conditions of the families which are the preparatory ground for leading girls in the path of prostitution. In many cases the parents have been separated or divorced ; in many cases they have been living together, but they have been of a vicious and immoral disposition, and their children with both parents living have to call their father a drunkard and a deserter and their mother a prostitute. From the comparative study of the age of the children, it appears that from the age of ten to fifteen years is the most dangerous period for delinquency. In reference to immorality it can be said that many girls scarcely reaching the age of fifteen have been used and placed in the way of prostitution by their own debased and denaturalized parents. In reference to the crimes with which these small delinquents were charged, we will examine the report of the month of May, 1906. Delinquents! BoyS ? 6 1 Girls 17 93 468 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS Incorrigibility .......... 22 Destruction of property ........ 8 Petit larceny .......... 6 Jumping cars .......... 2 Forgery .......... 1 Immorality .......... 10 Arson ............ 1 Truancy ........... 34 t^ , . ( Boys 26 Dependents ■{ I Girls 21 Improper homes 34 Homeless .......... 13 We must add that the juvenile court is a child-saving institution, which in co-operation with other institutions, and especially with the citizens, will successfully correct wrong tendencies of the delinquent youngsters, and remedy the evils which beset the life of the neglected and of the dependents. Before a juvenile is brought before the court a petition must be filed or a complaint has to be made to the prosecuting attorney of said court, and a time will be set for the hearing of the case. The juvenile must not be brought into court until the day set for the hearing of the case, and when a juvenile is taken into custody by an officer, he or she must be placed in the Children's Home, House of Detention or other suitable place, until a petition has been filed and a day set for the hearing of the case. The officer or other person, when a petition or complaint is filed, must be prepared to furnish the following information : 1. Xame of the juvenile. 2. The age of the juvenile, and if possible the day and month of birth. 3. A brief synopsis of the facts in the case. 4. The name and address of the person having custody of the juvenile. 5. Name and address of the father or mother ; if he or she has no father, or in case he or she has no parents, or they are unknown, then the name and address of the guardian, or of some relative of the juvenile. The names and address of one or two witnesses to the facts, when it is deemed necessary. When a juvenile is committed to a public or other institution, the officer to whom the commitment is issued must obtain the receipt of the superintendent or other chief officer of the institution, to which he or she is delivered, and must also make return of the commitment to the court. SYPHILIS AND PUBLIC HEALTH 469 The cases which are brought to the attention of the court are incredible, and much interest is aroused among the public. A charitable woman reported that a girl of sixteen had left her mother because of her evil, reputation, but was faced with drifting into a life on the streets. The girl after leaving home had obtained work, and boarded in a house. She lost her position, and had been told to leave her boarding house because of lack of funds to pay. Not being able to secure work, and being friendless, the street and its shameful life stared her in the face. The case was reported to the officers of the court. Occupation was found in an institution and then in a private house. Many cases of cadetism have been investigated. Three girls be- tween iourteen and sixteen had been enticed by a woman to her house, where she introduced them to men. Another object of this court is to place children who have no proper home in such surroundings as will most nearly approach a proper home. Indeed, the ideal place is the home itself. A home in the real sense of the word cannot be created by legislation, and the House of Refuge and other institutions are merely the best possible substitutes. The large number of children placed there make it lose the idea of a true home. The value of these institutions is in inverse ratio to the number of children placed there. In consequence when the erring girls can be placed in a good private house and there can be given them the idea of the home life, it is the greatest benefit that can be done to them. Miss Emma Woolley Utz, who is a Deputy Probation Officer of the Juvenile Court, asserted that children are seldom bad because they are born with evil in their hearts. In almost all cases which had come before the Juvenile Court the little ones have been forced into wrong directions on account of the conditions in which they were living, which seemed purposely arranged to conceal from them the right path. In nine cases out of ten the home environments, which should be the best and the purest, were the vilest and the most unwholesome of all. Bad food and bad clothing make the poor boys and poor girls weak in both body and mind. If they go to school, they cannot compete with the others, who are well fed and well cared for. The mothers have no idea of cooking, and if they attempt to prepare something it is unfit to eat. Many families live on the rotten vegetables which are thrown aw r ay in the dumps by the commission merchants. With such scanty and unwholesome food beer is given in plenty, even to infants, and is considered as nourishment. In some families beer is given in the place of coffee in the morning', and children go to school under the influence of beer and fall asleep at their work. 470 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS In the first year, from July, 1904, to January, 1905, the Juvenile Court of Cincinnati took care of 582. In the second year 1241 children were legally before the court, of whom 888 were bovs and 353 were girls. Sixty cases were dismissed; new homes were found for 75 of the children; 9 were boarded in good houses, the father or mother paying for their maintenance ; 430 were sent to institutions, the ma- jority because of dependency; 582 were released on probation, or on their good behavior, the probation officers being either detailed to look after them, or they being instructed to report weekly to the court. Of the 582 released on probation, Judge Caldwell stated that not two per cent, have had to be returned to the court on account of other misdeeds. There were 73 cases of children neglected by their parents, who were allowed to return to their homes, their parents being placed on probation and compelled to care for them properly. Besides this large number of children cared for officially, some 300 other children were looked after, who were never legally before the court. A certain number of young girls charged with immorality were examined by the physician and nearly all were found affected with some venereal ailment. They were sent to the Hospital and when cured were com- mitted to the House of Refuge or to some other institution. Children are no longer locked into jails or police stations with criminals. They are temporarily guarded in the house of detention, where they are looked after by women. In a short time this court will have a place of detention of its own, where children will be guarded by the officers of this court. Indeed, it is between the age of ten and seventeen when the best and most lasting impressions are implanted in children. Therefore it is of great importance not only for the future of the child, but also for the good of the state, that methods be adopted to preserve and develop whatever is best in these children. This court has full juris- diction over all dependent, delinquent and neglected children under the age of seventeen. It takes this jurisdiction away from the justice of peace, mayors of villages and police courts. It has not only the right to care for and punish children but to enforce the parental responsi- bility as well, and punishes all those encouraging and causing de- linquency in children by fine and imprisonment. The children who come under the care of the juvenile court are so treated that no possible stigma may remain on them in later years. While complete records of each case are kept, yet the trials are held in strict privacy, and by law the records of this court cannot be used in anv other court against the child. It is not a criminal court, but a court of equity. It is the aim of this court that the noble heart and SYPHILIS AND PUBLIC HEALTH 471 the humane tendencies, which are found in every boy and girl, shall be encouraged, that with them a good character may be built up. In the cases of delinquency, the aim is reformation and regeneration, which in many cases is obtained. The efforts of this humane institution have in many cases rescued childhood from squalor and the shadow of sin, from poverty and physical diseases, from misfortune and the grinding of misery, and taken those poor unfortunates who would have succumbed as victims of vice and crime to the healing atmosphere of wholesome environ- ments and kindly sympathy, and have thus changed entirely the path of their lives. In the by-ways are found the poor unfortunate youths wandering away into crime, and from there they are led to the high- ways of uprightness. Those poor boys and girls so rescued have a chance to grow into a manhood and womanhood that is not a menace to the community and a shame to themselves. It saves the helpless children from suffering, brings the vicious to virtue, and so restores to moral, mental and physical health those poor unfortunates upon whom especially venereal diseases and syphilis are preying. We have dwelt somewhat long on the mission of the juvenile court, not because it is a home institution, but because we expect from it a great advantage for the future generations. We would like to extend the jurisdiction of the court to all persons under eighteen years, and then we should see very little of the prostitution of minors. We hope that this system of juvenile courts will be adopted in every country, and the benefit will soon be found out. In France, for instance, there is the paternal correction. The father takes his incorrigible son before the judge so as to obtain a punishment for him. It is one month of detention in the house of correction for boys or girls less than fifteen years, and six months for youngsters between fifteen and twenty-one years. The judge commits the boy or the girl to the house of correction, and according to the condition of the family the parents have to pay the expenses, or in case of poverty they are sent free of charge. It is easily understood that very few will send their children to be committed with others by the court, leave them in a society of boys or girls much more corrupted, for the result would be the complete ruin of the young, together with the stigma of the commitment by the court. Professional schools, convents, etc., have had so far no better results. Mme. Leroy calls attention to the fact that the so-called fillcs repenties in France cannot find any occupation except amongst religious orders. Although the church has not been more successful than the government, yet we can say that it has been prompted by 472 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS a charitable motive. It has at least tried to do something- for lost girls, at the time when society offered to these unfortunate victims of the brutality of man nothing but a scornful repulsion. In Germany the age of protection is up to fourteen years, whereby a special punishment is inflicted on those who procure an attempt on their children or on minors placed under their guardianship. Art. 181, 182. Seduction of a virtuous girl is punished with imprisonment up to sixteen years. The Prussian law of 1878 tried correctional education for aban- boned children from six to twelve years, who were delinquent and could not be prosecuted on account of their extreme youth. Such a law had only a repressive purpose, and no moral or educational pur- pose. It was replaced July 2, 1900, with the object, not of punishment, but of reform. This law now concerns minors under twenty-one years and takes care of all children morally abandoned, and principally of those who refuse to heed the authority of their parents, or of those who remain in the society of dangerous and licentious people. On May 27 the Minister of the Interior sent a circular to the presidents of the judicial districts concerning the prostitutes of minor age. When a girl under eighteen years abandons herself to professional vice, either subject to the control of the police des moeurs, or in con- dition to be placed under surveillance, the authorities are required in the sense of this law on the tutelar education of minors, to apply this law. The rules of the police des moeurs are to be applied only to those to whom the court has refused the tutelar education, and when the appeal to the last decision has been refused. In Germany the number of these poor fallen girls is quite con- siderable and is under the direction of the pastors of the different congregations. In England the limit of protection for a girl is sixteen years, and much heavier punishment is given the betrayer if the victim of the attempt is under thirteen. Whoever makes an attempt on a girl under sixteen years is punished, and the proof that the girl was already cor- rupted does not diminish his guilt. The law not only punishes those who commit violence or attempt to do so on minors less than sixteen, but also those who allow, or abet, the perpetration of the outrage in their houses, or in places of their purtenance. If a young girl between thirteen and sixteen years is taken into a house of prostitution, or into any other place for immoral purposes, although with her own consent,, the proprietor, the owner, or the guardian is punishable with imprison- ment with hard labor. If the girl is over sixteen and less than eighteen", she is not protected, unless she has been taken from her parents or guardian without their consent. If taken against their consent, the SYPHILIS AND PUBLIC HEALTH 473 procuress, or the proxenet who has caused the ruin of the girl less than twenty-one, is severely punished. In regard to the action to be taken against young prostitutes, the English rules have a peculiar character. The intervention of the gov- ernment is combined with that of private interests, or better, the govern- ment helps private initiative. A large number of powerful philanthropic associations are organized for the needs. These associations in France are in the hands of the government ; in England they are active through the union and the free action of their citizens with an executive power. Minod says that the result is that in France with the repressive rules of the police the criminality of minors increases, while in Eng- land it decreases. This is a great argument for maintaining the super- iority of the English organization for the repression and prevention of vice among children. INDUSTRIAL SCHOOLS Since 1866 an act of the English Parliament authorized any person to bring before a judge or before a magistrate, any boy or girl under fourteen years who had been found begging or a vagabond in the streets, or if found in company with suspicious characters. An amend- ment to this act was adopted in 1880, extending the same disposition to children found lodging, living or residing with common notorious prostitutes, or in a house harboring lewd women, or kept for immoral purposes, and also children found in the company of prostitutes. In 1889 a new amendment made this same act applicable to chil- dren living w T ith one prostitute, or in a house frequented by a prostitute for immoral purposes. Under this law, by private charity and initiative, a great amount of work of preservation and of rescue has been accomplished. Indus- trial schools, reformatories, houses of refuge have been instituted by private initiative. The government has only given its authority and support to the institutions. The government leaves to the directors of the institutions full liberty in their administration, allowing them to choose their own officers and employees. They have legal power to keep children committed to their care, and the government allows sub- ventions with right of control. In England the institution of these establishments for prevention and reform was not until 1854, and now there is no city in England which has not its industrial school, its school of reform, or its house of refuge. The industrial schools take children who are not delinquent, but only dependent, and who, left to themselves, on account of improper homes would be started on a dangerous route. The school of reform 474 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS has some similarity to the French maison de correction; here are com- mitted delinquent children, and under good rules they try to reform. The houses of refuge are nearly the same as industrial schools, but they have no subsidy from the government, and are kept by private charity alone. The work of rescue, reform and prevention has a center in a general society, which has the control of all like institutions, and helps those deficient in means, and tries to obtain the foundation of others. It is the union of the reformatory schools and houses of refuge, which has its seat in London. Every two or three years they hold a general meeting for the purpose of studying improvements to be introduced in the struggle against vice. They have a monthly bulletin with the title of " Seeking and Saving." The union comprehends 666 institu- tions of prevention or reform under their supervision. For that which concerns the reform and rehabilitation of the young prostitutes in England, there are a large number of institutions on the same principles as the others, under the name of the Rescue Society, which has under its surveillance many hundreds of young girls kept in different institutions. It has been found that large institutions, with their routine of administration, with a large number of girls, have rather a tendency to estrange them, and remove from them the affection for the family life. For this reason in England they are trying to establish small institu- tions, to take girls in small numbers, so that their school shall more closely resemble family life. In the United States we are trying now to place the houses of refuge, the reform farms, etc., on the cottage system, so that only a limited number of boys or girls are, like in one family, under the direction of a teacher or of a matron. Prevention is the object, and the most useful institutions are those which help unhappy and unfortunate girls in danger of being lost, which give them instruction and education, and so furnish them the means to procure work, and with their honest work to earn their living. Indeed, in order to diminish the evil of prostitution, we must begin by stopping the minors, and bring them to the right path of life by just and friendly means. In France, in 1892, the committee for the defense of children brought to justice established that: It is neces- sary to consider as vagabonds minors of sixteen years who have left, without consent or without excusable cause, the house of their parents and guardians, or the educational institutions where they had been placed by the authorities to whom they had been trusted when found wandering about, or in lodging houses without any regular occupation, or getting their resources from debauchery or forbidden professions. SYPHILIS AND PUBLIC HEALTH 475 In the following year the Court of Paris decided that a minor girl less than sixteen should not obtain her means of living from public prostitution, and her corruption should not exempt her from the obliga- tion to have a home and to do some work. Having placed prostitution together with vagabondage, it succeeded in having girls less than six- teen arrested and committed to the house of correction or to any rescue home. It is interesting to refer to a study of Marc Reville, a lawyer of the Court of Appeals of Paris, on the prostitution of minors according to the penal law. He said : Prostitution is a free act, which cannot be restrained but by the respect for liberty or for the existence of others. A woman has the right to dispose of her body just as she likes, but she must have full knowledge of what she is doing, and of the consequences. For this reason prostitution in a strict sense has no dependence on the penal law, but it can and must be prevented and suppressed among the minors, who must be protected on account of their inexperience in the matter of morality and of civil capacity. Law and private initiative have to go together, and the important question is to oppose poverty and proxenetism. Societies of patronage for poor girls are of great assistance. The government can only repress, and it remains for private initiative to bring to justice pro- curesses and all who are recruiting young victims. The girls who are willing to return to their families have to go back to them, if the latter can assure honorability and sufficient financial means to protect the young fallen. Best of all is the commitment of the girl by the juvenile court to the different institutions, where they can be educated and instructed. The society of patronage has to look after the girl dur- ing her education, and when she has given evidence of reform, it then finds the way for her to return to honorable life. It is better for girls, when they behave themselves, to be placed in some other institu- tion of less austere rules, and finally to give them to families, so as to have them used to family life. The girls have to look to the society as their friend and to consider it their resort in case of necessity. When the society for the abolition of the surveillance of prostitu- tion was agitating the question of suppressing the police des moeurs before the Municipal Council of Paris, Mme. Emilie de Morsier re- marked that the question of minors ought to be considered first by the Council. Indeed, female minors are more directly and more un- justly persecuted by the police, and for such the responsibility of society and of the state is much more serious. According to Lecour more than 120 minor girls have been registered as prostitutes even- year in Paris. Those poor girls, placed in unfortunate conditions, sur- 476 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS rounded by bad examples, are too weak to resist privations. They give way to the temptations, and once they have fallen into the fatal pit, they find the police, representatives of the government, push- ing them on downward. The fatal struggle begins between the police and the poor woman, who mad with the terror of losing her liberty, seeks to conceal herself; the end is the physical and moral death of the victim. From all these considerations it was decided that prostitution of minors of both sexes up to eighteen years, even though not habitual, should be assimilated with vagabondage. That prostitutes of minor age have to be allowed special proceedings before the committee, which orders that the court, in the interest of the child, returns the child to his or her parents, if they can give proof of morality. Otherwise the girl or boy shall be committed to an industrial school, or to a cor- rectional house until the age of twenty-one. The parents when found unworthy and negligent towards their children are made responsible in all or in part for the expenses of guardianship and the education of their children committed to state institutions. In our judgment the juvenile court which has been instituted in many American cities covers the ground much better, and insures better results in the reform and education of delinquent and of depend- ent children. A minor is a person who before the law is considered to have not yet enough power of reasoning and of discernment. This power of judgment is necessary to govern ourselves in order to make legal all acts concerning civil life. Consequently, if a minor is forbidden to sign documents, he is not even to be allowed to dispose of his own person. Minors must be protected by the state, and in the same way as they are not allowed to administer their properties, which they could lose on account of inexperience, they must be protected in regard to their person against seduction. The punishment applied in different degrees is considered by Mile, de Miilinen as a good preventive for crimes against morality among minors. The division of the ages would furnish the degree of the crime, considering childhood until twelve years, adolescence from twelve to sixteen, and then from sixteen to majority. A violence committed on children ought to be made a capital crime; on adolescents a crime; on girls near majority, it would come under the cases of violence. Dr. Fiaux would consider the infection of a minor with syphilis a crime. At the same time punishment must be insisted upon for any- one who has not only attempted to corrupt a minor girl, but also for anyone who will excite, abet and favor the corruption of the young of both sexes. SYPHILIS AND PUBLIC HEALTH 477 This, however, leaves entirely untouched those who keep brothels and houses of prostitution where are harbored adult prostitutes. Here we find ourselves in the presence of the much discussed and difficult question, surveillance of prostitution, or abolition of all rules. It is true that so long as the markets are open, the merchandise will be always in demand. The governments fix rules, license prostitution, and consequently prostitution and proxenetism must flourish. The aboli- tionists consider the regulation of prostitution as establishing a social profession of the procuresses. The young prostitutes find in the pro- curess their support and their protection, not only from the dangers connected with this profession, but especially against the police. Any system authorizing, recognizing or licensing prostitution is repudiated by the abolitionists, and they want it suppressed. Indeed, they do not care to suppress the system of surveillance on account of its purpose, but for the more important question, whether, in reference to the public hygiene, free prostitution, or licensed prostitution is better. The abolitionists consider the rules of surveillance of prosti- tution entirely insufficient for the purpose. Furthermore, they attack the principle of licensing as false and immoral, because it is based on the wrong idea that prostitution is a necessary evil. That prostitution is an evil is admitted by everybody, even by those who enjoy it. From the fact of the existence of prostitution there cannot be made a good reason to legalize its exercise, and recognize it as of public utility. They rightly maintain that licensing prostitution is a cause of demoralization. It is a disgrace for a man to obtain women who sell themselves or are placed at his disposal by the public authorities, and with whom the commerce is entirely free from any responsibility for the man. Where there is no responsibility, there is no morality, and morality and liberty are the essential conditions of responsibility. The system of licensing prostitution takes liberty from the woman, and all the responsibility from the man. When the woman gives herself for money, she commits a horrible crime, for which she is placed beyond the protection of the law ; the man who pays the woman to satisfy his carnal appetite, attends only to a natural act, which is granted to him by the law, and moreover, the state guarantees also the quality of the goods. Indeed, it seems that morals are only for one sex. The morality of woman is one thing, and quite another is the morality for the man, and these principles are upheld by the rules of the government. There is no doubt that the state cannot diminish the carnal appetite, the sexual passions, which the abolitionists believe to be in- creased by the licensing of prostitution. We, too, agree with them, that the best way to combat the evil of prostitution is the moral prin- 478 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS ciples, the dignity of the man, and the respect of the woman. But these moral rules are based on instruction and on education, and will only be practiced by the smaller part of society, which consists of those who can obtain a liberal education. Rules of the police, which have for their result the plunging of the woman into the abject state of prostitution and keeping her there, should be abolished. In many cases, if the woman had been left free she would have found her way to reform, and rescue herself, which has been precluded by the arrogance of the police agents. While the police persecutes the girls, yet they protect and support the houses of prostitution, and this conditions of affairs is the reason why the girls look to the procuresses for their patronage and protection. Very often the police agents take arbitrary powers, violate all principles of legislation, and entirely disregard personal liberty. Al- though we look upon a good regulation of prostitution with in- terest, and consider it of public good, yet we severely condemn the extreme measures which touch upon persecution. According to the German Strafrechts reform, as referred to by Neisser, prostitution can be punished. It is considered a professional debauchery. The way of living of the prostitute is against morality and is condemned by the public opinion as a dishonor. It has a bad influence on young people, among whom it destroys the inclination for family life and leads them to roughness and prodigality. The woman who practices prostitution, although she had in the beginning some moral sense, has lost every feeling, and undergoes a physical and moral degeneration. She is unwilling to give herself up to any work, loses every moral sense, loses her memory, what she says has no sense, and she often lies, just for the pleasure of lying. Step by step she constantly descends, from the house of prostitution to the jail, from the jail to the hospital, and back again, until she is a wreck and a charge upon public charities. If we do not consider prostitution as a crime in itself, yet we must see in it the beginning of a criminal life. They are rejected by society and find easy association with criminals, whom they help and abet in their nefarious enterprises. For these reasons, if prostitution cannot be punished as a crime, it has nevertheless to be combated as profes- sional prostitution, in the view to morality and in the interest of society. If also prostitution could be punished, the result would be of no bene- fit. As Liszt 36 said, it is necessary to study the origin of the crime, which is rooted in the social conditions. The punishment strikes the individual alone, but does not change the social conditions, and as a consequence it is only of secondary importance in its influence on the criminality, causing neither increase nor diminution. 36 Liszt. " Bekampfung des Verbrechens." SYPHILIS AND PUBLIC HEALTH 479 From all these considerations we can say, that with the best will, the state, legislation, society, by means of punishment, of ostracism, will- not be able to chang'e the conditions of this social evil. With edu- cation and with moral inculcations only a small number of the best class of people will be reached, and yet the venereal diseases, and especially syphilis, will continue to spread without any restraint. The teaching of the venereal peril as advocated by Valentine will be of some benefit for a few thoughtful ones who consider the sad conse- quences for their future life from the illicit gratification of the sensual appetite. Even* means which can check the spreading of the venereal dis- eases, and especially syphilis, must be employed with all energy possible in order to succeed in stamping out so dangerous a scourge of society. If we turn now to consider as physicians the venereal diseases, we will see that gonorrhea, chancroids and syphilis are eminently contagious. As contagious diseases they must be treated and those infected must be compelled to subject themselves to a good scientific treatment, and in the same way the infected have to be isolated so long as there is danger of spreading infection. For this reason, setting aside the question of morality, we will see that a well-regulated system of surveillance of prostitution will have and has a very good effect, not only as a preventive means against the spreading of infection, but also as beneficial for the unfortunate girls, who, when infected, are compelled to undergo a good treatment and save themselves from the ravages of neglected syphilis. IV THE REGULATION OF PROSTITUTION IN THE PUBLIC PROPHYLAXIS OF SYPHILIS The statement, so often repeated, that the regulation of prostitu- tion is an implicit forbearance of the authorities, even a legalization of the crime, although true in an abstract way, does not, nevertheless, bear any weight when the health of the public is at stake. The idea alone that prostitution is to woman what crime is to man, calls for the necessity of a police surveillance. The same physical and moral char- acteristics are found in the prostitutes as in the delinquents, and every- body knows the relations and the sympathy which exist between these two classes. Yet like crime, prostitution has existed from the remotest times of society, and has always been subject to some form of regulation. Prostitution, to use the words of Sanger, 1 is coeval with society. In every age there have been men who, opposed to the marriage ties, and craving for lust, have created a demand for illegitimate pleasures. The weakness of the woman excited by passion, together with the idea of gain, has made it possible. In fact prostitution is found to shade with its dark colors the re- motest mythological figures. It can be traced, as Sanger said, from the earliest twilight in which history dawns to the clear daylight of our days, without pause or a moment of obscurity. In Biblical history, prostitution appears as an existing fact. The legend of Tamar, who covered her face and, wrapped in a veil, sat in an open place . . . and Judah took her for a harlot because she had covered her face, shows that prostitutes covering their faces were rather common in those times. From the books of Moses it is clearly shown that prostitution was common among the Jews, whose morals had been badly influenced by their sojourn in Egypt. Moses with his great wisdom and sagacity established strict and inflexible laws to check prostitution, and punished adultery and rape with death. He formally commanded, " Do not prostitute thy daughter, lest the land fall to whoredom. . . . There shall be no whore of the daughters of Israel." He tried to check the progress of venereal diseases among both 1 Sanger. " The History of Prostitution." New York, 1899- 480 THE REGULATION OF PROSTITUTION 481 sexes, and in Leviticus forbade sexual intercourse and all associations with persons afflicted with flow from the genitals, which was without doubt what we call gonorrhea. Although Moses had given such earnest laws in order to eradicate evil customs from his people, yet male Jews went to have intercourse with foreign prostitutes — Syrians, Moabites, Midianites, who were neighbors of the Jews. Some of those women, debauched and led by vicious tendencies, had invaded the land of Israel. To them, however, was forbidden, until the time of Solomon, admission into Jerusalem and into the large cities. Those prostitutes, driven to the highways, lived in tents, pretending to exercise the trade of peddlers, while they followed the calling of harlots. Moses pursued a policy of tolerance so long as the practice of those prostitutes did not offend the laws of nature. When he found that they were inviting young Jews to participate in the revolting worship of Baal, then the ire of the legislator rose and he set up severe punishment, not only on moral and religious, but also on hygienic grounds. His wise laws were followed and inculcated by Aaron and his successors. An express command forbade the establishment of groves near the Jewish temples, in order to avoid shady retreats, which might afford possible convenience to prostitutes. Solomon, who with his wisdom associated a great tendency for sensuality, repealed the just restrictions of his predecessors in regard to prostitutes, and allowed them to practice their calling even within the city of Jerusalem. History says that the prostitutes then multiplied so fast that they were wandering on the hills committing obscene acts under the trees, and they were even seen in the temple and in its courts. That sacred edifice at the time of the Maccabees had been changed into a brothel where meretrices were swarming. Prostitution was exercised in Judea in spite of the severe ordi- nances, and from an early period never lost its foothold, so much so that the prostitutes were recognized as a class, although stamped with the ban of shame. In these conditions, the best that could be done was to set forth restrictive measures in order to protect the health of the masses. The old Egyptians, according to Herodotus, had lax and ludicrous customs. Their deities, Isis and Osiris, as types of the sexes, made their religion very suggestive. In Chaldea their religion enforced pros- titution, and every Babylonian female was compelled to sacrifice herself in the temple of Venus Mylitta. Among the early Phenicians, obscene festivities were dedicated to the deity Astarte, and among Persians to Mithra, with the same voluptuous and obscene rites. The first attempt to regulate prostitution was made amongst the old Greeks, when Solon formally established houses of prostitution 482 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS in Athens, which were filled with female slaves. They were bought with public money and were kept there to satisfy male visitors. The money gained in these houses was the property of the state, and a temple was built to Venus, the courtesan, with the funds proceeding from the infamous trade. The persons who kept houses of ill repute, so-called Dicteriades, were kept apart from the Athenian women of repute, and when in the street had to wear a special dress as a stamp of infamy. They had lost all rights of citizenship, and if a procurer or a procuress had been the cause of introducing into the Dicterion a free-born Athenian girl, death was the penalty. The law branded prostitutes and their accomplices with infamy, and their children were bastards and were forbidden to inherit. They could not associate with other youths, and could not acquire the rights of citizenship unless they had performed an act of bravery. Laws governing prostitution are found among Romans dating from the time of Emperor Augustus. The prostitutes were required to register themselves in the office of the sedile. They had to go per- sonally to the aedile, give their age, place of birth, their real name and the name they intended to assume in their shameless career. The sedile tried his best to recall the misled woman to the path of righteous- ness, but failing in it he issued her the license, licentia stupri, ascer- tained the sum she was to ask of her customers, and entered her name on the list. The prostitute once inscribed had incurred the stamp of infamy, and no repentance, no marriage, nothing could wipe it away. In those times, too, there were clandestine prostitutes, who were not registered and who were called prostibulce. The aedile was com- pelled by law to arrest, punish and drive out of the city all unlisted prostitutes, but it was never done. Although the habits of the old Romans were rather luxurious, yet a married man who visited a house of ill fame was an adulterer and liable to the penalties of adultery. A frequenter of such places was called a moechus or a scortator as a rebuke. It was well known at that time that secret diseases were arising from sexual intercourse with prostitutes, and Juvenal and Martial allude to some disgusting diseases, which resembled syphilis. Celsus described diseases of the generative organ as the result of venereal intercourse. The idea of a woman affected with secret diseases made her despicable, and she was called aucunnuenta, and had to pray Juno Fluonia for relief. As a remedy an herb was given called in Greek Bonbomion, which was converted by the Romans into the name of Bubonion, and was then applied to a disease, which modern science still calls bubo. It was said of a diseased woman " haec te imbubinat." 2 2 Scaliger. Quoted by Sanger, p. 85, 1. c. THE REGULATION OF PROSTITUTION 483 Diseases of a secret nature contracted by illicit intercourse were called morbi indeccntcs, and Roman physicians declined to treat this kinds of ailments. Anyone who was afflicted with these diseases was restrained by shame from confessing his secret, and when discovered, was driven to seclusion. Under Nero a public physician was appointed as archiater, which position was filled by Andromachus for the em- peror's person, and others were appointed to attend the people called archiatri populares, who in consideration of their privileges were bound to treat the poor free of charge. Many of the diseases which they had to treat could be traced to prostitution. The first idea of legislative rules tending to regulate prostitution are found in France in the Capitulaires of Charlemagne. He was bitter against common prostitutes, whom he directed to be scourged, but on the other hand he excused women who granted pleasure to rich people. He also inflicted severe penalties on all who kept houses of debauchery, or harbored lewd women for the purpose of prostitution. Louis VIII. tried to regulate prostitution, but he was not success- ful. The task was resumed by Louis IX., who strove to check the evil of prostitution in France. He directed that all prostitutes and all per- sons making profits out of prostitution were to be exiled. If they were found again in France after their expulsion, they were severely punished. On account of fear, decency was enforced, but the morals at large had to suffer so much that these arbitrary laws were repealed, and prostitution allowed under certain restrictive measures. From Louis IX. to Henry II., from Henry II. to Louis XIV., there is a continuous alternation of severe penalties against prostitution, and repeals of the same. Louis XIV. was the first to provide prisons for the detention of prostitutes and he drew a broad line between licentious women and true prostitutes. The first, who were not prostitutes, had a right to all the privileges of accused persons, sentences rendered were subject to appeal, and their punishment was usually a fine. For the prostitutes the proceedings were summary, they were sentenced, im- prisoned or exiled without right of appeal. Yet on the authority of Parent-DuChatelet, in spite of so many laws, brothels were licensed by the police, and prostitutes were never troubled unless on complaint of a responsible person. In 1 79 1, after the legislation of the monarchy had been abolished, the republican legislation made no reference to prostitution, leaving it open and free. As a consequence, prostitutes monopolized streets and public places, and Paris was scarcely habitable as a residence for modest women. This caused complaints to the Executive Directory, and in 1796 it was earnestly urged upon the Council of Five Hundred to establish restrictive laws for prostitution. Several attempts were 484 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS made by the prefects of police to make effective a severe regulation of prostitution. Indeed, the government had gradually assumed control of the prostitutes, and although without constitutional warrant, exer- cised full authority, so that the deficiency of the law could be scarcely perceived. Towards the end of the fifteenth century, on account of the fear- ful spreading of syphilis amongst the populations, public attention was directed to the subject of sexual diseases. These diseases usually mak- ing their first appearance on the genitals were called for some time pudendagra. In London there were established public regulations in order to prevent admission of persons affected with these diseases into the houses of prostitution. The police maintained a constant watch on anyone who showed symptoms of this infirmitas nefanda. In 1497 in France, by an ordinance of the Parliament, all persons affected with large pox were ordered to vacate the city within twenty- four hours, and not return until they were cured. Hospitals were prepared for those who were so sick that they could not move, and enough money for the journey was supplied to those so exiled. As early as 1497 a house was opened in Paris for the purpose of treating patients infected with syphilis, but the treatment was still left in the hands of quacks and of barbers. Although the treatment at that time consisted mostly of decoc- tions of sudorific woods, barks, etc., yet we find that in the beginning of the fifteenth century in Rome, Jacopus Berengarius da Carpi was using mercury in the treatment of syphilis. It is asserted by Fallopius that he used inunctions with mercurial ointment, and by these means he obtained successful cures. His services were liberally paid and he accumulated a large fortune, which at his death in Ferrara in 1530, was left as an inheritance to the duke of that city. The barbarism of the Middle Ages dominated even in the treatment of the poor unfortunates affected with syphilis. Not until 1614 was the project of the parliament of France realized and a hospital for the pauvres veroles opened. Patients when admitted and when discharged were soundly whipped as a punishment for having contracted the dis- ease, a practice which kept many persons from applying to the hospital from fear of showing their condition, and thus it was gradually abandoned. Under Louis XIV. a hospital prison for the prostitutes was founded, la Salpetriere, but admission was forbidden to those suffering from syphilis. The urgency of the cases applying for treatment showed the necessity of admitting syphilitic prostitutes also, and a small room was arranged to accommodate them. This, however, was not sufficient, and was dangerous on account of the overcrowded con- THE REGULATION OF PROSTITUTION 485 dition. and finally the government allowed the use of a ward in the hospital of Bicetre for treatment of syphilitic prostitutes. For many years afterwards severe cases of venereal diseases were sent to Bicetre, and milder ones were kept at la Salpetriere. The way in which the patients were treated, according to the report of Cullerier, surgeon in chief, and referred to by Parent-DuChatelet, was absolutely abominable and a disgrace to humanity. In reference to treatment only, they had but few remedies, and patients were treated in turn. While some were treated, the others were obliged to wait months be- fore they could get their treatment. As a consequence, many died before they reached the time for their turn. It is not necessary to say that with this horrible state of affairs, the mortality was frightful. Owing to the reports of Cullerier, the government finally took action, and in 1789, removed the prisoners from Bicetre and made room for the accommodation of syphilitic patients. The means at their disposal were just the same, no conveniences for treatment, no baths, and it made necessary urgent reforms. The republican government then placed at the disposition of syphilitic patients the hospital of Capuchins, which was enlarged, arranged with the needed conveni- ences, provided with gardens, and was called L'Hopital du Midi. It w T as found barbarous and unjust to admit female patients of good moral character, who were affected with syphilis without their fault, together with vile and debauched prostitutes, suffering the ravages of syphilis on account of their indiscretions. The govern- ment, to obviate these grave inconveniences, provided the prison of Saint Lazare for the accommodation of the inscribed prostitutes, leav- ing the hospital du Midi for the other women. It is necessary to come down to 1810 in order to find a dispensary erected in Paris, with a strong medical staff, for the purpose of visiting the prostitutes. In the beginning, they were given the choice of being treated at home or in the hospital. The majority took the first alterna- tive, but soon the necessity of giving up the house treatment was made plain. The medicines were not taken, and those affected with dis- eases did not abstain from the exercise of their calling. Parent-DuChatelet gave interesting statistical tables of venereal diseases among the prostitutes of Paris, aggregating a period of twenty years. They show that the proportion of venereal diseases in pros- titutes varies widely in the different years. In 1828 six out of one hundred prostitutes were diseased, and in 1832 barely three per cent, suffered from venereal diseases. DuChatelet himself candidly admits that he can trace no law, and inclines to the belief that the variation in the number of diseased women is wholly due to chance. 486 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS The regulation of prostitution in Paris at present is so interesting that it deserves to be briefly described. The total number of prostitutes in Paris at the beginning of 1800 was estimated at 25,000 or 30,000, of which the city of Paris furnished nearly one-third, the remainder coming from the departments, more from the north than from the south. The vast majority of these prostitutes were the children of operatives and mechanics, and the fathers of one-third of them are unable to sign their names. The houses of prostitution in Paris are under the surveillance of the police. These houses cannot be near the principal streets, must not be near a church or a public school. The owner of the house must give his consent before the house can be used for a brothel. The interior of the house is also watched by the police. It must have one room for each girl, it is not allowable for two girls to live in the same room, and much less sleep in the same bed. Each room must be amply provided with utensils, soap and water for ablution. No back entrance or side doors are allowed, nor can a house have dark passages or concealed places. No trade or traffic is permitted. To open a house of prostitution in Paris requires the authorization of the police. Men are not permitted to run houses of this kind. The woman who intends to open a house of prostitution must make a written application to the prefect of police. She will never receive authorization if she has been condemned for crime or for misdemeanor, or if her name appears in the police books as a woman requiring super- vision. In general those women who have been prostitutes themselves are preferred, because they understand the business, and they can only aspire to the most demoralizing position, such as a brothel keeper. They must be of sober habits, and of a certain force of character to be able to command a house of prostitutes. Furthermore, they must have some money to guarantee against immediate failure, and must own the furniture of the house. When the applicant has fulfilled all these conditions, she receives a pass book, wherein is specified the number of girls she can keep, and she must enter the name of every prostitute she receives as a boarder or as a transient lodger, her age, date of entry into the house, date of inspection by the physician, and the date of her departure. In the book the housekeeper is reminded that she must under heavy penalty inscribe on the police rolls every girl she receives, within twenty-four hours of her arrival. The girls who enter upon the debasing career of the prostitute are inscribed as such in the department of the prefecture of police called the Bureau des Moeurs. Prostitutes are inscribed either : THE REGULATION OF PROSTITUTION 487 1. On their own request. 2. On the requisition of the mistress of the house. 3. On the report of the inspector of prostitutes. The girl who, under these circumstances, is taken before the Bureau, has to answer a list of twelve questions concerning herself, her family, her past life, and the reason for which she wants to be inscribed. If she is from some place outside of Paris, the prefect will write to the Mayor of the town, informing him that a girl of such a name from his town has made such a petition, and requests that he see her parents or relatives, and notify them of her wretched resolution. If the family declines to interfere, then the girl is duly inscribed on the register. At the same time she signs a document where she states, " that, being duly acquainted with the sanitary regulations established by the pre- fecture for public women, she declares that she will submit to them, will allow herself to be visited periodically by the physicians of the dispensary, and will conform in all respects to the rules in force." Although in some instances the girl may give a false place of birth, yet at the present time it very rarely happens, because they consider the police as an omniscient machine, which cannot be de- ceived. In case a girl is brought to the bureau by an inspector as giving herself up to clandestine prostitution, she is only admonished and is soon released. Only after the third or fourth offense the girl is in- scribed on the registers. If the girl has relations or friends in Paris, they are sent for and notified. A girl is inscribed only when she is evidently lost, but if she shows signs of contrition and shame, she is sent home by the police. When the girl is found to be diseased she is sent to the hospital. In rare cases it has happened that the girl apply- ing for inscription has been found a virgin ; in this case the officials have the right to use compulsion to rescue her from infamy. The system of inscription of the prostitutes in Paris is so carried out that a girl cannot be inscribed unless it is manifest that she will carry on the calling of a prostitute whether she be inscribed or not. In the same bureau a prostitute who has repented has the right to erasure. The amendment of prostitutes is encouraged as much as possible. The prostitute, however, will not be released from supervision of the police and from the visits of the dispensary physicians until there is reasonable grounds to believe her repentance and her resolution to be sincere and permanent. The women, when inscribed as prostitutes, are divided into three classes. 488 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS i. Those who live in licensed houses. 2. Those who live alone in furnished rooms. 3. Those who live in rooms they furnish and outwardly bear no mark of infamy. Before the law there is no difference between the three classes. The girl who is inscribed receives her card, with her name and the number of the page corresponding to the page of the register. A blank column on her card has to be filled by the physician at each visit. The dispensary physicians visit the women inmates of the brothels in the house where they live; the other prostitutes go to the dispensary. Another branch of the dispensary is in the prefecture of police, in order to ascertain the sanitary condition of those prostitutes who are arrested during the night for drunkenness, or for disorderly conduct. Every house of prostitution is visited once a week by the dispen- sary physicians ; every girl must be present and be inspected. The result of the examination is noted in a memorandum by the physician and on the pass-book of the house. When a girl is found diseased, the mistress of the house is cautioned not to allow the girl to have any visitors. In the afternoon of the same day the girl is taken to the dis- pensary, where she is again examined, and if found sick, she is sent to Saint Lazare to be treated. Free prostitutes who live in lodgings, or in rooms furnished by themselves, are compelled to visit the dispensary and undergo a visit once every two weeks. Experience in the French capital has proved that the only means of diminishing the spread of venereal diseases is the seclusion of the infected prostitutes. The prostitutes and the houses of prostitution were obliged to pa> a tax, which was used for the support of the dispensary. The product of the taxes and fines imposed for transgressions, amounted to some 75,000 to 90,000 francs per annum. But this system was abolished on the ground of immorality. Similar taxes have existed in Lyons, Stras- burg and other cities, but the police authorities have taken off these taxes and the municipal councils of the city have undertaken to defray the expenses of the dispensary. The regulation of prostitution in Paris deserves to be specially studied. It is the model which has been adopted by every other city or state which has intended to regulate prostitution. The abolitionists of the control of prostitution have raised strong objections to this system. It may be that their objections are well founded, but it is undeniable that on reviewing the conditions of pros- titution in the different states and cities, it appears, on comparing the THE REGULATION OF PROSTITUTION 489 two conditions, that the regulation of this social evil has always brought good results, diminishing the venereal scourge. In Spain very little was done to regulate prostitution. Ramon de la Segra, 3 in a paper read at the Congress for prevention of syphilis and venereal diseases in Brussels, greatly lamented the state of affairs in that country, where neither the municipal authorities nor the govern- ment had taken any interest in so vital a question of the public health. He stated that in Seville, the first-class houses of prostitution retained the services of a physician at their own expense, whose office was to make examinations of the women. At the last Congress of Brussels, the necessity for a surveillance of the prostitution was shown to be a fact, and it should be the least vexatious possible, but effective in order to attain the great purpose of preventing the spreading of syphilis and venereal diseases. This prompted the Commission of the Royal Council of Public Health in Madrid 4 to propose a project of regulation for prostitution at the Section of Hygiene. The purpose of this law is : First, to reduce the cases of contagium which is caused by prostitution ; second, to treat the diseased prostitutes ; third, to treat and cure men affected with venereal diseases. In the individual prophylaxis we have already shown the neces- sity of making the treatment as accessible as possible for infected men, and this will result in a powerful means for diminishing the contagium. The male element, which is so active in the spreading of the disease, is yet considered as irresponsible, and can only be checked indirectly by treating those infected and by teaching and cautioning the young men as to the dangers of venereal diseases. It has been recognized that the most effective means of diminish- ing the diffusion of syphilis is in an intervention of the municipal authorities in the hygiene of prostitution. For this purpose medical inspection has been established in Spain, which is exercised to inspect the sanitary condition of the public women, and they must be compelled by law to obey the rules of hygiene. The medical inspector in visiting the inmates of a public house has to sign the individual card of each girl. When he finds that a woman is affected with any disease, he will write on the card the diagnosis, and will order that the woman be immediately taken to the hospital. When the woman is infected with syphilis she is compelled to remain in the hospital as long as she has symptoms of a condition capable of conveying infection. Azua finds it a necessity to establish in the hospitals, small apart- ments in pay wards or separate rooms to accommodate women who are able to pay for their treatment, while they are compelled to remain in 3 " Ramon de la Segra." Compt. Rend. Bruxelles, T. i, 1901. 4 Azua, J. " Reglamentacion Sanitaria." 1905. 490 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS isolation. In this way the clandestine prostitution would be dimin- ished, as those who practice it would not have a horror of being taken to the hospital together with prostitutes of the lower class. For the regulation of prostitution the strong hand of the police is necessary in order to enforce the rules, otherwise the whole system will be a farce. A police system should be established in every city of 10,000 inhabitants, where there is a Board of Health, in order to inspect the sanitary condition of the prostitutes and compel them to undergo a regular treatment. The same police inspection should be made in all industrial and mineral districts, and also where there are military barracks, in order to protect their health from venereal infection. The physicians in charge of this service must be selected from men well versed in handling venereal diseases, in dermatology* and syphilology. They must be able to make microscopical examinations, and bacteriological cultures to such an extent as to be able to ascertain the diagnosis of the disease. Every district in the country should have a dispensary for the inspection of the prostitutes. The medical office in the dispensary should be opened every day except Sunday, but the prostitutes should be compelled to undergo the sanitary inspection twice per week. In the dispensaries there should be given instructions to the prostitutes as to how to recognize some diseases in order to protect themselves, and to the men instructions on the prophylaxis of venereal diseases. Punishment by fine or detention is established for the women who refuse to undergo the sanitary inspection, and the raiding of the house if the housekeeper allows women to remain without recogni- tion of the police officer. There are rules to be observed by the police inspectors, and also regulations for obtaining the necessary funds, which must be taken from the Commission of the Board of Health of the different cities. In a country where no surveillance of prostitution was exercised it has been found to be a dire necessity. In England it seems that prostitution does not exist : the town laws regulating prostitution were abolished in 1883, an ^ since then prostitution has been left to the common law. and no control is exercised. The opinion is that in every community there is some prostitution, which is in relation with the habits and education of the place, and remains constant so far as the conditions of the place are not changed. But in the large cities the search for lust exists under all conditions and contributes to the maintenance of prostitution. Procuresses are trying to give good service to their patrons, and are THE REGULATION OF PROSTITUTION 491 exerting their hellish ingenuity to find sources of amusement and gratification. They go around in the country, to the railroad depots, hunting for poor girls to whom they offer friendship and support. Sanger relates instances where the procuress has gone to the Sunday school in order to approach and decoy female children. The London Society for the Protection of Young Females has recorded instances of children of eleven years of age entrapped by procuresses into houses of prostitution. A constant trade in prostitution is carried on between London and Hamburg, London and Paris, and London and the country. In some cases prostitutes of Paris have been hired for this purpose for London, but in the greatest number of cases women have been decoyed on the pretence of a legitimate engagement. The number of brothels, houses of prostitution and assignation houses in London have been variously estimated, and they are found in every district. Poverty, poor wages for female work, and over- crowded dwellings are the most common causes which lead to prostitution. The policy of the English law is to compel the woman to pro- tect herself, yet unfortunately the scale of human justice is not evenly maintained. Legal actions for seduction are very unpopular. It is difficult to prove the case, and they usually result in the acquittal of the male delinquent. The spreading of venereal diseases in Great Britain, and especially in London, was found a menace to public health. On February 21 , 1867, Chas. Drysdale and Tilbury Fox persuaded the members of the Harveian Society to establish a permanent committee to study this important hygienic question with special reference to the problem of prostitution. The committee began to study the venereal diseases in the army, which is considered the thermometer of the sanitary condition of the population. In 185 1 the English Army in garrison in the United Kingdom, in a total of 44,611 men, gave 8032 cases of venereal infection; an average of 180 infected in each 1000 soldiers. In 1862 the English Army had over 318 infected in each 1000 men. At the same time in the French Army 5 with the prophylactic rules on prostitution, there were 113 in each 1000 who were infected with venereal diseases ; while in Belgium, where the prophylactic measures are even stricter, the infected soldiers numbered 72 in each 1000. 5 Crocq et Rollet. " Prophylaxie International des Maladies Ven. Ann. Derm, et Syph." 1869. 492 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS This large number of cases of venereal diseases in the English Army prompted on June II, i866 ? an act for the better prevention of contagious diseases at certain naval and military stations, which had in view the prevention of venereal diseases in the army and navy. The law had effect in Portsmouth, Plymouth, Woolwich, Col- chester, Sheerness, Aldershot, Windsor, Chatham, Sorncliffe, the Cur- ragh, Cork, and Queenstown, all military and naval stations. Under this act for prevention of contagious diseases the police of those cities had power to take the women known to pursue the calling of the prostitute, to a dispensary for medical examination. If they were found infected with any venereal or syphilitic disease, they were compelled to enter a hospital of the government and remain there until recovery was effected. The prophylaxis of venereal diseases applied only to the military and marine posts, could not bring much benefit unless it was extended to the entire population. In fact, referring to the number of venereal diseases in Great Britain, and especially in London, there is a great deal of conjecture, on account of the great number of hospitals, dis- pensaries and clinics, from which it is difficult to obtain positive data. Sanger 6 referred to the service of the out-patients in St. Bartholo- mew's Hospital under the direction of Lloyd and Vormald, assistant surgeons, which has given in a total of 5327 general patients, 2513 venereal cases. From the work of Commenge 7 there can be obtained a good idea of the value of the control of prostitution. He gives accurate statistical tables which show that in 1875 the French army gave the highest number of venereal patients ; amounting to 74.9 in 1000. In the same year in the English Army the venereal patients were 1394 per 1000. The largest number of infected soldiers in the English army was in 1885 with 274.4 per 1000, while in the same year in the French army the proportion of infected soldiers was 52.1 per 1000. For the five years, 1888, 1889, 1890, 1891 and 1892, the soldiers of the English army entered the hospitals for venereal diseases in the proportion of 224.5 P er 1000, 212. 1 per 1000, 212.4 per 1000, 197.4 per rooo, 201.2 per 1000. In the same years the French army had venereal patients in the number of 46.7 per 1000, 45.8 per 1000, 43.S per 1000. 43.7 per 1000, 44 per 1000. In reference to syphilis alone, the highest number of infected soldiers in the French army, which was in 1875. reached 11.3 per 1000, and in the same year in the English army the syphilitic soldiers were 28.8 per 1000. In 1887 in 6 Sanger. L. c, p. 357. 7 Commenge, O. " Les maladies veneriennes sans les armees Anglaise, Franchise et Rnsse." Paris, 1895. THE REGULATION OF PROSTITUTION 493 the English army syphilitic soldiers reached the proportion of 42.6 per 1000. In the same year in the French army the proportion of syphilitics was 8.9 per 1000, which is only one-fifth of the English rate. The following statistical table is taken from Commenge to show the difference in the proportion of syphilitic soldiers in the two armies. French army English army Year 9.3 per cent. 40.3 per cent. 1888 9.1 " 35.7 " 1889 9.1 37.3 " 1890 8.9 " 32.2 " 1891 9.2 33.8 " 1892 A report to the Minister of War showed that in 1892 of the effective force of 196,336 soldiers, 52,155 had been sent to the hospitals with venereal diseases, more than one-fourth. This caused Commenge to write, " La liberte de la prostitution amene ches nos voisins des resultats qui ne peuvent pas nous surprendre et qui ne doivent pas nous faire regretter les restrictions apportees dans notre pays, a cet empoisonement general." The great increase in venereal diseases in Great Britain has been attributed to the abolition of the Acts of Contagious Diseases. In fact in 1 87 1, before the abolition of the Acts, soldiers had been re- ceived into the hospitals for secondary syphilis in the proportion of 21.2 per 1000, while after the abolition the proportion increased to 33.35 and even 37 per 1000. Officers of the army in India stated that nearly half of the soldiers were affected with syphilis. In the period 1874 to 1879 under the strict regulation of prosti- tution in the military hospitals, there was found an average of 9.53 per 1000 of soldiers suffering with venereal diseases. After the obligatory inspection of the women was suppressed the average of venereal diseases has increased to 17.46 per 1000. The daily average of soldiers laid up in the hospitals for venereal diseases is 4191, which forms four large battalions. After these considerations there is no doubt that free prostitution increases considerably the spreading of venereal diseases. Commenge after studying carefully the statistics of each army corps of the French army, shows that clandestine prostitution has great influence on the increase of the venereal diseases in the different army corps. He refers to Longuet, who remarked that the different army corps con- stantly show the number of venereal diseases in nearly identical proportion. Those corps of the army most affected are those of the 494 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS Southern part of France, of Algeria and of Tunis and the 3d army corps of the military government of Paris. In 1890 the whole French army showed a proportion of venereal diseases of 43.8 per 1000, the third corps of the army had 84 per 1000 of soldiers in the hospitals for venereal affections. The nth army corps, which was stationed in the northern provinces, had only 26.3 per 1000 of diseased soldiers. The difference in the proportion of the venereal diseases is to be found, according to Commenge, in the facilities which the different places of garrison offer to the soldiers. In Algeria and in Paris clandestine prostitution is exceedingly common, and so the number of infected soldiers is much larger. In manufacturing cities, where the young girls are often early debauched, there the number of soldiers infected is increased. The ascending progression of the venereal diseases is in proportion to the laxity of morality and to the facility of the clandestine prostitution. In the report of the Surgeon-General of the United States Army to the Secretary of War, June, 1900, he shows that in Cuba and Porto Rico in the years 1898 and 1899 venereal diseases amongst our troops have been indeed excessive, so much so as to cause anxiety to our medical officers. Syphilis in Porto Rico had reached 28.38 per cent, among the regulars and 50.00 per cent, among the volunteers. In the provinces of Santa Clara, Cuba, venereal, diseases had developed at the rate of 176.28 per 1000 amongst regulars and 115.69 amongst the volunteers. The colored troops were more prevalently affected, reach- ing 195.92 per 1000, against 127.35 m the United States. Major F. J. Ives, Surgeon United States Volunteers, chief sur- geon of the department, was prompted to institute measures of re- pression, subjecting the soldiers to a weekly sanitary inspection, and those whom he found diseased, were deprived of the privilege of the canteen and of the passes from the garrison until cured. In those places prostitution was free from all control. In Italy the surveillance of prostitution, which had been estab- lished under Cavour's ministry as a system of regulation modelled on the French plan, was abrogated by Crispi in 1888. The cause was that the Section of hygiene at the Congress of Geneva in September 1887 branded as immoral every system of police des mocurs and all regulation of prostitution on the following ground : " The obligatory sanitary inspection of the women is revolting to human nature and it can reach only a limited number of prostitutes ; this inspection cannot discover constitutional syphilis and conse- quently gives a false confidence in the women visited." As a consequence of these pathetic representations of the aboli- tionists, all laws controlling prostitution were repealed, leaving prosti- THE REGULATION OF PROSTITUTION 495 tution free, without registration and without sanitary surveillance. The prostitutes, when diseased, could have been treated in any place they wanted, by anyone, and in any way. In a question of so great importance it is always interesting to learn from the experience of others. Free prostitution lasted three years and after this period they were compelled to return to the same rules, and on October 27, 1891, a new regulation of prostitution was enacted and enforced. The results of those three years in Italy are entirely identical with those observed in England and in Russia. Tarnowski s made a trip to Italy through all the principal cities for the purpose of ascertaining the results of the abolition of the control of prostitution in the spread of the venereal diseases. In the military hospitals, soldiers were laid up with venereal diseases to the fearful extent of 62 per cent. All the officers expressed the desire for the re-enactment of the laws controlling prostitution. In the civil hos- pitals, patients affected with venereal diseases had rapidly increased, and in the Ospedale Maggiore of Milan, from 5916 venereal patients, in the year 1887-88, the number had increased to 7570 in 1888-89. In the Maternity of Milan he found syphilis increased among the pregnant women from 1.28 per cent, to 4.27 per cent. In the foundling: house of the same city children affected with hereditary lues in 1887-88, numbered 23 ; in 1888-89 tnev numbered 49, while in 1889-90 they had increased to 98. In the hospitals there was found an increased number of" un- married women suffering with aggravated cases of venereal and syphilitic diseases. In Palermo the rate of diseased women admitted to the hospital, which had been on an average of 150 per day, had increased by 12 and a great many were suffering with venereal affections. In the sanitary inspections of the houses of prostitution, when under the police surveillance, it was found that 30 per cent, were affected with transmittable diseases, but after three years of free prostitution the number of diseased prostitutes had risen to 75 per cent. These 75 per cent, of prostitutes, affected with gonorrhea, chancres, syphilis and every kind of pathological filth, had been left free to continue in their callings ; they have spread diseases to hun- dreds of young men, with all the consequent results. These disastrous consequences in Italy are also perceptible in all large cities. They are largely due to those philanthropists who preach liberty and morality while holding that sanitary inspection, instead of diminishing, increases the chances of spreading venereal diseases. 8 Tarnowski, B. " Erfahrungen des Abolitionismus in der Prostitution Frage in Italien." Ref. Monatsheft. f. prakt. Derm., 1892. 496 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS The Crispi abolition law, which had been accepted with great enthusiasm by the abolitionists, and by many physicians in Italy, after three years of free prostitution caused a true reaction in presence of the terrible results. At the Twelfth International Congress- of Medicine held in Moscow in 1897, Serebriakoff 9 stated that the spreading of venereal diseases in Moscow was mostly due to the increase of clandestine prostitution practiced by women, the majority of whom escaped all surveillance. The number of women affected with syphilis, admitted into the municipal hospital, is about 50 per cent. Those affected with syphilis in the secondary stage form fully one-third of the total. Behrend, of Berlin, at the same meeting, expressed frankly his opinion that it is the duty of every physician, in spite of the protests of women's associations, to demand a strict regulation of prostitution. Indeed, women who give themselves to a life of shame, who make a trade of their body for the sake of gain and for making their living, must be subjected to a sanitary visit from a recognized specialist. When the prostitute is found affected with venereal diseases, she should be treated in hospitals and not in clinics. They must be detained until cure is effected, or at least until there is no more danger of spreading infection. In the hospitals, the prostitutes, on account of their vicious habits, have to be separated from the other patients. "All measures proposed by the " abolitionists " show on their part dense ignorance of the real condition of the contagiosity of these diseases and especially of syphilis. The sanitary inspection is only instituted for the purpose of checking venereal diseases and syphilis amongst debauched people of both sexes, and so prevent the possible spreading of these diseases amongst innocent people, and infecting families and even the entire communities. On this ground of public hygiene the British Federation is at great fault in asserting that the state has no right to interfere in the matter of prostitution, because the danger is not in reference to the public health, but only to the individual. They claim that the man who visits prostitutes willingly and knowingly exposes himself to all dangers of infection. But as Sormani remarked, if syphilitic con- tagium does not spread through the air at a distance, yet it may so insidiously spread that in some cases many members of a family of the purest moral habits have, without their knowledge as to the manner, been infected with syphilis. It is one of the saddest infections which is transmitted to the offspring, which never occurs in other contagious 9 Ref. Journal of Cutaneous and Genito-urinary Diseases, December, 1897, P- 573- THE REGULATION OF PROSTITUTION 497 diseases. The child born with congenital syphilis, is often made the center of infection and is capable of spreading the disease amongst healthy people. Cases of epidemics of syphilis have been reported by Riccordi, 10 when in 1863, a foundling babe tainted with congenital syphilis was adopted into a family who did not know its condition ; this child was the cause of communicating the disease to 23 persons. In the same year in Uboldo, another foundling babe infected her wet nurse, and the disease spread among 18 persons. In the province of Abruzzi in Capistrello, an epidemic of syphilis developed, which was not recognized by the local physicians, and in five years infected nearly 300 persons. The epidemic was found to have started from an infected babe taken from the foundling house and adopted into a family. The well-known work of Dr. L. Duncan Bulkley, " Syphilis in the Innocent," which has already been quoted, gives a sufficient idea of the large number of victims of the syphilitic infection, where there has been no fault of the infected. In 1861 the Bavarian Parliament voted a law, which imposed severe penalties on all women who practiced prostitution. All houses of prostitution w r ere closed, and all sanitary inspection was discon- tinued. It was found in the city of Munich that in the preceding years the number of venereal patients in the hospital of the city were on an average 1006 per annum. In the five years following the abolition of surveillance, the number of venereal patients increased to 1500, and in 1866 reached the number of 1835. Commenge, referring to the abolition of surveillance of prostitution in Bavaria, found a great difference in the proportion of venereal patients of both sexes. In the time of surveillance, male venereal patients had been received in the hospitals in proportion of 203 for 100 female venereal patients. At the time when the inspection was discontinued the number of male venereal patients reached 335 for 100 female patients. This shows that diseased women do not apply willingly to the hospital for treatment, but they remain outside to spread infection as long as they can, without any thought of the sad consequences resulting from their criminal carelessness. Neisser, 11 after his philosophical considerations on prostitution and crime, on the difference between a fallen woman and a prostitute, reaches the conclusion that prostitution is an unavoidable evil, which cannot be fought, but must be tolerated, consequently with some restrictions. When the prostitute is infected with venereal diseases she is a danger, and therefore the prostitutes must be subjected to sanitary inspection so as to be able to isolate them in the beginning 10 Riccordi, quoted by Commenge, 1. c, p. 37. 11 Neisser, A. " Rapport sur la Phophylaxie Publique," Brussels, 1902. 498 THE MEDICO-LEGAL AND SOCIOL9GICAL ASPECTS of the disease. The elimination of diseased women is useful for them and for others. It is useful for them because the disease taken in the very beginning yields much more easily to treatment, and useful for others who would without any doubt be infected. In a recent work Blaschko, 12 with well selected statistics from Denmark, where physicians are compelled to report all cases of venereal diseases under their treatment, without mentioning the name of the patients, in a period of twenty years from 1876 to 1895, was able to demonstrate a decrease in the percentage of these diseases. In Copenhagen in the decennium 1876- 1885 gonorrhea is given as 5645; ulcus molle as 1450; syphilis as 1203. In the decennium 1886- 1895 gonorrhea is found as 4618; ulcus molle as 842 ; syphilis as 1254, showing a small increase for syphilis only. In the same paper he refers to statistics taken in Prussia in 1900, where it is shown that on April 30 of that year in the whole kingdom 41,000 persons were suffering with sexual diseases, of which 11,000 were infected with recent cases of syphilis. In Berlin there were recorded 11,600 venereal patients of whom 3000 had fresh cases of syphilis and were under medical treatment. From the same statistics it is shown that in Berlin for every 10,000 inhabitants, 142 are suffering venereal diseases. These statistics, however, give only a very faint idea of the real number of infected persons, because of the physicians who were requested to send the number of their venereal cases, only one-half answered the request. Furthermore many of these cases go to be treated by drug- gists and by quacks, who surely were not asked for any information on the subject. This shows that the number given in the statistics must be considered about one-third of the real number of venereal patients in Berlin. Blaschko thinks that every year the number of diseased persons is 200 in each 1000 young men between twenty and thirty years of age, of which five-sixths are suffering with gonorrhea, and one-sixth or 34 are affected with fresh cases of syphilis. In reference to the spreading of the venereal diseases in the different classes of society, we find it interesting in the same statistical tables that in Berlin, soldiers are affected at the rate of four per cent., working people at nine per cent., merchants at sixteen per cent., students at twenty-five per cent., clandestine prostitution at thirty per cent. The large number of infected students has indicated the necessity of instituting societies for the prevention of sexual diseases among students. The object of the society is to show to the young students the danger of infection which is connected with each sexual relation 12 Blaschko, A. " Der Einfluss der Syphilis auf die Lebensdauer." Int. Kongr. f. Versiches Mediz., 1906. THE REGULATION OF PROSTITUTION 499 and the sad and disastrous consequences of these diseases on the individual health. Besides this, it is the duty of the society to inculcate on the students who have the misfortune of being infected, the necessity of applying for a good medical treatment. In the same way the society teaches them not to be misled by false shame, to hide the disease and go to consult quacks or follow advice of so-called friends, but to immediately place themselves under the care of a reputed physician, and obtain the recovery without risking tedious and dangerous complications. Scholtz, 13 who has charge of the sick students in Breslau, remarks that he finds among them a great ig- norance of the possibility of infection through sexual relations, and of the consequences, and so they readily and thoughtlessly expose themselves to the venereal peril. It seems that from the teachings of these societies there have been obtained some good results, as shown by the clinical histories. Formerly, thirty-five per cent, of the students were affected with gonorrhea and went to the dispensary only once for a free consultation, and now seventeen per cent, of the students affected with gonorrhea are following their treatment to the end. This shows that the students at present have a much better idea of the venereal peril, are more careful, and nobody attempts to apply a treatment of his own. The efforts made by Professor Neisser, who has given some public lectures to all students on the venereal peril, are producing good effects in diminishing the venereal scourge. On the other hand, the regulation of prostitution by the police with a sanitary inspection made by men who have made vener- ology and dermatology their special studies is a necessity for checking the spreading of these contagious diseases. Indeed, under the English regulation system at home and abroad British soldiers and sailors were required to denounce the women who had infected them. The women were examined and most of them were declared free from disease. Miss Blanche Leppington, 14 quoting the official statistics for Hong Kong, gave an instance where 139 women were denounced, of whom 102 were found clinically free from disease, and another instance where of 103 denounced women, in 101 there could not be found any venereal infection. At that time, 1886-1888, these medical reports were accepted as proof that the women had been falsely charged. To-day a simple medical inspection will have no value unless it is corroborated by microscopical examination. For this reason not 13 Scholtz, W. " Ueber die Bekampfung- der Geschlechtskrankheiten unter der Studenten." Munch, med. Wochensch. No. 5, 1901. 14 Leppington, Miss B. " Responsabilite civile et penale." 77 Confer. Intern. Brussels, 1902. 5 oo THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS every physician can fill the position of medical inspector, unless he is well trained in this branch of medical knowledge. Kromayer 15 referred to a statistical table from Blaschko 16 to show the frequency of syphilis in the different cities. The table shows also the difference between the prostitutes in the brothels and the free prostitutes. In the brothels Free Paris, 1878-1887 12.0 7.0 Brussels, 1887-1889 25.0 9.0 Petersburg, 1890 33.5 12.0 Antwerp, 1882-1884 51.3 y.y Hammer 17 referred to the condition of prostitution in Stuttgart when a mild system of regulation was enacted in 1894. At that time among 1725 prostitutes arrested by the police, 146 were affected with secondary syphilis, an average of 8.5 per cent. Gratifying results from the regulation were shown by the number of venereal patients amongst the soldiers of the garrison. In 1893 before the surveillance, gonor- rhea was 16.7 per cent., ulcus molle 7.09 per cent., syphilis 6.07 per cent. In 1896, two years after the regulation of prostitution, the number of soldiers affected were, gonorrhea 10.3 per cent., ulcus molle 3.0 per cent., syphilis 4.7 per cent., showing a considerable diminution. Kromayer in reviewing the statistics of many states and cities, compares those where prostitution is under surveillance and those where prostitution is free, showing the difference. He referred to the city of Colmar in Alsace, where in 1881 by order of the Mayor the houses of prostitution were closed and all surveillance abolished. Taking the statistics from the diseased soldiers of the garrison, it was found that in the first year there was a diminution of venereal patients, but this diminution was only ephemeral, because in the fol- lowing years venereal diseases increased more than double. In the beginning, this closing of the public houses brought a diminution because the soldiers were somewhat afraid and restrained themselves, but soon a clandestine system of prostitution developed, which caused in 1890, 128 disabled soldiers to be in the hospital with venereal in- fection, while in 188 1 only 64 soldiers had been diseased. The proportion of diseased soldiers in a small garrison in Colmar with free prostitution was 57 per cent., while the whole Alsatian army 15 Kromayer, E. " Zur Austilgung der Syphilis," Berlin, 1898, p. 14. 16 Blaschko. " Syphilis und Prostitution vom Standpnnkt der offentlichen Gesundheitspflege," Berlin, 1893. 17 Hammer. " Ueber Prostitution und venerische Erkrankungen in Stutt- gart." Arch. f. Derm. u. Syph, 1897. Bd. 38, p. 253. THE REGULATION OF PROSTITUTION 50I corps had given only 26 per cent, and in Strasburg, the capital of the province, the proportion was 29 per cent. On the other hand, it seems that a too strict and vexatious system of surveillance of prostitution has the opposite effect ; instead of dimin- ishing it has increased the number of venereal patients. In Breslau, when a strict control of prostitution was enacted, at first the number of venereal soldiers of the garrison greatly diminished, so much so, that from 37 per cent, in 1886 it fell to 20 per cent, in 1889, but in the following years the number of infected soldiers began to increase and in 1892 the prostitution had again reached 27 per cent, in com- parison with 28 per cent, of the year 1887 before the regulation. The too strict rules, which had been enforced in 1887, took many prostitutes out of their regular houses and as a consequence clandes- tine prostitution took place, producing nearly the same results as did the closing of all the houses in Colmar. These results, however, are not to be considered from the point of view of the abolitionists, because the strict control of prostitution has always the object of removing infected women from the position of being able to spread infection, and this is always a public benefit. If on account of the frequent relapses in the gonorrheal infection the control of prostitution does not give such good prevention results, yet in syphilis it is greatly beneficial. By means of the sanitary in-' spection, syphilitic infections are easily recognized, and the infected women are soon placed in hospitals and treated until cure is effected. Moreover by a prophylactic treatment the relapses of syphilitic symp- toms are easily prevented. Indeed, the greatest beneficial result of the surveillance of prostitution is mostly found in checking the spread- ing of syphilis. For this reason Kromayer earnestly censures those states, where, through the indolence of the legislatures, so terrible a disease as syphilis is left alone to spread among the masses without an effort to combat its progress. This check can be obtained, not by the private efforts of the physicians, but by all the restrictions and compulsory laws of the government, and of the municipalities. In the United States, and only recently, a system of surveillance of prostitution has been adopted in a few cities at different times and with variable results. To the efforts of Dyer 18 is due the scanty information which could be obtained from forty-four cities, in refer- ence to the condition of prostitution. For all 44, excluding Philadelphia, in a population of 7,684,938, there was found a total of prostitutes of 69,440, giving one prostitute to every no inhabitants. 18 Dyer, Isadore. "The Municipal Control of Prostitution in the United States." New Orleans Medical and Surgical Journal, 1899. 502 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS From many cities no information could be obtained for the reason that as prostitution was forbidden by state and city laws no records are kept. From the replies obtained by Dyer it is clear that in eleven cities prostitution was free, and in thirty-four cities prostitution was under surveillance. In two cities prostitution was restricted to a cer- tain part of the city, in twelve it was prohibited, and in nine it was ignored. In reference to the existing laws concerning prostitution it was found, that of 68 cities, 20 had no laws ; 12 had State laws ; 32 had prohibitory laws ; 9 had a license or enacted fine ; 3 confined the loca- tion of houses and of prostitutes to certain districts ; one city rang a curfew bell at 9 P. M. requiring prostitutes to be indoors ; 2 cities occasionally raid houses and two others occasionally arrested prosti- tutes for the effect produced ; two cities have laws to suppress ; one to restrict ; one city had no legal recognition of prostitution and one stated that this condition is tacitly tolerated. In going over the work of Dyer it clearly appears that the health officers or the mayors of the cities had only very little idea of this occult evil, prostitution, and of its consequences in spreading infection. Very little could be learned concerning the examination of prosti- tutes, no answer could be obtained in reference to the microscopical examinations of the secretions for gonococci. Xo definite idea could be obtained in reference to the age of prostitutes, to the prostitution among minors, to the class of society from which they came, to the general influences driving them to prostitution. In reference to a law requiring medical examination of prosti- tutes, it can be said that no such legislation or regulation exists in the United States. In San Francisco, Cal., San Antonio, Texas, and St. Louis. Mo., they have tried to force such regulation, but not effectu- allv. When prostitutes were found to be diseased, are they compelled to remain in a hospital or are they treated at home? To this question replv was that no compulsory treatment was instituted in the United States ; they stay where they wish and are usually treated domiciliarily. In reference to the danger of spreading venereal diseases and especially syphilis, it seems to be the general opinion that clandestine prostitution is the most dangerous. From all the meager data that Dyer was able to collect, the im- pression was that there is a woeful lack of municipal supervision, knowledge and control of prostitution and of venereal diseases in the United States. The general public is not only indifferent, but scorn the question of prostitution, which is left to the police department as a vice, crime and nuisance. Their ignorance of this evil has indeed contributed to the grade of outlawry shown by prostitution. THE REGULATION OF PROSTITUTION 503 Prohibition of prostitution does not stop the evil, but makes things worse, increasing the number of clandestine prostitutes. The efforts of religious fanatics have succeeded in nothing but spreading the evil and in increasing the number of street walkers and soliciting prostitutes who were formerly housed. A clear example was found in 1891 in Pittsburg and in 1892 in New York, where the closing of the public houses had no other effect than spreading clandestine prostitution to every corner of the city. In the report of the Committee of Seven on the prophylaxis of venereal diseases in the city of New York, the chairman, Dr. Prince A. Morrow, 19 greatly lamented the lack of statistics concerning the prevalence of venereal diseases in that city. That the existence of this class of diseases had always been ignored by the sanitary authori- ties, and in consequence the amount of venereal morbidity was only conjectural. From the answers obtained from one-third of the 678 physicians asked to reply to a circular, it was found that in New York at that time, in 1901, were 23,196 venereal cases, of which 15,969 were cases of gonorrhea and 7200 cases of syphilis. This number does not include the cases of chancroid, which is estimated at from 9 to 35 per cent, of the total venereal morbidity. In the same way in this number there was not included the large number of the sequelae of gonorrhea, as pelvic complications, strictures and all the troubles which have a venereal origin. Morrow justly remarked that the 23,196 cases were given only by one-third of the physicians, and assuming that an equal amount of diseases had occurred in the practice of those who gave no report, the total of cases of gonorrhea and syphilis would reach 162,372 for that year in the city of New York. This calculation cannot even be considered approximative, when we think that from 25 to 50 per cent, of venereal diseases are treated by quacks, and by druggists, or by friends. In the small part of statistics collected, 12,956 cases of gonorrhea there were only 194 1 women of whom 724 were suffering with pelvic complications. Among children there were 265 affected with gonor- rheal ophthalmia; 218 with vulvovaginitis; 5 with urethritis. In the group of syphilis 1657 cases were in women and 61 in children in acquired form, showing infection in the family. Four hundred and sixty-eight children were tainted with hereditary syphilis. In reference to the origin of the infection, the committee could not obtain definite information, for the reason that in this country there does not exist any regular system of registration such as there is in Europe. From the few data it resulted that 8053 cases of infec- 19 Morrow, P. A. The Medical News, Dec. 21, 1901. 504 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS tion were attributed to public and 3915 to clandestine prostitutes, which is entirely in opposition with the observation of other countries. Nine hundred and eighty-eight cases of infection were reported as from husband to wife. From the report of dispensaries and of charitable institutions in Manhattan, there could be obtained informa- tion from 37. The aggregate number of venereal diseases was 14,649 cases of gonorrhea, and 7607 cases of syphilis, giving a total of 22,256. In the hospitals it was found difficult to get information in reference to venereal diseases, which are usually recorded under different names so as to mask their origin. They found in the eye hospitals 136 cases recorded as purulent ophthalmia, in all of which the microscopic examination had revealed the presence of the gono- cocci. In the same institutions 38 cases of interstitial keratitis, un- doubtedly of syphilitic origin, were not recorded as such. In the annual report of the general hospital there were registered 371 cases of salpingitis; 1762 of endometritis; 335 of pyosalpinx; 45 of salpingo-ovaritis ; 48 of vulvovaginal abscess; 169 of vaginitis; 651 of stricture ; 173 of gonorrheal rheumatism. From all the data which the members of the committee could gather, it resulted that in the hospitals and dispensaries of New York city there had been treated 41,439 cases of venereal diseases and of sequelae or consequences of the same origin. Yet in presence of so enormous a spreading of venereal diseases, the hospitals still refuse to admit patients at the time when they can be cured and also be prevented from infecting others. They are admitted into the hospitals when they are suffering from some grave consequences of the disease, but then it receives a different name and does not hurt the feelings of the susceptible directors of the institution. Sanger estimated that 59^ per cent, of all inmates admitted into any public institution, city hospital, almshouse, workhouse, peniten- tiary, etc., were suffering with venereal diseases. From all the dif- ferent sources of information Sanger concluded that in 1892, 100,000 persons in New York were suffering from syphilis out of a population of 1,800,000. At the present time the population of New York has reached 3,500,000, and calculated at the same rate of the increase in the venereal affections, it can be assumed with Morrow that 200,000 of all the population are infected with syphilis, and according to the calculation of Sanger 365,000 men are suffering with venereal diseases in Greater New York. In the presence of so serious a state of affairs, we see the health officers busy with the precautions to be taken for all contagious diseases and entirely ignoring the venereal diseases which belong in the category of the most contagious, and are of the most insidious. THE REGULATION OF PROSTITUTION 505 A system of surveillance does not acknowledge or legalize the vice, but is in conformity with the Prussian laws, which formally state that vice is tolerated but not permitted. Indeed, as Morrow refers to the different views of the medical profession, 340 physicians have recommended, as a radical measure to prevent the spreading of the venereal contagium, the regulation of prostitution. The system of regulation in France, which is not too strict nor vexatious, has been copied by nearly all countries or munici- palities which have established rules of this kind. It represents an association or a combination of the efforts of the administration of the authorities and of the medical profession in order to render prostitution less dangerous to the public health, eliminating the source of contagium in women who are engaged in it. A regular medical visitation of all prostitutes is the essential part of any regulation. This sanitary inspection subjects, of necessity, the prostitute to an effective supervision by the police. The medical inspection is also advocated by the brothel-keepers, so that at the first symptoms the disease may be checked. All the arguments to show the horrors of the venereal scourge have not been capable of removing the prejudice. The good people prefer to ignore the matter, they would rather let the river rise and devastate the properties than build dykes and regulate the current. So far State or municipal legislation for the control and regulation of prostitution has remained but a recommendation of the committee. In 1894 a system of protection was inaugurated in the city of Cincinnati, through the efforts of an eminent jurist, Hon. John A. Caldwell, who was at the time mayor of the city. He was greatly affected by a pathetic letter written by a mother, who complained that her only boy, a lad of sixteen, had been so badly diseased that he was laid up in bed. The mayor requested the lady to have a conference with him in order to ascertain the party who had infected her son. A few generalities were given pointing to a young woman riding a bicycle, etc. The mayor detailed a special detective, who ascertaining the identity of the woman, took her to the hospital, where she was found suffering with secondary syphilis, mucous patches of the lips and of the tongue, and gonorrhea. The detective worked on the case, and found that nine other boys had been infected by the same woman, and to her was traced the cause of the suicide of one of the most prominent business men. Continuous complaints of the same kind prompted the mayor to have a consultation with the chief of police, then Col. Phil. Deitsch, to see if any steps could be taken to provide for some restriction of prostitution. He found in the law, Sec. 112 Revised Statutes for Ohio, that 506 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS when a woman in a house of disreputable character, or an assignation house, is found affected with disease, she must be sent to the hospital and detained there until cured, and the expenses of the treatment art to be a lien on the house. This law afforded a good ground to institute some regulation of prostitution. The chief of police then detailed two detectives to look after the houses of prostitution and all places of a suspicious character. The dive-keepers were obliged to report to the police the number and the names of the girls, who were inmates of their houses, and also report the changes, those who had come to, or had left the house. When the dive-keeper knew of a girl being diseased, he was compelled to report the case and the girl was sent to the hospital. If a case of a diseased girl was not reported, a sanitary inspection was ordered by the police, and when found diseased, the house was raided and the inmates were taken to the station house, and those affected with venereal diseases were sent to the hospital. In order that the city should not be charged with the expenses, Mayor Caldwell ordered that for the sanitary inspection the brothel- keepers could choose their own physician, who left them the required certificate of good health. The women were visited once in a while by a physician appointed by the mayor, and when girls were found infected with syphilis or venereal diseases the house was raided, the diseased women were committed to the hospital, and the physician who had left the certificate was notified that he could not serve any more in that capacity, because his certificate would be rejected. In the Cincinnati Hospital where the O Ward was purposely established for venereal patients, amongst prostitutes we find the fol- lowing data. In 1890, 117; in 1891, 164; in 1892, 131; in 1893, 142; in 1894, 224; in 1895, 220; in 1896, 182; in 1897, 194; in 1898, 144; in 1899, 149; in 1900, 248; in 1901, 529; in 1902, 324; in 1903, 369; in 1904, 914; in 1905, 688; in the year 1906, 203. Sanitary inspection with the regulation of prostitution was ordered and effected in 1894 and the number of diseased prostitutes which in 1890 to 1893 had oscillated between 117 and 142 rose to 224, showing an increase to nearly double. In 1897 by order of Mayor Gustave Tafel, the sanitary inspec- tion was discontinued, and diseased prostitutes could no more be detained in the hospital during their treatment. The physician in charge was compelled to obey the orders of the prostitutes who came of their own accord, when they were a mass of decay, and as soon as they were somewhat better they asked for their dismissal. The venereal ward for women was converted into a kind of boarding house ; they had a right to habeas corpus, and were free to go whenever they THE REGULATION OF PROSTITUTION 507 liked. This condition of affairs caused the number of diseased prosti- tutes, which was 194 in 1897, after the abolition of surveillance in 1898 to drop to 144 and in 1899 to 149. In 1900, under the administration of Mayor Julius Fleischmann, the regulation of prostitution was reinstated and the administration was entrusted to the hands of the Board of Health. Dr. Clark W. Davis deserved a great deal of credit for setting the machinery in working order. He first selected his own physicians on whom to rely for their skill in venereal and cutaneous diseases, and on their good character, so as to avoid the many irregularities and the many mistakes, which were committed by physicians not very familiar with this branch of medical science. The prostitutes and all sporting women were all secretly registered in the private office of the health officer, their name was known only to him and to the officers of the department. Together with their names, they recorded their address. When registered, they were compelled to be examined by one of the examining physicians, and received a certificate of good health from the Health Office. When they were found suffering with syphilis or with a venereal or contagious disease, they were sent directly to the hospital. The houses of prostitution were inspected by a special officer, to ascertain the number of the inmates and see that the report of the house-keeper was truthful. When it came to the knowledge of the inspector that in the house there were girls not registered or not accounted for, the house was raided. It was the duty of the house- keeper to report every new girl, and the latter had to be registered and examined by the Health Department before she was permitted to remain there. The health officer, before permitting a girl to be registered, tried to explain to her the gravity of the step she was going to take. Usually all those women asking for registration were found so well advanced in their calling, that the admonition never had a good effect. Yet once in a while girls had been sent back to their homes at the expense of the Health Department. They were good honest girls decoyed by procuresses and detained as prisoners by the brothel- keepers. The prostitutes were examined once a week; the inspecting physi- cian made an examination of the skin to see whether any eruption was present either due to syphilis or any other contagious cause such as scabies, etc. The mucous membrane of the mouth, tongue and throat was to be carefully inspected, to ascertain the presence of syphilitic mucous patches. The genital organs were then carefully inspected for any eruption, moist papules, or venereal warts. Next the urethra 508 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS and the excretory ducts of the Bartholinian glands were inspected, and when any secretion was seen, it was placed on a glass slide for micro- scopical examination. The speculum was then introduced and any mucus found in the cul-de-sac of the vagina, or oozing from the cervix, was likewise taken, spread on a glass slide for microscopical examina- tion. The slides were labeled and on each one was the name of the girl from whom it was taken. The bacteriologist of the city made the examination, and when gonococci were found present, the house- keeper was notified not to let the girl have any visitors, and in the afternoon or on the following morning she was taken to the hospital. In the examination when girls were found affected with pediculi pubis they were also taken to the hospital to be sure that they were free from that filth. At the hospital there often apply for treatment women affected with deeply ulcerated gummata, with syphilitic periostitis, etc., but this kind of women usually do not come from the brothels ; they apply for relief of their sufferings of their own accord. The examining physician at every weekly sanitary visit left with the examined girl a new certificate, on which he wrote, well — or, affected with syphilis, or — affected with gonorrhea. He wrote the same on the stub, which was sent to the Health Office to give account of the result of the examination. From the registers of the Health Office from January, 1903, to January, 1904, it is found that 625 women had registered as public prostitutes. They had been visited weekly during the year and 340 of them had been found diseased, and had been sent to the hospital for treatment. Some of them requested to leave the city, or they had been claimed by their relatives and had been sent home. In one week 482 girls were visited by the inspecting physicians, and only 19 were found diseased and were sent to the hospital. This number gave an average of 4 per cent, as diseased prostitutes. This system of protection in a short time gave wonderful results. The number of diseased women diminished from 529 in 1901 to 324 in 1902. When the women know that they have to be examined, they keep themselves clean and try to avoid infection, as they know that, when they are found diseased, it means they must be taken to the hospital. Moreover, when they are infected, the disease is treated in the very beginning and in a short time it yields to the remedies and the woman leaves the hospital cured, or at least in condition not to be a menace to public health. In 1906 the change of administration has brought men to power who do not believe in the regulation of prostitution and they have abolished all the system, and all inspection has been discontinued. 1904 1 905 ] 906 MALE FEMALE MALE FEMALE MALE FEMALE 14 15 14 I 17 2 75 192 52 139 65 78 10 14 4 5 12 4 5 12 9 — 6 3 76 713 77 544 72 135 3 2 2 1 4 2 30 9 43 4 53 4 2 8 2 16 1 — 25 16 22 8 18 9 18 5 6 5 15 3 THE REGULATION OF PROSTITUTION 509 The venereal ward for females was soon deserted and from 688 dis- eased prostitutes in 1905, their number dropped to 203 in 1906. The diminution in the number of diseased prostitutes has been usually followed by the increase of patients in the male venereal ward. Only a few women had applied for treatment to the venereal ward of their own accord, and were in such miserable condition that they were utterly disabled. The following statistical figures were taken from the records of the venereal wards of the City Hospital in order to t>e able to maintain the truthfulness of the assertion. CINCINNATI HOSPITAL Syphilis Initial lesion Secondaria Tertiaria Congenital Gonorrhea with complications 76 Ophthalmia Chancroid with bubo Venereal Warts Scabies Phthiriasis Total 258 986 231 723 263 240 It is clearly shown that in 1904 there were treated in the City Hospital 1244 venereal patients; in 1905, 954, and in 1906, when the surveillance of prostitution was abolished, 503. The results would at the first glance appear as if the venereal diseases under the time of regulation had increased and under free prostitution diminished. This, however, is entirely misleading, because venereal diseases are concealed and it is necessary to find them out and take them to the hospital for treatment and isolation. When prostitution is left free, the few cases of gonorrhea in females which come to the hospital are all grave cases with complications extending to the endometrium, tubes and ovaries. In most of the cases surgical intervention is neces- sary and the patients remain a long time for treatment. Under regu- lation the cases of gonorrhea that come in at the very beginning, are limited to the cervix or to the vaginal cul-de-sac, and in an average of three or four weeks gonococci are not found and the girls are dis- charged well. Cases of syphilis at secondary period when the contagium is more easily transferred, at the time of free prostitution came to the hospital at an average of 28 to 32 ; when the regulation of prosti- tution was enforced, prostitutes with secondary symptoms were taken to the hospital at the rate of from 95 to 193 ; when prostitution was 5io THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS left undisturbed, prostitutes with grave secondary syphilis applied willingly to the hospital because they could not continue in their calling, and they could not stand on their feet. The number of syphi- litic prostitutes dropped again to 37, 53 and 78, not because their number had diminished, but only because they were not inspected, and they were not compelled to remain in the hospital. This shows that more than 50 per cent, of syphilitic prostitutes at the height of contagi- osity are left free to inoculate syphilis in every way, even accidentally. A comparative table taken from the clinics of the Medical College of Ohio of the years 1905 (last year of regulation) and 1906, when all rules were abolished, was furnished by our clinical assistant, Dr. E. B. Tauber. 1905 1 906 MALE FEMALE MALE FEMALE Syphilis 42 24 58 35 Gonorrhea 190 22 347 1 10 Chancroids 9 2 17 3 Scabies 16 13 22 23 Phthiriasis 17 IS 29 22 Total ... 274 76 473 193 It is clearly shown that under free prostitution the number of male patients suffering with venereal diseases has doubled. The num- ber of gonorrheal patients is so large in the clinics, because they are not accepted in the hospital unless affected with complications which render them disabled. The increase in the number of cases of scabies in our city is so ap- parent that nearly every physician has noted the large number affected by this disease. Entire families in the city have been found suffering with scabies, which, although, not a venereal disease must, nevertheless, be laid at the door of prostitution. Many prostitutes suffering with scabies have the disease for a long time before they decide to be treated, and they distribute their filth without any care. The surveillance of prostitutes is also of great advantage for the scope of the police ; among prostitutes some are guilty of other crimes or misdemeanors, and the knowledge of their whereabouts is a necessity. Many prostitutes go from one city to another, and when they know that in a city there is no control of prostitution, they flock there in order to be free from inspection. It is therefore of great importance for the health officers of different cities where regulation is maintained, to have an understanding, that when a prostitute affected with syphilis at the condylomatous period leaves a city to go to another, to notify the Health Department of her arrival in the other city. Often pros- titutes suffering with secondary syphilis have been released from the THE REGULATION OF PROSTITUTION 511 hospital because they requested to be sent home to their relatives. This ought never to be allowed as long as they have symptoms which are dangerous as a source of infection, and they ought to be detained in the hospital. Another danger to the community at large is shown in our statis- tics., where of 2768 women affected with venereal diseases, 875 were domestics. In our city we have always found that when prostitution is free some of these women styling themselves domestics follow the calling of the harlot, and when so diseased that they could not remain in the houses of prostitution, they looked for employment as servant girls in a family. There is no better protection for the public than the hospitalization of the diseased prostitutes, and of any woman infected with venereal diseases leading an immoral life. A woman of this kind as long as she can receive a visitor will not decline his company. For this reason the treatment must be carried on in the hospital, and the woman must be secluded. In the hospital the venereal department for females ought to be furnished with sewing and working rooms, where diseased prostitutes can find occupation in the seclusion during their treatment. In these working rooms, Christian and philanthropic women will find a good opportunity to improve the condition of these poor misled creatures, and to try to elevate their morals, so as to change their lives and bring them back from vice to virtue. Philanthropists will find ample oppor- tunity to establish houses of patronage and rescue institutions, where a prostitute who intends rehabilitation may be sheltered, taught and helped to find honest occupation in order to earn her living. The conclusion reached at the second International Conference in Brussels for the prevention of syphilis and venereal diseases will always remain from the standpoint of public prophylaxis a maxim, "Prostitution must be regulated by law," and the application of this law must be left in the hands of the Health Department of the com- munities and of the municipalities. Medical inspection of the prostitutes is a necessity, an inspection which has to be made by experts in that branch of medicine. All persons who, being infected with venereal diseases, continue to have sexual intercourse are committing a crime and should be punished by law. Prostitution is not to be considered as a crime, and should only be, punished as such in the cases in which society is offended by the demoralizing conduct of the prostitute. In order to avoid the spreading of syphilis accidentally, the health officers of the communities should regulate the barber shops, and 512 THE MEDICO-LEGAL AND SOCIOLOGICAL ASPECTS insist that barbers should sterilize their instruments before using them on the next customer. The dentists have to be taught the dangers of communicating syphilis with their instruments, and the necessity, after the instruments have been used, of placing them in a sterilizer with boiling water. The public in general has to be taught of the danger of infection by drinking from cups used by everybody in the factories or in the public places, and of the necessity of rinsing them before putting them to the mouth. The government, the administration and the physicians have to join hands to combat all the possible causes capable of spreading syphilis as a contagious and insidious ailment, one which tends to degenerate the individual, ruin the welfare of man, the family and society. Experience has shown that a well-directed system of sur- veillance is advantageous and useful to the community in lessening this evil. INDEX INDEX Adenopathy, primary, 36 Albuminuria, syphilitic, 81 Alcohol, effect on syphilis, 140 Alimentary canal, syphilis of, 65 Alopecia, syphilitic, 42, 52 Aneurisms in syphilis, 74, 75 Animal inoculation, 9 Antitoxins of syphilis, 259 Apes, inoculation of, 9 Aphasia in syphilis, no Aponeuroses, syphilis of, 104 Army — venereal diseases in, 491 Arteritis, 74, 100 Arthritis differential diagnosis, 101 gonorrheal, ioi, 161 ' syphilitic 100 Bacteriology of syphilis, i Blood in acquired syphilis, 39, 185 in hereditary syphilis, 295 Blood vessels in syphilis, 72 Bones differential diagnosis, 99 pain, character of, 96 syphilis of, 90 Brain acquired syphilis, 105, 117 hereditary syphilis, 288 Bronchi, syphilis of, 69 Bubo chancroidal, 16, 36 syphilitic, 16, 36 Bursae, syphilis of, 103 Carcinoma with syphilis, 58, 65, 168 Cerebral syphilis, 105, 117 Chancre eroded, 29 extra-genital, 22 Hunterian, 15, 28 induration, 30 initial papule, 31 location, 22, S3 "mixed," 31 multiplicity of, 33 chancre parchemine, 15, 28 pathological anatomy, 28 post-initial, 17 symptoms, 34 treatment of, 179 ulcerated, 30 Chancroid, 31 Cheeks, syphilis of, 60 Circumcision, 225 Colles' Law, 254 Congenital syphilis, 264 constitutional treatment of, 27s diseases associated with, 270 general treatment of, 271 idiocy in, 289 prophylaxis, 275 symptoms, 266 Conjunctiva, syphilis of, 129 Cornea, syphilis of, 129 Cortex, syphilis of, 107 Coryza in syphilitic children treatment, 272 Courts, juvenile, 465 Crime, syphilis predisposing cause, 392 Cutis variegata Dactylitis, syphilitic, 98 Damages in syphilis, 324 Dangers from syphilis, 144 Decadence of population and syphilis, 37° Degeneracy in relation to syphilis, 352 physical signs of, 366 Diabetes in syphilis, 84 Divorce and syphilis, 319 Dystrophies, 311 in hereditary syphilis, 307 parasyphilitic, 153 statistics, 307 Ear, syphilis of, 131 Edema indurativum, 34 Education of young men, 224 Elephantiasis, 60 Endarteritis, 74, JJ, 364 Epididymis, syphilis of, 85 Epilepsy in syphilis, 109, 288, 345 Erysipelas and syphilis, 163 Ethics with syphilitic patients, 326 Eye, syphilis of, 127 Eyebrow, syphilis of, 127 Eyelid, syphilis of, 128 Fasciae, syphilis of, 104 Fetus, syphilitic, 248, 264 Fever, syphilitic, 19 malarial type, 21, 40 Fragilitis ossium, 93 Fungus testiculi syphiliticus, 87 515 5i ( INDEX Genito-urinary tract, FEMALE — SYPH- ILIS OF, 89 Genito-urinary tract, male — syphilis of, Glossitis cicatrisans, 65 Glycosuria in syphilis, 84 Gonorrhea and syphilis, 138, 158, 161 Hair, syphilitic affections of the, 42, 52 Headache in syphilis, 106, 107 Hemiplegia in syphilis, 108, in, 288, 289 Hereditary syphilis, 284 blood in, 295 bones in, 292 brain in, 288 deafness, 287 epilepsy in, 288, 345 interstitial keratitis in, 286 latency of, 297 lymphatic glands in, 294 mortality in, 279 prophylaxis in, 275 skin in, 290 testes in, 293 tongue in, 292 treatment, 312 Heart _ acquired syphilis of, "J2 hereditary syphilis of, 312 History of syphilis, 370 Hot Springs, Ark., 212 Hutchinson's teeth, 286 Idiocy, relation to syphilis, 289 Immunity, syphilitic, 254 Impotence, 87 Infection in syphilis direct, 235 germinative, 238 mixed, 138, 157 modes of, 22 pathology of, 13 post-initial, 39 Insanity in syphilis, 117, 122 Introduction of syphilis into Europe, 370 Iodides, 213 Iodipin, 217 Iodism, 214 Iris, syphilis of, 131 Joints differential diagnosis, 101 gonorrhea, 101 syphilis, 100 Keratitis, 130, 286 Kidneys, syphilis of, 80 Larynx, syphilis of, 68 Leprosy and syphilis, 168 Leucoderma, 43, 48 Leucoplakia, 64 Life insurance and syphilis, 425 Ligaments, syphilis of, 104 Lips, syphilis of, 60, 63 Liver, syphilis of, 80 Locomotor ataxia, 121, 124 Lungs, syphilis of, 70 Lymph glands in hereditary syphilis, 294 in primary syphilis, 36 diagnosis of syphilitic and chan- croidal, 36 Lymphangitis, syphilitic, 35 Malaria and Syphilis, 167 Malignancy of syphilis, 136, 139 Marriage and syphilis, 317, 338 Medical secret, 329 Meninges, syphilis of, 106, 113 Mercury, absorption through skin, 198 physiological action of^ 205 poisoning, 211 stomatitis, 208 Metasyphilis, 123 Microcephalus, 366 Monstrosities, 310 Mucous patches, 62, 63 Muscles, syphilis of, 101 Nails, changes in, 53 in tissue surrounding, 53 Nephritis in syphilis, 80 Nervous system, syphilis of, 105 Neuritis in syphilis, 108, no, 121, 131 Nose, syphilis of, 66 Olfactory nerve, syphilis of, 133 Optic neuritis, 108, no, 121, 131 Orchitis, syphilitic, 86 differential diagnosis of tuberculosis. 88 Osteitis, condensing, 92 formative, 91 rarefying, 91 Ovaries, syphilis of, 89 Palate, syphilis of, 60, 63 Pancreas, syphilis of, 80 Paralysis in syphilis, 108, in, 114, 121, 123, 126 Paranoia, 388 Paraphimosis, 226 Parasyphilis, 152, 309 characters of, 153 treatment in, 155 Paresis, 118, 121 Penis, elephantiasis, 60 syphilitic eruptions of, 84 INDEX 517 Periostitis, syphilitic, 90, 93 Phagedenic ulcers, 290 Pharnyx, syphilis of, 61, 63 Phimosis, 225 Phlebitis, syphilitic, 78 Pigmentation, 48 Placenta, infection through, 246 pathology of, 246, 264 Plaques des fumeurs, 64 Polyuria in syphilis, 84 Populations, decadence of in syphilis, 370 Prevention and coercion, 463 Profeta's law, 256 Prophylaxis, circumcision in, 225 individual, 223 in regard to prostitution, 439 Prostitution, causes of, 452 of minors, 448 legal penalties for, 444 proxenetism and procuresses, 456 public prophylaxis, 439 regulation of, 480 in Paris, 486 in Spain, 489 sanitary consequences, 459 Protozoon-like bodies of Schtiller, 8 Proxenetism and procuresses, 456 Pseudo-tabes, 115 Public health and syphilis, 412 Purpura syphilitica of newborn, 75, 269 Respiratory tract, syphilis of, 66 Saddle nose^ 67 Schools, industrial, 473 Sclerotic, syphilis of, 130 Sexual perversion and syphilis, 405 Skin (see syphilodermata), 41 absorption of mercury, 198 congenital syphilis, 266 hereditary syphilis, 290 late syphilis of, 54 Smokers' patches, 64 Spermatic cord, syphilis of, 88 Spinal cord, syphilis of, 112 Spirochaeta pallida, 10 Giemsa's stain for smears, 11 Levaditi's silver method for tissue, 11 location of, 12 morphology of, 11 Schaudinn's discovery of, 10 Spirochaeta refringens, 11 Spleen, syphilis of, 79 Stages of syphilis, 136 Stains Giemsa's for spirochaetae, 11 Levaditi's silver stain, 11 Statistics, mortality in congenital syph- ilis, 279 mortality caused by syphilis, 146, 416 Statistics of offspring of syphilitics, 302 of syphilis in prostitutes, 459 pregnancies in syphilis, 150, 302 registration of prostitutes, 449 venereal diseases in armies, 491, 493, 494 venereal diseases in hospital of Cin- cinnati, 419, 420, 421 Sterility from syphilis, 251 Stomatitis mercuralis, 64, 208 Syphilis, adenopathy, 36 alcohol in, 140 and marriage, 317 animal inoculation, 9 antitoxins in, 259 associated with other diseases, 142 bacteriology of, 1 blood in, 39, 185, 295 brain in, 105, 117, 288 carcinoma associated with, 58 congenital, 264 constitutional, 19, 21, 34, 38 coryza in syphilitic children, 272 dactylitis, 98 differential diagnosis, 59 edema indurativum, 34 fever in, 19 gonorrhea and, 161 hair in, 42, 52 hereditary, 284 hereditaria retarda, 284 Hutchinson's teeth, 286 immunity in, 254 individual dangers from, 143 influence of, on other diseases, 158 influence of other diseases on, 142 locomotor ataxia, 121 of male genito-urinary tract, 84 malignancy, causes of, 136, 139 medico-legal aspect of, 317 mixed infection, 138, 158 modes of infection, 22 mortality from, 146 nails in, 53 of alimentary canal, 65 of aponeuroses, 104 of blood vessels, 72 of bones, 90 of brain, 105, 117 of bronchi, 69 of bursas, 103 of cheeks, 60 of conjunctiva, 129 of cornea, 129 of cortex, 107 of ear, 131 of epididymis, 85 of eye, 127 of eyebrow, 127 of fasciae, 104 5i8 INDEX Svphilis of female genito-urinary tract, 89 of heart, 72 of iris, 131 of joints, 100 of kidneys, 80 of larynx, 68 of ligaments, 104 of lips, 60, 63 of liver, 80 of lungs, 70 of meninges, 106, 113 of muscles, 101 of nervous system, 105 of nose, 66 of olfactory nerve, 133 of optic nerve, 108 of ovaries, 89 of palate, 60, 63 of pancreas, 80 of penis, 85 of pharynx, 61, 63 of respiratory tract, 66 of sclerotic, 130 of skin, 41, 54 of spinal cord, 112 of spleen, 79 of tendons, 103 of testicle, 86 of third generation, 299 of tongue, 60, 63, 64 of tonsils, 60, 63 of trachea, 69 of urethra, 84 of uterus, 90 of vagina, 89 of vas deferens, 88 of vulva, 89 protozoon bodies of Schiiller, 8 pseudo-tabes syphilitica, 115 sociological aspect of, 317 spirochasta pallida, 10 stages of, 136 statistic data of, 125 symptoms second incubation, 40 tobacco in, 141 toxins in, 259 treatment of, 171 tuberculosis with, 59 Syphilis binaria, 301 Syphilis hereditaria tarda, 284 Syphilodermata, annular, 42 ecthymatous, 50 framboesiform, 50 gummatous, 54, 56 gyrate, 42 lenticular papular, 43 macular, 41 miliary papular, 43 moist papules, 46 palmar, 43, 45 Syphilodermata, papular, 42 papulo-crustosa, 49 papulo-pustulosa, 49 pigmentary, 48 plantar, 43, 45 _ pustular syphilide, differential diag- nosis of, 51 rupial, 51 ulcerative, 55 vegetating, 46 vesicular, 44 Taste in syphilis, 133 Tendons, syphilis of, 103 Testicle : acquired syphilis, 86 differential diagnosis, 88 hereditary syphilis, 293 hydrocele, 86 tuberculosis, 88 Tobacco in Syphilis, 62, 141 Tongue : acquired syphilis, 60, 63, 64 hereditary syphilis, 292 Tonsils, syphilis of, 60, 63 Touch in sj^philis, 134 Toxins of syphilis, 259 Trachea, syphilis of, 69 Transmission of S3*philis by conception, 235 direct, 229 from maternal side, 245, 250 from paternal side, 241 by tertiary products, 231, 241, 258 Treatment of syphilis : baths, 212 external, 177 fumigation, 202 injection, 189 internal, 183 iodides, 213 iodipin, 217 iodism, 214 inunction, 195 of congenital syphilis, 271 time for beginning, 184 Tuberculosis with syphilis, 58, 140, 165 lupus of oral cavity, 64 of vulva, 59 treatment of, 59 Typhoid fever and syphilis, 167 Urethra, syphilis of, 31, 84 Uterus, syphilis of, 90 Vagina, syphilis of, 89 Vas deferens, syphilis of, 88 Vulva : elephantiasis, 60 syphilis of, 89 S}Hphilitic ulceration, 59 tuberculous ulceration, 59 Waters of Hot Springs, Ark., 212 SEP 7 1907 LIBRARY OF CONGRESS — 029 827 900 9